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Passion or addiction? Correlates of healthy

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Article in Addictive Behaviors · February 2018

DOI: 10.1016/j.addbeh.2018.02.031

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 Addictive Behaviors 82 (2018) 114–121

Contents lists available at ScienceDirect

Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh

Passion or addiction? Correlates of healthy versus problematic use of T

videogames in a sample of French-speaking regular players
⁎ ⁎⁎
Jory Deleuzea, , Jiang Longa,b, Tie-Qiao Liub, Pierre Mauragea, Joël Billieuxa,c,d,
a
Laboratory for Experimental Psychopathology, Psychological Science Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium
b
Mental Health Institute of the Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
c
Addictive and Compulsive Behaviours Lab, Institute for Health and Behaviour, University of Luxembourg, Esch-sur-Alzette, Luxembourg
d
Addiction Division, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland

H I G H L I G H T S

• The study confirmed the distinction between engagement and addiction in video games.
• Addiction is linked to impulsive traits and depressive symptoms, but engagement is not.
• Both addiction and engagement correlate with the DSM-5 Internet gaming disorder (IGD).
• IGD criteria do not necessarily reflect problematic use and can pathologize gamers.
• The study calls for refinement of current diagnosis criteria of gaming disorder.

A R T I C L E I N F O A B S T R A C T

Keywords: A criticism of current diagnostic approaches to gaming disorder is that they fail to take into account that high
Engagement and repeated engagement is not problematic per se, nor is it necessarily associated with adverse consequences.
Addiction To tackle this controversy, we used Confirmatory Factor Analysis (CFA) to test, in regular gamers (N = 268),
Online gaming whether high (but healthy) engagement can be distinguished from problematic engagement by using the
Internet gaming disorder
Addiction-Engagement Questionnaire (Charlton & Danforth, 2007). We then tested whether differential re-
lationships exist between the engagement and addiction constructs, DSM-5 criteria for Internet gaming disorder
(IGD), and psychological factors linked to gaming use and misuse (self-reported impulsivity, motives to play, and
depression). Results indicated that a model holding engagement and addiction as two distinct, but related,
constructs fits the data well. Second, we showed that although both constructs are linked to the number of IGD
criteria endorsed, the relationship is more pronounced for the addiction construct. Third, a differential pattern of
correlations was observed with the other study variables, further supporting the need to distinguish the two
constructs. Our study emphasizes that research is needed to refine the diagnostic approach to gaming disorder to
avoid conflating healthy passion with pathological behavior.

1. Introduction clinical reality.

A growing number of studies focused on excessive use of video-
games and its associations with psychiatric, health, and interpersonal
problems (e.g., Achab et al., 2011; Longman, O'Connor, & Obst, 2009;
Pawlikowski & Brand, 2011; Stetina, Kothgassner, Lehenbauer, &
Kryspin-Exner, 2011). Studies also included treatment-seeking cases
(Müller et al., 2017; Sakuma et al., 2017; Thorens et al., 2014), in-
dicating that problematic engagement in videogames has become a
Section 3 of the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric Association, 2013)
integrated Internet gaming disorder (IGD) as a condition for further
study, and the beta draft of the 11th revision of the International
Classification of Diseases (ICD-11; World Health Organization, 2017)
included gaming disorder in the section “Disorders due to substance use
or addictive behaviours.” Following the release of the DSM-5, numerous
epidemiological and case-control studies were conducted and

⁎
Correspondence to: J. Deleuze, Institute of Psychological Science, Université catholique de Louvain, Place du Cardinal Mercier, 10, B-1348 Louvain-la-Neuve, Belgium.
⁎⁎
Correspondence to: J. Billieux, Institute for Health and Behaviour, University of Luxembourg, Maison des Sciences Humaines, 11, Porte des Sciences, L-4366 Esch-sur-Alzette,
Luxembourg.
E-mail addresses: Jory.Deleuze@uclouvain.be (J. Deleuze), Joel.Billieux@uni.lu (J. Billieux).

