Morphcva with Macula Atrophica\ 
BY 
LOUIS A. DUHRING, M.D., 
I’RUFKSSOR OF SKIN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. 
FROM 
THE AMERICAN JOURNAL OF TIIK MEDICAL SCIENCES, 
Novkmukk, 1892. Reprinted from 
The American Journal of the Medical Sciences, for November, IH'.CJ. 
MORI’HCEA WITH MACUL.K ATROPHICjE.' 
My Ixhjis A. Duhrino, M.D., 
I'KoKKMKoR OK SKIN DISEASE* IN THE UNIVERSITY OK KKNNryLVANIA. 
The patient is an Englishwoman, fifty-five years of ago, a brunette, 
spare, but in good general health. There is no apparent cause for the 
disease. It first manifested itself a year and a half ago, and has been 
gradually spreading. The regions invaded are the nape of the neck, 
and the adjoining scalp to a slight extent; the chest just below the left 
clavicle ; the wrists and forearms. Several stages of the process exist, 
and the lesions are so different as to require separate description. 
Three distinct kinds are noted : 
Ist. Whitish patches of skin with manifest structural change in the 
true skin, of the nature of a |>ecuiiar fatty degeneration of this structure, 
constituting the commonest form of the disease. 2d. Distinctly circum- 
scribed, depressed, and cicatrifonn whitish spots, varying in size from a 
small to a large pea, which plainly exhibit wasting and thinning of the 
true skin, the lesions resembling scars from syphilis, l>eing thin, soft, 
and pliable. .‘ld. Patches of mottled, brownish-red, pigmented, struc- 
turally altered, atrophic skin, with a broken border or margin of firm, 
variously sized, irregularly sha|>ed. papular elevations. Over these 
patches here and there are distinctly marked bluish-purple veins 
running in various directions. The skin in the central portion is 
thinned, and the border, as stated, is thickened, but nowhere is the skin 
bound down to the subcutaneous tissue, the whole patch being freely 
movable over the tendons and fasciae. 4th. Enlarged, bluish-purple 
veins, identical with those on the patches of the wrists, which run up 
the forearm and are not associated with the other forms of disease de- 
scribed, although they are in the neighborhood of some atrophic macules. 
Having thus outlined the chief features which characterize the affection 
as a whole, the individual lesions and their distribution upon the several 
regions involved may be referred to more definitely. 
On the back of the neck at the line of the hair, partly on the scalp 
and partly on the non-hairy portion of the neck, there1 exists an irregu- 
larly shafted, sharply defined, whitish patch of skin, the normal struc- 
ture being changed into a whitish, lardaceous, non-indurated, soft, 
pliable, freely movable patch. The sense of touch with the fingers di»es 
not determine any increased thickness or structural change, so that in 
picking up the skin with closed eyes one would hardly detect disease. 
This |Hitch is about two inches in diameter and is nut surrounded by 
any border or hypenemic zone or by injected veins. The hair of the 
scalp growing from the patch is of natural color, blackish, and uot 
1 K«u<l before the College of RlTvsiciaai, TJTO.' DUHRINQ, MORPHffiA WITH MACULA ATROPHICA. 
whitish as might he expected. This lesion represents one of the varieties 
of morphcea, and according to my experience the earliest and mildest 
phase of the disease. 
Near by this patch, on the hack of the neck, are several pea-sized, 
rounded, sharply defined, slightly depressed, shallow, whitish or pearl 
colored atrophic macules with thin skin which at first glance resemble 
scars from the large pustular syphiloderm or from burns resulting from 
the application of a hot iron. They are disseminated upon the neck on 
either side of the median line, and show no special distribution or 
arrangement. They are in no way different from the typical maculie 
atrophica* which are met with occasionally upon various regions, and 
usually without other forms of cutaneous disease. 
Upon the flexor surfaces of the wrists tire two symmetrical, rounded, 
atrophic patches, the size of a silver half-dollar, defined in outline, with 
a raised, indurated, irregular, uneven, papular border, and pigmented, 
of a mottled, brownish-red hue. The central portions of these patches 
are somewhat wasted and depressed, the skin being thinned, but soft 
and supple. Some enlarged and purplish veins run irregularly over the 
surface. On the flexor surface of one forearm, running up toward the 
elbow, there exist several pea-sized, whitish, atrophic macules, identical 
in character with those on the back of the neck. They incline some- 
what to take on a linear arrangement rather than to be widely dis- 
seminated. 
The lesions which have been described constitute the whole disease. 
The several varieties have no association with one another, but they are 
plainly due to the same cause. They are not stages of one process, but 
are distinct forms of cutaneous change, beginning and running their 
course as such. The patient complains of no pain or serious inconven- 
ience from the disease, and seeks medical advice because of the disfigure- 
ment and of the tendency of the process to waste and atrophy. 
The case represents an unusual phase of the somewhat rare disease 
morphcea. Many years ago I pointed out that this affection was charac- 
terized not only by the so-called “ patch,” but moreover in some cases by 
a variety of lesions, which might occur either singly or in combination. 
In the third edition of my Treatise on Skin Diseases (published some 
years ago) attention was directed to the observation that atrophic 
macules sometimes were present with the characteristic lardaceous patch. 
The occurrence of these two forms of lesion together, however, as in 
the case before us, I regard as rare, one or the other variety of atrophy 
alone usually existing. 
Morphcea must be classified with the atrophies, and not with the 
hypertrophies, as it has been by some prominent authors. The process 
is distinctly atrophic in all its essential features, especially in its course 
ami termination, which are characterized by degeneration of the skin 
and subcutaneous tissue with usually more or less thinning, shrinking, 
and wasting or degenerative atrophy. The present case illustrates the 
close relationship pathologically of raacuho et stria) atrophica) with the 
common plague of morphcea, as this latter was originally described by DUHRINO, MORPHCBA WITH MACULA ATROPHICA. 
Addison and K. Wilson. At that date the affection seemed to have 
been scarcely known in Germany, and moreover even now it appears 
to be rarer there than in England or in this country. Many 
years ago, during a long sojourn in Vienna with daily attendance 
upon the clinics for skin diseases, I do not recall having observed 
a case. 
Concerning the diagnosis, no difficulty can exist, it seems to me, if we 
are in the habit of studying cutaneous disease from the standpoint of 
anatomy and pathology, and more particularly the latter. This classi- 
fication of skin diseases, upon the basis of general pathology, is not 
only the most scientific, but what is of more importance, is also the 
most practical and useful for our daily dealings with these diseases. 
The affection before us belongs manifestly to the atrophies, the process 
at work being essentially degenerative and atrophic in its phases. 
This point established in our minds, there remains merely to find a 
place for it in this class, and it plainly must be grouped with atrophies 
of the true skin. Such forms of atrophy are comparatively rare, the 
true skin not being prone to take on atrophy as a primary process. 
The several affections of this kind which may be classed together are 
atrophy of the skin proper (atrophia cutis propria); maculae et striae 
atrophica;; raorphoea; and some forms of scleroderma, the two latter 
affections sometimes coexisting. 
The treatment of these cases is generally unsatisfactory, the prognosis, 
however, dej>ending a good deal on the variety of the disease present 
and on the stage of the process. In some cases arsenic internally is 
useful, but in the patient before us local inunctions with stimulating 
ointments and oils, with massage, electricity, and frictions will probably 
prove more beneficial.  Joiirijal 
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