https://doi.org/10.1016/j.addbeh.2018.02.031
Received 9 February 2018; Received in revised form 25 February 2018; Accepted 25 February 2018
Available online 27 February 2018
0306-4603/ © 2018 Elsevier Ltd. All rights reserved.
J. Deleuze et al.
accumulating data about IGD were gathered, although the validity of
the proposed IGD criteria remains debated (Deleuze et al., 2017;
Griffiths et al., 2016).
Still, most studies fail to take into account that high engagement is
not necessarily problematic (Colder Carras & Kardefelt-Winther, 2018;
Király, Tóth, Urbán, Demetrovics, & Maraz, 2017) and that not all
highly engaged gamers experience adverse consequences (Billieux
et al., 2017; Charlton & Danforth, 2007; Kardefelt-Winther et al., 2017).
In this regard, the seminal works of Charlton (2002) and Charlton and
Danforth (2007) questioned the approach that consists of applying re-
cycled substance use disorder criteria to the screening of computer-re-
lated addictive behaviors. Using Browns's (1993) criteria for behavioral
addictions as a rationale, Charlton and Danforth (2007) highlighted
that when applied to gaming, these criteria constitute either “core”
criteria that potentially reflect addiction (i.e., conflicts, withdrawal,
relapse and reinstatement, and behavioral salience), or, in contrast,
“peripheral” criteria that reflect elevated yet non-problematic engage-
ment (i.e., cognitive salience, tolerance, and euphoria). Crucially, the
IGD criteria included in the DSM-5 comprise both core and peripheral
criteria, which is a concern when defining a potentially new disorder.
Along the same lines, Deleuze et al. (2017) suggested that IGD criteria
conflate high and problematic engagements. Other studies supported
the notion that high engagement must be distinguished from harmful
engagement. Thus, Billieux et al. (2013) showed in a longitudinal study
that fast in-game progression is not associated with symptoms of dis-
ordered gaming, implying that high engagement is not necessarily
problematic. More recently, Przybylski, Weinstein, and Murayama
(2017) used IGD criteria in a large sample from the general population
and reported that only a small proportion of the sample could be
qualified as having clinically relevant problematic use of online gaming
(between 0.3% and 1%). Furthermore, most participants endorsing the
IGD diagnosis are highly engaged players who face minimal con-
sequences in relation to gaming. Failing to distinguish between a dys-
functional from a high but healthy engagement might have important
repercussions, such as generating unreliable epidemiological studies or
pathologizing normal behavior (Aarseth et al., 2017; Bean, Nielsen, van
Rooij, & Ferguson, 2017; Billieux, Schimmenti, Khazaal, Maurage, &
Heeren, 2015; Markey & Ferguson, 2017).
Accordingly, further disentangling the characteristics and correlates
of high versus maladaptive engagement in videogames is urgent. To this
end, we tested in a sample of regular gamers whether the two constructs
developed by Charlton and Danforth, “engagement” versus “addiction,”
are identified by using confirmatory factor analysis (CFA), as their in-
itial works relied only on exploratory factor analyses (Charlton, 2002;
Charlton & Danforth, 2007). If successful, this first objective will pro-
vide a psychometrically sound French version of the Addiction-En-
gagement Questionnaire developed by Charlton and Danforth (2007).
Our second objective was to explore whether differential relationships
exist between Charlton and Danforth's engagement and addiction con-
structs and specific factors that have been linked to gaming use and
misuse, including impulsivity (Billieux, Thorens, et al., 2015; Choi
et al., 2014; Ko et al., 2015), depression (Bargeron & Hormes, 2017;
Gentile et al., 2011), and motivations to play online (Billieux, Thorens,
et al., 2015; Kirby, Jones, & Copello, 2014; Yee, 2006). We expected to
find differential associations, so that the addiction construct only would
correlate with factors having been related to problematic videogame
use in previous studies. Finally, we explored the relationships between
the tentative DSM-5 IGD criteria and the engagement and addiction
constructs. Because IGD criteria are supposed to measure pathological
behavior, we expected them to correlate specifically with the addiction
construct.
115
Addictive Behaviors 82 (2018) 114–121
2. Method
2.1. Participants and procedure
Participants were recruited through an online contact survey sent to
the entire student community of the Université catholique de Louvain
(Belgium) by using an online platform (Qualtrics, Provo, UT), reaching
a total of 1637 potential participants. Inclusion criteria were being
18 years or older, native or fluent French speaker, and playing online
videogames at least once per week. Of the 645 eligible participants, 291
gamers completed the entire survey, of which 23 were removed because
of incomplete data.
The final sample consisted of 268 participants (48 females) between
18 and 34 years (M = 21.52, SD = 3.00). Completing the survey guar-
anteed their participation in a random draw in which five respondents
of the total sample received 20 euros in cash. The ethical committee of
the Psychological Science Research Institute of the Université cath-
olique de Louvain approved the study protocol.
The participants started the online survey by providing their in-
formed consent. They filled out demographic (age, gender, language,
educational level) and online gaming-related information (favorite
genre, number of hours spent playing per week). They filled out ques-
tionnaires in the following order: the Addiction-Engagement
Questionnaire (Charlton, 2002; Charlton & Danforth, 2007), IGD cri-
teria (Petry et al., 2014), the short UPPS-P Impulsive Behavior Scale (s-
UPPS-P; Billieux et al., 2012), the Center for Epidemiologic Studies
Depression Scale (CES-D; Radloff, 1977), and the Motivation to Play in
Online Games Questionnaire (MPOGQ; Yee, 2006). All alpha values
reported below were obtained in the current sample.
2.2. Instruments
2.2.1. Addiction-Engagement Questionnaire
The Addiction-Engagement Questionnaire (Charlton & Danforth,
2007, 2010) is a 24-item scale measuring two types of online video-
game engagement. The participants first indicate which specific game
they currently play the most, the name of this game then being im-
plemented in each of the questionnaire's items. In developing the
French Addiction-Engagement Questionnaire, the 24 items were first
translated into French before being back-translated into English by a
bilingual English-French speaker. The back translation resulted in a
solution that was acceptable for all items. The first 12 items measure
dysfunctional engagement in videogames (Addiction subscale), while
the last 12 items are assumed to measure healthy engagement in vi-
deogames (Engagement subscale). The French questionnaire, along
with the corresponding English items, are reported in the Appendix 1.
2.2.2. Internet gaming disorder (IGD)
The nine IGD criteria were assessed with a nine-item questionnaire
provided by Petry et al. (2014). The respondents have to provide a
binary answer regarding whether they endorse each item as having
occurred over the past 12 months. The IGD items measure preoccupa-
tion, withdrawal, tolerance, loss of control, loss of interest, excessive
gaming despite problems, deception, negative mood regulation, and
jeopardizing. Five or more positive answers are required to indicate IGD
(American Psychiatric Association, 2013; Petry & O'Brien, 2013).
2.2.3. Short UPPS Impulsive Behavior Scale (s-UPPS-P)
Impulsivity was measured with the s-UPPS-P (Billieux et al., 2012).
This 20-item questionnaire measures five distinct impulsivity facets on
a 4-point Likert scale: negative and positive urgency (i.e., acting rashly
under the influence of strong negative and/or positive emotions;
Cronbach's alphas of 0.81 and 0.75), lack of premeditation (i.e., diffi-
culties taking into account the consequences of an action; Cronbach's
α = 0.84), lack of perseverance (i.e., difficulties remaining focused on a
difficult or boring task; Cronbach's α = 0.90), and sensation seeking
J. Deleuze et al. Addictive Behaviors 82 (2018) 114–121

(i.e., searching for new and thrilling experiences; Cronbach's α = 0.81). Table 1
Descriptive statistics, internal consistency, and Pearson correlations for the
Addiction–Engagement Questionnaire.
2.2.4. Center for Epidemiologic Studies Depression Scale (CES-D)
Scale Mean SD α 1 2
The 20-item French version of the CES-D was used (Fuhrer &
Rouillon, 1989; Morin et al., 2011) to measure depression. Items are 1. Total score (24 items) 87.97 17.81 0.80 –
scored on a 4-point Likert scale (Cronbach's α = 0.90). The CES-D was 2. Addiction subscale (12 items) 32.98 12.44 0.75 0.84⁎ –
used in the current study as a dimensional measure of depression. 3. Engagement subscale (12 items) 54.99 9.96 0.79 0.74⁎ 0.26⁎

⁎
p < 0.001.
2.2.5. Motivation to Play in Online Games Questionnaire (MPOGQ)
The MPOGQ (Yee, 2006) is a 39-item questionnaire that measures 3. Results
the motivations to play online videogames on a 5-point Likert scale. Ten
motivations to play are assessed under three main categories: (1) 3.1. Structural validity of the addiction and engagement constructs
Achievement, including Advancement (i.e., progression in the game;
Cronbach's α = 0.79), Mechanics (i.e., knowing how the game system To confirm the bi-factorial nature of high engagement in gaming
works; Cronbach's α = 0.79), and Competition (i.e., challenging other (engagement versus addiction), we computed a series of CFAs on the 24
players; Cronbach's α = 0.73); (2) Social, including Socializing (i.e., items of the Addiction-Engagement Questionnaire.
helping and chatting with others; Cronbach's α = 0.80), Relationship Means, standard deviations, internal consistency coefficients
(i.e., forming long-term relationships; Cronbach's α = 0.77), and (Cronbach's α), and correlations for the Addiction-Engagement
Teamwork (i.e., being part of the group effort; Cronbach's α = 0.76); Questionnaire are reported in Table 1. Cronbach's α ranged from 0.75
and (3) Immersion, including Discovery (i.e., discovering as many to 0.80, suggesting good internal consistency for the 24-item scale and
things as possible within the game; Cronbach's α = 0.85), Role-Playing its two subscales.
(i.e., creating a background for the avatar, interacting with others as if Absolute fit indices of the three computed models are summarized
you were the character; Cronbach's α = 0.84), Customization (i.e., in Table 2. First, the results showed that the single-factor model in
liking to customize the appearance of the avatar; Cronbach's α = 0.82), which all items loaded on a unique latent factor poorly fits the data (see
and Escapism (i.e., escaping from real-life problems through the game; Table 2, Model 1).
Cronbach's α = 0.67). The French version (Billieux et al., 2013) was Second, the two-factor models both had a better fit than the first
used in the present study. model did (see Table 2, Model 2), and the two-factor model that as-
sumes an interrelation between the engagement and addiction con-
structs offers the best fit to the data (see Table 2, Model 3a).
2.3. Data analysis From the modification indices provided for Model 3 and a sub-
sequent content and semantic analysis of the items (see Appendix 2 for
To determine the factorial structure of the Addiction-Engagement details), 11 residual pairs of errors were allowed to covary (see Fig. 1).
Questionnaire, we undertook CFA with maximum likelihood estima- The CFA computed for the modified third model suggested that the
tion. We compared three models that consider the relationships among modifications improved the global model fit (see Table 2, Model 3b).
the two components of problematic playing of online videogames. The
first model holds that there is a single unitary construct of gaming 3.2. Correlation analyses
engagement. The second model identifies two independent constructs
of addiction and engagement, while the third model recognizes those Table 3 reports the Pearson's correlations measured between the
two factors as being interrelated. two subscales of the Addiction-Engagement Questionnaire, socio-de-
Regarding model evaluation, we chose to compute relative chi- mographics, and other variables included in the study.
square values (χ2/df) to test the goodness of fit for each model, because First, the number of IGD criteria endorsed were positively correlated
χ2 is known to increase with sample size, and it is unusual to obtain with both subscales, with a significant stronger relation for the
nonsignificant χ2 values when performing CFAs on self-reported ques- Addiction subscale (r = 0.56 for Addiction and r = 0.30 for
tionnaires (Byrne, 1994). A relative χ2 of between 1 and 2 indicates a Engagement). In contrast, the magnitude of the relationship between
reasonable fit (Byrne, 2012; Marsh & Hocevar, 1985). Moreover, in both subscales and self-reported time spent playing was equivalent.
addition to χ2, two other indices that depended on conventional cutoffs Regarding socio-demographic variables, no significant relationship was
were computed, namely, the root mean square error of approximation observed. Concerning factors that have been linked to videogame
(RMSEA) and the standardized root mean square residual (SRMR) (Hu overuse, specific significant relationships were identified for the
& Bentler, 1999). Their combination was adopted because the RMSEA is Addiction subscale (with all s-UPPS-P variables, except for lack of
sensitive to misspecification of the factor loadings and the SRMR is premeditation and with depressive symptoms). Numerous relationships
sensitive to the misspecification of the factor covariances. An RMSEA of were observed between the two facets of the Addiction-Engagement
between 0 and 0.05 indicates a good fit and that between 0.05 and 0.08 Questionnaire and the various motives to play online. First, all
represents an acceptable fit. An SRMR of between 0 and 0.05 indicates a
good fit and that between 0.05 and 0.10 represents an acceptable fit Table 2
(Schermelleh-Engel, Moosbrugger, & Mäüller, 2003). We also reported Fit indices of the CFAs for the Addiction–Engagement Questionnaire based on the various
the comparative fit index (CFI). A CFI higher than 0.90 indicates an hypothesized models.
acceptable fit (Hooper, Coughlan, & Mullen, 2008). Internal reliability
Model df χ2 χ2/df RMSEA SRMR CFI
of the Addiction-Engagement Questionnaire and its two postulated
subscales was measured with Cronbach's α coefficient. 1 252 847.67⁎ 3.36 0.094 0.1040 0.544
Two-tailed Pearson correlations were used to explore the relation- 2 252 590.12⁎ 2.34 0.071 0.0952 0.741
ships between the Addiction-Engagement subscales and the other con- 3a 251 572.90⁎ 2.28 0.069 0.0788 0.754
3b 240 363.35⁎ 1.514 0.044 0.0665 0.906
structs included in the study. When both scales of the Addiction-
Engagement Questionnaire significantly correlated with a specific CFA = confirmatory factor analysis; RMSEA = root mean square error of approximation;
construct, Fisher z-to-r transformations were performed to compare SRMR = standardized root mean square residual; CFI = comparative fit index.
⁎
these correlations. p < 0.001.

116
J. Deleuze et al. Addictive Behaviors 82 (2018) 114–121

Fig. 1. The standardized estimates of the modified, inter-related, two-factor model. Latent variables are represented by ovals and manifest variables are represented by rectangles. Single-
headed arrows represent error variance and factor loading; double-headed arrows represent the correlation between the latent variables.

achievement motives were correlated with both Engagement and 4. Discussion

Addiction subscales. The only quasi-significant difference in correla-
tions' size concerned the mechanics component, which tended to be
more important for players with a high engagement score. Second, the
only social motive linked to both engagement and addiction was the
relationship motive. However, the latter did not have a significantly
more pronounced relationship with any of the videogame engagement
subscales. Third, a differential pattern of correlations appeared for
immersion motives. Indeed, whereas the escapism motive was similarly
linked to both engagement and addiction, the other immersion-related
motives were significantly related only to the Engagement subscale.
The purpose of this study was to further test the relevance of dis-
tinguishing between high engagement and problematic engagement in
videogames. Indeed, current conceptualizations of problematic use tend
to overlook this distinction, engendering conflation between healthy
and pathological gaming patterns. The current study thus tested the
structural validity of the Addiction-Engagement Questionnaire (using
confirmatory analyses) and explored its relationships with DSM-5 IGD
criteria, depressive symptoms, and factors that have been related to
videogame use and misuse. The main findings of the study are as

117
J. Deleuze et al. Addictive Behaviors 82 (2018) 114–121

Table 3 Baier, Mößle, & Petry, 2015; Subramaniam et al., 2016) is likely to
Pearson correlation between Addiction-Engagement subscales and self-report measures. result in an inflated prevalence rate because of the conflation between
pathological and highly engaged individuals. The diagnosis must in-
Variable Engagement Addiction z p
stead focus on the functionally impairing nature of gaming engagement
Age .115 −.081 – – (Billieux, King, et al., 2017; Ferguson, Coulson, & Barnett, 2011). The
Gender .047 .114 – – latter approach is aligned with the conceptualization of gaming dis-
IGD .303⁎⁎ .558⁎⁎ −3.65 .0003
order included in the beta draft of the ICD-11 (World Health
Hours/all games .255⁎⁎ .195⁎⁎ .073 .4654
s-UPPS-P – urgency .047 .159⁎⁎ – – Organization, 2017) and with a recent broader definition of behavioral
s-UPPS-P – positive urgency .112 .199⁎⁎ – – addictions (Billieux, van Rooij, et al., 2017; Kardefelt-Winther et al.,
s-UPPS-P – lack of premeditation −.034 .075 – – 2017). Along the same lines, time spent playing weekly was also posi-
s-UPPS-P – lack of perseverance .023 .171⁎⁎ – – tively correlated with both subscales, which is not surprising, given that
s-UPPS-P – sensation seeking .092 .123⁎ – –
it is systematically associated with pathological gaming, while highly
CES-D .061 .272⁎⁎ – –
MPOGQ – advancement .338⁎⁎ .322⁎⁎ .21 .8337 engaged gamers can also play a lot without experiencing negative
MPOGQ – mechanics .345⁎⁎ .192⁎⁎ 1.9 .0574 outcomes (Ferguson et al., 2011; Király et al., 2017; Kirby et al., 2014;
MPOGQ – competition .223⁎⁎ .291⁎⁎ −0.84 .4009 Lemmens, Valkenburg, & Peter, 2009).
MPOGQ – socializing .092 −.037 – –
Our findings also fit well with the dualistic model of passion
MPOGQ – relationship .212⁎⁎ .141⁎ .84 .4009
MPOGQ – teamwork −.049 −.057 – – (Vallerand et al., 2003), which posits that any activity in which people
MPOGQ – discovery .201⁎⁎ .013 – – invest time and energy can be conceptualized as either “harmonious” or
MPOGQ – role-play .230⁎⁎ .051 – – “obsessive” passion. Harmonious passions are adaptive and character-
MPOGQ – customization .184⁎⁎ .076 – – ized by autonomous internalization (i.e., the activity becomes part of
MPOGQ – escapism .287⁎⁎ .303⁎⁎ −0.2 .8415
the self in an integrated and positive way; see Deci & Ryan, 2000) and
Note. The z and p columns refer to the Fisher z-to-r transformation. free will (i.e., the activity is performed on a voluntary basis), and it is
IGD = Internet Gaming Disorder; s-UPPS-P = Short UPPS Impulsive Behavior Scale; CES- practiced in harmony with other aspects of life. In contrast, obsessive
D = Center for Epidemiologic Studies Depression Scale; MPOGQ = Motivation to Play in passions are maladaptive and globally imply a strong urge to engage in
Online Games Questionnaire. the activity that is beyond one's control. The activity is internalized to
⁎
p < .05. such an extent that self-worth depends on the compelled commitment
⁎⁎
p < .005.
to the activity. Obsessive passions are the result of compensatory be-
haviors for unfulfilled needs and tend to enter into conflict with other
follows. First, CFA analyses emphasized that a model holding engage-
aspects of the person's life, engendering negative consequences
ment and addiction as two distinct but related constructs fits the data,
(Lalande et al., 2017). We hypothesize that the engagement construct is
further supporting the need to distinguish high from problematic en-
underlain by a harmonious passion for videogames (e.g., linked to
gagement. Second, both constructs are linked to the endorsement of
achievement and immersion motives, but not to depressive symptoms),
IGD criteria, yet this relationship is more pronounced for the addiction
whereas the addiction construct is instead the consequence of an ob-
construct. Third, a differential pattern of correlations was observed in
sessive passion (e.g., mainly linked to achievement motives and es-
which the addiction construct is specifically related to heightened im-
capism, and associated with impulsivity and depressive symptoms).
pulsivity and more elevated depression. The engagement construct is
This assumption is consistent with previous researches showing that the
specifically related to several immersion motives (role-playing, ex-
harmonious use of videogames predicts life satisfaction, improved
ploring, customization).
psychological adjustment, and a sense of self-realization (Lafrenière,
The present study corroborates previous findings by Charlton
Vallerand, Donahue, & Lavigne, 2009), whereas obsessive use of vi-
(2002) and Charlton and Danforth (2007), indicating that recycled
deogames was linked with dissatisfaction, game use to fulfill basic
substance abuse criteria (e.g., preoccupation, tolerance, euphoria)
needs, lower game enjoyment, and more negative consequences
might not be valid in defining pathological engagement in a behavior
(Lafrenière et al., 2009; Przybylski, Weinstein, Ryan, & Rigby, 2009).
such as gaming (Kardefelt-Winther et al., 2017). They constitute per-
On the whole, our study emphasizes the crucial need to distinguish
ipheral criteria that are not indicative of a genuine disorder. In support
repeated healthy versus repeated maladaptive engagement in video-
of this statement, our study shows that factors that are typically linked
games to avoid conflating passion with disorder, ultimately patholo-
to problematic behaviors such as impulsivity or depressive symptoms
gizing healthy gamers (Aarseth et al., 2017; Billieux, King, et al., 2017).
are not related to the engagement construct, which comprises items
Notably, our results support a critical approach to diagnostic criteria for
that assess peripheral criteria. In contrast, the addiction construct
gaming disorder, in particular those included in Section 3 of the DSM-5
comprises core criteria that are potentially indicative of a disorder (e.g.,
that adopt a polythetic approach mixing core and peripheral criteria to
conflicts, withdrawal symptoms) when co-occurring, and are associated
establish the diagnosis. In this vein, gaming disorder, as defined in the
with increased impulsivity and depressive symptoms. These results call
ICD-11 approach (World Health Organization, 2017), is interesting in
for a refinement of the criteria generally used to measure behavioral
the sense that it considers functional impairment as a mandatory cri-
addictions, as well as for caution when, for example, applying Brown's
terion, and includes core criteria as diagnostic guidelines (e.g., loss of
components model of addiction (1993, modified by Griffiths, 2005) to
control, continued use despite negative consequences). In contrast, the
excessive behaviors. Indeed, such an approach gained popularity in the
DSM-5 criteria define the condition as a pattern of persistent or re-
behavioral addiction field (e.g., “Facebook addiction”, Andreassen,
current gaming associated to clinically significant impairment or dis-
Torsheim, Brunborg, & Pallesen, 2012; “TV series addiction”, Orosz,
tress, even though functional impairment per se is not listed in the nine
Bőthe, & Tóth-Király, 2016), insidiously resulting in potential patho-
potential inclusionary criteria. As a consequence, most of previous
logization of normal behavior.
studies having used the DSM-5 criteria have not considered functional
Along the same lines, an important finding was that both Addiction
impairment as a mandatory diagnosis criterion, which might have in-
and Engagement subscales positively correlate with the number of
flated the prevalence rates reported (Billieux, King, et al., 2017).
DSM-5 IGD criteria endorsed, although the size of this relation is more
An additional benefit of our study is that it provides a French and
pronounced for Addiction. This correlation results from the reliance of
psychometrically sound version of the Addiction-Engagement
IGD criteria on polythetic scoring, which mixes core and peripheral
Questionnaire. The limitations of the study must be acknowledged,
criteria. From this observation, the use of IGD criteria to screen for
however, in particular its correlational nature, the convenience sample
pathological gaming in epidemiological studies (e.g., Rehbein, Kliem,
used, the absence of clinical participants, and the use of self-reports.

118
J. Deleuze et al. Addictive Behaviors 82 (2018) 114–121

Further studies should also consider the impact of psychosocial well-
being and several background variables (e.g., socio-economic status,
parenting or school support, family and school environments) which
have been found to importantly contribute in identifying individuals
with problem video gaming (Colder Carras & Kardefelt-Winther, 2018).
Despite these limitations, the present study offers important avenues for
improving the conceptualization and diagnosis of gaming disorder.
Role of funding sources
Jory Deleuze is funded by a Special Research Fund (FSR) from the
Université catholique de Louvain (Belgium). Pierre Maurage (Research
Associate) is funded by the Belgian Fund for Scientific Research (F.R.S.-
FNRS, Belgium). The funding agencies had no further role in study
design; in the collection, analysis and interpretation of data; in the
writing of the report; or in the decision to submit the paper for pub-
lication.
Contributors
Jory Deleuze and Joël Billieux designed the study. Jory Deleuze
elaborated the online survey and collected the data. Jory Deleuze and
Jiang Long did the statistical analyses. Jory Deleuze and Joël Billieux
interpreted the results and wrote the article. Jory Deleuze, Jiang Long,
Tie-Qiao Liu, Pierre Maurage, and Joël Billieux reviewed the manu-
script. All authors approved the final version of the manuscript.
Conflict of interest
All authors have no conflicts of interests to declare.

Appendix 1. Items of the Addiction-Engagement Questionnaire in English and French versions. Examples are provided using the game
“League of Legends”

English French

1. I sometimes neglect important things because of an Je néglige parfois des tâches importantes à cause de mon intérêt pour League of
interest in League of Legends Legends
2. My social life has sometimes suffered because of me Ma vie sociale a parfois souffert du fait que jouais à League of Legends
playing League of Legends
3. Playing League of Legends has sometimes interfered Jouer à League of Legends a parfois interféré avec mon travail ou mes études
with my work
4. When I am not playing League of Legends I often feel Quand je ne joue pas à League of Legends, je me sens souvent agité
agitated
5. I have made unsuccessful attempts to reduce the time I J’ai tenté de réduire, sans y arriver, le temps passé à jouer à League of Legends
spend playing League of Legends
6. I am sometimes late for engagements because I am J’ai parfois du retard dans mes obligations/engagement parce que je joue à
playing League of Legends League of Legends
7. Arguments have sometimes arisen at home because of Des disputes ont parfois eu lieu à la maison à cause du temps que je passe sur
the time I spend on League of Legends League of Legends
8. I think that I am addicted to League of Legends Je pense que je suis accro/addicte à League of Legends
9. I often fail to get enough sleep because of playing League J’ai souvent manqué de sommeil parce que je jouais à League of Legends
of Legends
10. I never miss meals because of playing League of Legends Je n’ai jamais raté de repas parce que je jouais à League of Legends
11. I have never used League of Legends as an escape from Je n’ai jamais utilisé League of Legends pour échapper aux relations sociales
socializing
12. I often feel that I spend more money than I can afford on J’ai souvent l’impression que je dépense plus d’argent que ce que je peux me
League of Legends permettre dans League of Legends
13. It would not matter to me if I never played League of Ça ne me dérangerait pas si je ne jouais plus jamais à League of Legends
Legends again
14. I feel happy at the thought of playing League of Legends Je me sens heureux quand je pense au fait de jouer à League of Legends
15. The less I have to do with League of Legends the better Au moins je joue à League of Legends, au mieux c’est
16. League of Legends is unimportant in my life League of Legends n’est pas important dans ma vie
17. I would hate to go without playing League of Legends for Je détesterais ne pas jouer à League of Legends pendant plusieurs jours
more than a few days
18. I rarely think about playing League of Legends when I Je pense rarement au fait de jouer à League of Legends quand je n’utilise pas un
am not using a computer ordinateur (ou autre support me permettant d’y jouer)
19. I pay little attention when people talk about League of Je ne fais pas beaucoup attention quand les gens parlent de League of Legends
Legends
20. It is important to me to be good at League of Legends C’est important pour moi d’être bon à League of Legends
21. I often experience a buzz of excitement while playing Je ressens souvent un frisson d’excitation quand je joue à League of Legends
League of Legends
22. I like the challenge that learning to play League of J’aime le défi que représente le fait d’apprendre à jouer et de progresser dans
Legends presents League of Legends
23. League of Legends jargon sounds stupid to me Le vocabulaire/jargon utilisé dans League of Legends me parait stupide
24. I can't understand why people like League of Legends Je ne peux pas comprendre pourquoi les gens aiment League of Legends

119
J. Deleuze et al.
Appendix 2. Items for which error pairs were allowed to covary. Examples are provided using the game “League of Legends”
Items of residual correlations implemented for modification
1 1. I sometimes neglect important things because of an interest in
League of Legends
2 1. I sometimes neglect important things because of an interest in
League of Legends
3 2. My social life has sometimes suffered because of me playing
League of Legends
4 3. Playing League of Legends has sometimes interfered with my
work
5 10. I never miss meals because of playing League of Legends
6 13. It would not matter to me if I never played League of Legends
again
7 14. I feel happy at the thought of playing League of Legends
8 19. I pay little attention when people talk about League of
Legends
9 20. It is important to me to be good at League of Legends 22. I like the challenge that learning to play League of Legends presents
10 21. I often experience a buzz of excitement while playing League 22. I like the challenge that learning to play League of Legends presents
of Legends
11 23. League of Legends jargon sounds stupid to me 24. I can't understand why people like League of Legends
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 CHAPTER XXVII.
THE SKIN.
It is proposed here to treat only of those diseases of the skin which
may complicate surgical cases or call for surgical treatment.
Dermatitis may be produced by chemicals, caustics, and various
irritants; the former, for instance, by the use of strong antiseptics
upon sensitive skins, and the latter as when fecal matter or urine is
poured over unprotected skin or allowed to remain in contact with it.
Ammoniacal urine will prove irritating, as will also that of diabetes.
When carbolic acid was in general use it gave rise to great trouble
upon the hands of many surgeons, while iodine, iodoform, and other
such remedies, as well as the stronger mercurial preparations, will
cause local symptoms similar to those produced by poison ivy.
This may be prevented, when the condition has occurred, by
applying soothing lotions or mild astringents, with anodynes, in dry
dusting powder or in ointment form. Cocaine in small amounts, or
preferably orthoform with menthol, may be employed in either of
these ways. When an acid discharge is expected the skin should be
protected with an ointment or with collodion or rubber cement; the
latter by drying will leave a thin film upon the surface. Thus around a
fecal fistula the skin will be irritated and more or less macerated, and
should always be thus protected when possible.
Between sixty and seventy drugs are known to produce distinct
forms of dermatitis, such as copaiba, cubebs, the various
preparations of iodine, bromine, and arsenic, some of the aniline
preparations, quinine, etc.; while the various antitoxic serums,
especially that of diphtheria, will sometimes produce a skin
disturbance. In these cases it is only necessary to recognize the
source of the trouble and remove the cause by stopping the drug.
Should dermatitis produce such restlessness as to interfere with the
physiological rest necessary for a wound or fracture an opiate should
be administered.
 DERMATITIS CALORICA.
Dermatitis calorica means the varying degrees of irritation which
may be set up by extremes of heat and cold, continuous or alternate,
as in so-called chilblains. These are often seen upon the feet, but
occur upon the hands and even the face, i. e., in places most
exposed and least supplied with blood. The lesion occurs in patches,
often with livid discoloration, and causes sensations varying from
discomfort to acute pain, almost always aggravated by warmth; while
the skin appears inflamed, though to the touch it usually seems cool.
Treatment.—Chilblains occur most frequently in the anemic and
those with uric-acid diathesis, but may be met at any
time. The constitutional treatment should not be overlooked. Much
pertains to good care of the feet, especially after exposure. After
wetting or chilling they should be dried and then rubbed with boric-
acid talcum powder, containing 1 or 2 per cent. of menthol; this may
be dusted upon the feet, before going outdoors, upon return, and
when there is discomfort.
It will often give relief to immerse the feet in warm water containing
sufficient tincture of iodine to give it a mahogany color; or the feet
may be simply dipped in this and then allowed to dry without using a
towel. The use of hydrogen dioxide diluted two or three times has
been highly commended. If this proportion of dioxide be added to
four or five parts of hot saturated solution of sodium bicarbonate the
efficacy of the measure will be much enhanced. In extreme cases
frequent use of the following formula will probably give more relief
than anything else: Carbolic acid 1 part, ichthyol and tincture
calendula each 4 parts, and glycerin 16 parts. With this the skin may
be kept constantly moistened.
The expressions of dermatitis produced by heat may vary from an
efflorescent rash to complete destruction, and will be treated of
under the following head:

BURNS AND SCALDS.

The term “burn” is applied to lesions produced by flame or dry
heat, while moist heat (i. e., boiling materials or steam) causes
injuries known as “scalds.” Between the two there is but little
essential difference, except that with the latter there is usually
loosening of the hair of the part, and sometimes much loosening of
the epidermis as well, so that it is easily detached in more or less
large patches. Whether heat is relatively feeble but prolonged, or
higher in degree and of shorter duration, the results of dry heat are
about the same. Some differences will exist according to whether the
part is exposed to actual flame or to hot or melted material,
sufficiently hot perhaps to cause complete charring or carbonization
of a part.
 Fig. 97

Burn by electric current from “live wire” carrying 1200 volts. (Original.)

Similar injuries are produced by concentrated caustics, acids, or

alkalies, while such materials as phosphorus or sulphur produce
deep burns. The burn produced by lightning is rarely deep, although
it may be extensive (Fig. 97). Persons coming in contact with live
wires sustain burns which partake much of the nature of the electric
discharge, and are sometimes of a character to deserve the term
“brush-burn.” Formerly burns were divided by Dupuytren into six or
seven degrees, but this classification is too cumbersome and
artificial to be acceptable. Morton’s classification is now everywhere
accepted, by which they are divided into three degrees: (1)
Dermatitis without vesication. (2) Vesication even to the formation of
bullæ. (3) Destruction of the skin, with or without that of the deeper
parts, which may include actual carbonization of a limb.
Burns may vary within the widest imaginable limits. To an
extensive burn of the surface may be added the features produced
by inhalation of smoke, steam, or flame; accordingly the eyes and
the mucous membrane of the nose and mouth suffer, the parts
becoming chemotic and disfigured, so as to make the individual
unrecognizable. Burns constitute one of the most painful and
distressing injuries known to the surgeon, particularly when the area
is large and the case is complicated by injuries which necessitate
more or less prolonged rest in bed. When the body is burned
completely around it is difficult to ensure rest without the use of
anodynes.
Shock is a marked feature of every serious case of burn or scald,
and albumin quickly appears in the urine in these cases. Ulceration
of the duodenum may follow extensive injuries of this kind, and is
occasionally the cause of death. It is to be attributed to a toxic action
produced by absorption of putrid material connected with the surface
sloughing process. A temporary diabetes is sometimes noted.
Laryngitis, bronchitis, and pneumonia may occur from inhalation of
steam or smoke, while the inhalation of flame may bring about a
rapid edema of the glottis, which may necessitate tracheotomy as an
early and emergency measure. It is generally stated that a burn of
the second degree, which even involves half of the surface of the
body, may prove fatal; while this is not invariably the case, it is too
frequently true, and may afford aid in prognosis.
Burns of the second degree are always followed by exudation with
formation of blebs, usually within a few hours. In the more serious
cases the exudate may be bloody. Burns of the third degree are
necessarily followed by more or less gangrene, and this fact affords
the reason for the radical treatment recommended.
Treatment.—By the time the surgeon is called to treat a burn the
first indications are usually relief of pain, and perhaps
stimulation for shock. The circumstances attending such injury
generally leave the patient in an excited mental condition, and for
several obvious reasons it would be well to use sufficient anodyne to
tranquillize and give comfort. An excellent application in emergency
cases is a saturated solution of sodium bicarbonate, or it may be
dusted over the affected surface.
The unpleasant visceral complications that follow burns are due to
absorption of decomposing fluids or tissues, so retained or so in
contact with readily absorbing surfaces as to produce a more or less
violent degree of toxemia. In this way are to be explained delirium,
convulsions, or coma, as well as the ulcerative and toxic intestinal
symptoms which constitute the distressing complications.[17] For this
reason the radical method of prevention is the best; hence whenever
there is any prospect of sloughing, or when even the epidermis is so
burned as to make it appear that it will soon separate, the best
method of treatment is to anesthetize the patient and then with a stiff
brush and antiseptic soap scrub the part and remove everything that
is at all loose, if necessary even using a wire brush, scissors, or a
razor. Beneath every sloughing area toxic absorption will go on, and
it will be far better to have fresh raw and bleeding surfaces than
those which cover sources of danger; the resultant scar will not be
any greater, while the subsequent course of the case will be
favorably influenced. Exquisitely tender surfaces thus have their
sensibility blunted, and the comfort of the patient is greatly enhanced
by thorough cleansing and sterilization; moreover, dressings will not
need to be so frequently changed. A soothing, antiseptic ointment
should be applied; there are few better than the ordinary ointment of
zinc oxide, to which may be added bismuth subnitrate and
orthoform.[18] Treatment of this kind would probably not need to be
repeated, and the duration of the trouble would be reduced to one-
quarter or one-third of the time which would otherwise be required.
When actual carbonization has occurred amputation is generally
necessary. Diluted solutions of ichthyol have proved satisfactory, and
the dressings should be covered with some impermeable material,
so as to exclude the air. Another advantage is that the amount of
subsequent discharge is limited, and thus there is less need for
frequent change of dressings. In extreme cases there is no method
which gives so much comfort and certainty as continuous immersion
in warm water; to this may be added common salt or some other
antiseptic, but the water alone is sufficient, if changed frequently. In
burns covering a great part of the body this treatment is the most
serviceable. It should be employed until the sloughs have separated
and surfaces are granulating and ready for skin grafting. This
implies, of course, immersion of the entire body in a bath-tub, the
body lying on a sheet fastened to the sides of the tub. The
advantage of brewers’ yeast dressing, when sloughs are present,
has been previously emphasized in the chapter on Ulcers and
Ulceration.
[17] The Poisons Produced in Superficial Burns.—The intoxication
which often proves fatal in from a few hours to a few days after an extensive
burn of the surface, with its attendant delirium, albuminuria, hematuria,
vomiting of blood, diarrhea, etc., is very similar to the acute intoxications
produced by bacterial products. The sympathetic nervous system is
seriously involved in both. These toxins are evidently the result of
hemolysis, and it has been shown that they are slow poisons, especially for
nerve tissue, apparently eliminated by the intestines and kidneys, which
thus suffer during the process of elimination. This is a more rational
explanation than the theories of thrombosis or of alterations in the red
corpuscles, which would not account for duodenal ulcers, necroses in the
Malpighian bodies of the spleen, etc. These poisons are formed in the burnt
area and not externally; hence, if this burnt area be removed immediate
death may be prevented, whereas if it be permitted to remain for a few
hours it may be too late. The poisons seem to be produced in the skin, as
the burning of the muscle is not followed by any such degree of intoxication.
They seem to be neither ptomain nor pyridin derivatives, but rather
resemble the poison of snake venom. Pfeiffer believes them to be derived
from the splitting up of proteids altered in composition by the heat of the
burn.
[18] Cargile membrane makes an excellent covering for burns whose
surfaces have been cleaned of sloughs and which are granulating. It adapts
itself perfectly to all irregularity of contour, may be snugly applied and not
changed until necessity requires it.

The disfigurement caused by a superficial burn will fade after a

few months. In cases where the skin has sloughed there is a
tendency to cicatricial contraction as soon as granulations begin to
form, and the tendency then is to the formation of disfiguring scars.
About the limbs the flexor muscles will always overcome the
extensors, and bridle-like deformities will be formed at flexures of the
joints. These are to be prevented so far as possible by two measures
—proper splinting and early skin grafting. About the face splints
cannot be used, but one of the grafting methods should be used.

Fig. 98

Epithelioma following ulcer due to burn. (Lexer.)

A tendency in the scars of old burns is to formation of keloid (see

below) and epithelioma. The writer has seen epitheliomatous ulcers
covering at least an area of a square foot, which had formed upon
the sites of burns received years previously. In one case of this kind
it was necessary to remove the entire upper extremity; even then the
disease recurred and finally destroyed the patient (Fig. 98).
Burns produced by caustic acids or alkalies call for appropriate
chemical antidotes at first and later essentially the same treatment
as that already mentioned. In cases of severe burn there is danger of
neglecting the ordinary rules of general treatment, which consist in
maintaining elimination and nutrition.
 FROSTBITE.
Effects similar to those produced by heat are caused also by cold,
varying from a superficial dermatitis with its surface irritation, its
possible vesication, and, later, desquamation, to complete freezing
of an extremity or a part (e. g., the nose, or the ear), which may be
followed by gangrene. Portions which are not frozen beyond the
point of restoration of vitality undergo a marked reaction and become
swollen and discolored, save in rare instances where they shrivel.
Gangrene is not so immediate a process as in a severe burn, as it
takes a number of hours, sometimes days, for the establishment of
the so-called line of demarcation, by which the dead tissue is
separated from the living. On one side of this line putrefaction goes
on rapidly, as in moist gangrene from any cause; on the other side
there is active circulatory disturbance, with phagocytosis, by which
the line becomes more marked; no portion of tissue on the distal side
of this dead line can be saved. The location of the lesion and the
exigencies of the case will indicate where amputation should be
made. (See chapter on Gangrene.)
Treatment.—A rapid restoration of warmth to the part is most
undesirable. The thawing-out process in a case of
severe freezing should be begun in cold or ice-cold water. Crude
petroleum at a temperature of 60° F. has been recommended as a
substitute for cold water, and immersion may be continuous for
several hours. A rubbing with alcohol and water may be substituted
for the cold water, and then a gradual restoration to the ordinary
temperature of the air. Unless this treatment be skilfully managed
there may be such a rapid reaction as to be painful and even
injurious. By the time there is any active exudation, or putrefaction
has begun, an absorbent dry dressing and suitable antiseptics may
be used.

DERMATITIS OF RADIO-ACTIVE ORIGIN.

The common expression of this form of skin affection is called a
burn. This is something more than its name implies, for it is
understood that the active factors are the ultraviolet rays, or the rays
beyond the color region of the spectrum; that it is not due to the heat
rays is shown by the intense burning that is frequently seen in the
Arctic regions. In the skin of the young and tender, sunburn is
sometimes followed by vesication and desquamation; ordinarily it
simply produces the latter. Any soothing ointment or solution is
usually sufficient for the treatment of sunburn, which should,
however, include avoidance of the exciting cause.
 Fig. 99

“X-ray burn,” result of nine exposures in nine days. Extensive necrosis and
sloughing, with an intractable ulcer. (From collection of Dr. G. W. Wende.)

Much more intense actinic effects are produced by the x-rays,

leading sometimes to complete destruction of the skin. These
phenomena are usually called x-ray dermatitis. They vary from local
discomfort, with itching, loss of hair on hairy surfaces, and partial
anesthesia, with later a glossy appearance, to edema of the cellular
tissue, by which anatomical outlines are effaced. The natural color of
the skin, owing to pigmentation, appears dark. If the exciting cause
be stopped before or as soon as this stage is reached complete
recovery is possible, save that hair does not always grow from the
surface which has lost it. The x-ray treatment should be pushed up
to this stage. Careful management is now necessary, especially
should any surface irritation like chafing occur. That x-ray burn, so
called, may result from x-ray exposure made some time previously
seems to be established by a case reported to me by Dr. L. L.
McArthur, of Chicago, where he had to do skin grafting upon a lesion
of this kind which did not appear until fifteen months after the last
exposure.
The stage of danger is characterized by extreme itching with
multiform eruptions in successive crops, desquamation, formation of
minute vesicles, and ulcers; or the process may be more acute and
the skin begin to slough. Small lesions will become confluent, and
large excavations may be formed. The sloughing process is usually
slow, and by it are produced ulcers characterized by extreme pain
and discomfort and a lack of tendency to heal.
These ulcers are exquisitely sensitive and applications intended
for relief are of themselves most distressing. Everything about such
an ulcer seems sluggish, while small areas which have apparently
healed break down again; healthy scabs are not formed and
granulations are extremely indolent.
Treatment.—In the treatment of these lesions, so long as they are
mild, the surgeon should confine himself to soothing
applications and rest; at the same time discontinuance of x-ray
exposures and even avoidance of light seem to be essential. Any
operator threatened with such trouble should wear thick rubber
gloves during all his work. The local treatment of this lesion is not
essentially different from that described in the chapter on Ulcers and
Ulceration, but the surfaces are often so erethistic as to demand
either anodyne applications, containing such remedies as orthoform,
anesthesin, or even cocaine, or else they need radical treatment with
a sharp spoon.
 Sloughing surfaces should be treated with brewers’ yeast until the
surface has become healthy. Picric acid in solution has been
recommended, a saturated solution being diluted seven or eight
times before using.
The writer has rarely seen any more distressing or obstinate
lesions than presented in some of these cases. In speaking of
epithelioma it has been stated that some of these ulcers are prone to
thus degenerate. It seems an extreme contradiction in physics that
the agent used so frequently in the treatment of superficial cancers
should, when used to excess, produce lesions which themselves
become cancerous. It has been the writer’s privilege to witness
amputation of all of one hand and a large part of the other, in the
case of a well-known colleague, who carried the x-ray treatment to
excess, and until he suffered to this extent. Careful and
discriminating judgment is therefore necessary in the management
of vacuum tubes.
Since radium has come into use it has been found to exercise a
deleterious effect upon the skin. The radium emanations are known
to influence living cells and tissues, and their inhibiting effect upon
the growth of larvae has been well established. The prohibitive price
of radium preparations will make these lesions rare. After exposure
there appears an erythema followed by an active dermatitis, which
so closely resembles lesions above described, in their early stages,
that one description will suffice for both. Moreover, the treatment of a
radium burn differs in no essential respects from that of an x-ray
burn.

ACUTE INFECTIONS OF THE SKIN.

Furuncle or Boil.—A furuncle is a phlegmon having its origin in a
hair follicle and involving a small area of skin
and subcutaneous tissue. The infection is produced by one of the
ordinary pyogenic organisms, which have easy access to the base of
the follicles. Sometimes these organisms are of unusual virulence,
but ordinarily there is a local condition which favors the infection,
while it may be encouraged by a general diathetic condition, such as
diabetes. The lesion is usually single, but may be multiple. Boils
appear sometimes in groups or in crops, and when the condition has
become chronic it is called furunculosis, which may be local or
general. A boil commences as a tender papule, which rapidly
enlarges into a conical swelling, sometimes of considerable size.
Around it there is an area of dusky discoloration, while the apex
becomes quite dark. Pus, travelling in the direction of least
resistance, comes more or less readily to the surface, the apex of
the boil yielding and pus finally escaping, if not evacuated by
incision, usually with a small amount of necrotic tissue, which may
be sufficiently large to justify the term “core.” With the escape of pus
the throbbing pain is much relieved. A furuncle arising in tissues
where swelling is not easily treated, as in the nose, the external
meatus, and also in the axilla and the perineum, will produce an
abnormal amount of pain.
Treatment.—The domestic treatment of boils consists of poultices,
usually made of hot flaxseed. These are always nauseous
applications, and tend to favor the development of similar trouble in
adjoining follicles. An equally comforting application can be made
with a piece of spongiopiline, or a compress, saturated in an
antiseptic solution, and covered with rubber tissues, outside of
which, if necessary, a hot-water bottle may be applied. Inasmuch as
it is tension which produces pain, early incision, which can be made
under a little freezing spray, or with cocaine, will give the greatest
relief. This may be practised even before pus has appeared. After
such incisions the same moist applications may be applied. Incisions
should be made as soon as pus is shown to be present. The
appearance of a whitish point at the apex of the furuncle will always
indicate the presence of pus beneath.
General furunculosis has almost always an underlying diathesis as
a cause, and this should be sought out and treated according to its
nature. In the absence of recognized constitutional conditions the
writer has never found anything equal to aromatic sulphuric acid,
given in 10 or 12-drop doses, with tincture of arnica in teaspoonful
doses, to be freely diluted with water.
Carbuncle.—This differs from a furuncle in the extent of the local
infection, involvement of subcutaneous tissue, and the
amount of necrosis which it produces. It is in most instances a more
serious affair, life often being destroyed by the extent of the resulting
necrosis and the amount of toxins produced. It begins as a local
process, but always with constitutional disturbance, and sometimes
even with a chill. The affected surface rapidly assumes a brawny
hardness, and the infiltration is often extensive; pain is severe and
throbbing; the surface becomes more dusky in appearance,
numerous pustules appear, development of all the features of a
serious carbuncle usually taking place in a few days. Later it begins
to soften and the skin gives way at several points, at each of which a
small drop of pus is discharged, while after removing this there may
be seen white necrotic tissue beneath. The sloughing process
extends deeply, generally to the deep fascia, and this itself
occasionally succumbs. A person may have a distinct carbuncular
lesion where the area primarily involved is not much larger than that
of a five-cent piece; on the other hand, in debilitated or dissipated
subjects, a lesion of this kind may become as large as a dinner plate,
while the sloughing process may expose the underlying bone. This is
often the case on the back of the neck and trunk. A carbuncle may
occur in any part of the body, but is usually seen on the back; when
upon a limb it generally involves the extensor surface. It is especially
serious and dangerous when occurring upon the face, as septic
thrombosis may readily extend to a cranial sinus and rapidly kill. It
was formerly believed that carbuncles of the lip always terminated
fatally; while this is not necessarily true it will indicate the
seriousness of the condition (Figs. 100 and 101).
 Fig. 100

Carbuncle of the neck. (Lexer.)

Treatment.—There are few lesions where both constitutional and

local treatment need to be more judiciously combined. Many of these
patients are diabetic, and then it assumes malignant tendencies.
Others are syphilitics or alcoholics, whom dissipation has reduced to
a condition of serious malnutrition. The urine should always be
examined for sugar and albumin, and whatever indications it may
afford carefully followed. Septic intoxication and infection may so
rapidly depress the already weakened patient as to call for
stimulants and tonics, and pain may be so severe as to justify the
use of anodynes.
The local treatment should consist of soothing applications until
the extent of the plastic exudate has declared itself, after which it
should be more radical. It is better, therefore, to excise under an
anesthetic, the area which ordinarily would require days or weeks to
slough. The most satisfactory treatment is the radical. The knife, the
scissors, and the sharp spoon constitute the best means of
combating this disease. In other respects the treatment was
discussed when dealing with septic infection. Nothing will so hasten
the sloughing and cleaning up process as brewers’ yeast. The
writer’s custom is to make a thorough excision of the affected area
and treat the part with yeast for some days. About the lip and face
the sharp spoon should take the place of the knife, but even there, if
the case be attacked early, tissue can be saved and disfigurement
reduced to a minimum. The method used by some of injecting 5 per
cent. carbolic solution is less satisfactory, although the measure
above recommended is a rather severe operation and usually
requires complete anesthesia.

Fig. 101

Anthrax carbuncle of forearm. (Lexer.)

 CHRONIC INFECTIONS OF THE SKIN.
Tuberculosis.—Most of the skin lesions formerly described as
scrofulous are now known to be expressions of
tuberculosis. So, also, are some of the papillomatous growths and
the chronic ulcers, which do not assume distinctive form.
Lupus vulgaris is perhaps the most common of these cutaneous
lesions, especially in certain parts of the world. It is seen more often
among the young than the old. The lesions begin with a papule,
which becomes the well-known lupus, smaller nodules coalescing
and forming eventually a brownish-red patch, whose borders are
somewhat elevated and scaly. This lesion usually goes on to
ulceration, particularly in those parts of the body where it is kept
moist or frequently irritated. It is in these lesions that a healing or
cicatrizing tendency is seen at one point and progressive ulceration
in another. Ulceration does not always occur, but the papule just
described sometimes undergoes spontaneous absorption, the tissue
atrophying, losing its peculiar skin functions, and the scar being
depressed and scaly.
Lupus vulgaris is to be distinguished from lupus exedens, referred
to under Epithelioma. It is often mistaken for the latter, and a
differential diagnostic table has already been given. (See p. 293.)
Verruca necrogenica, as it used to be called, is now known as
verrucose tuberculosis. It consists of cutaneous warts, surrounded
by an erythematous zone or patch, which tend to break down, and
covered with scabs, intermixed with pustules. The lesion rarely
proceeds to complete ulceration. It occurs especially upon the hands
and exposed parts of those who handle cadavers or carcasses. The
lesion is usually slow and sometimes disappears spontaneously.
On or about the mucocutaneous borders of individuals suffering
from tuberculosis there appear small ulcers, secreting a thin,
puruloid material. These are seen especially about the nose, the
mouth, the anus, and the vulva. These lesions should be regarded
as local infections from a constitutional source. They are often
sensitive, show little tendency to heal, and are sources of danger to
others. They should receive radical treatment.
 Under the term scrofuloderm are included a variety of
subcutaneous tuberculous nodules which spread and involve the
skin. They begin in the superficial lymph nodes. The overlying skin
becomes bluish and gives way, while an ulcer remains which
discharges more or less puruloid material. The edges of these ulcers
are frequently undermined for a considerable distance. These are
ordinarily chronic lesions, which sometimes undergo a spontaneous
recovery, leaving disfiguring and discolored scars, usually irregular
and more or less striped or banded.
Some of the scrofuloderms are included under the erythema
induratum of Bazin, lesions which appear mostly on the calves of the
legs of young women, consisting of deep-seated nodules, which
break down into deep ulcers, having elevated and overhanging
edges. Again, there is the so-called lichen scrofulosorum, i. e., a
papular eruption seen in the young, especially those who show other
evidences of tuberculosis. It consists of rounded groups of papules,
usually on the sides of the trunk, at first bright in color, new papules
appearing as the old ones fade. In addition there is the pustular
scrofuloderm, which crusts over, heals, and leaves small cicatrices.
In all of these lesions the tubercle bacilli can be usually
demonstrated. There are other skin lesions in which no bacilli can be
demonstrated, which are supposed to be due to the toxins generated
in tuberculous foci elsewhere. Hallopeau suggests calling all
tuberculous skin lesions tuberculides and to group them as follows:
(a) Those in which bacilli are present, bacillary tuberculides, and (b)
those arising from tuberculous toxins, toxic tuberculides.
 Fig. 102 Fig. 103

Lupus of skin (hypertrophicus et Lupus vulgaris. (Hardaway.)

exulcerans). Finally healed by excision
and plastic operation. (Lexer.)

Among the latter he describes what he calls folliculitis, i. e., small

papules, firm, at first red, then elevated, becoming nodules,
appearing on the extremities, and gradually producing crater-form
ulcers covered with black crusts, leaving small pock-like scars. This
condition is chronic, lasting years. In these patients the skin is
furfurated, showing a sluggish circulation.
Treatment.—Inasmuch as tuberculous skin lesions tend to spread
and to recur, they need radical treatment—i. e. the sharp spoon, the
scissors, and caustic. Ordinarily it is best to scrape the affected
surface, to trim away all unhealthy edges, and then to apply a strong
caustic for a brief space of time, thereby sterilizing it and searing the