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Paller and Mancini -
Hurwitz Clinical
Pediatric Dermatology
A Textbook of Skin Disorders
of Childhood and Adolescence
SIXTH EDITION
Amy S. Paller, MD Anthony J. Mancini, MD

Walter J. Hamlin Professor and Chair of Dermatology Professor of Pediatrics and Dermatology
Director, Skin Biology and Disease Northwestern University Feinberg School
Resource-Based Center of Medicine
Northwestern University Feinberg School of Head, Division of Pediatric Dermatology
Medicine Director, Fellowship Training Program
Professor of Pediatrics Ann & Robert H. Lurie Children’s Hospital
Ann & Robert H. Lurie Children’s Hospital of Chicago
of Chicago Chicago, Illinois
Chicago, Illinois USA
USA
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
PALLER AND MANCINI – HURWITZ CLINICAL PEDIATRIC DERMATOLOGY, ISBN: 978-0-323-54988-2

SIXTH EDITION
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system, without
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
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contained in the material herein.
Previous editions copyrighted 2016, 2011, 2006, 1993 and 1981.
Library of Congress Control Number: 2020948302
Content Strategist: Charlotta Kryhl

Content Development Specialist: Kathleen Nahm
Content Coordinator: Reina Carmellite F. Cabusao
Project Manager: Janish Paul
Designer: Renee Duenow
Marketing Manager: Aly Abrams
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication
We again dedicate the text to our families,

whose ongoing patience, encouragement, support,
and personal sacrifice enabled us
to complete this project:
To Etahn, Josh, Max, Laura, and Ben, and
to Nicki, Mallory, Christopher, Mackenzie, and
Alexander: thank you.
We also dedicate this sixth edition

to Sidney Hurwitz, MD,
the epitome of a role model in academic
pediatric dermatology.
Preface
Amy S. Paller, MD Anthony J. Mancini, MD
We were truly honored when initially asked to consider updating expanded discussions of mycoplasma-associated disorders and up-
Hurwitz Clinical Pediatric Dermatology. Dr. Hurwitz was a true icon dated sections on congenital syphilis, toxoplasmosis, and pediatric
of our specialty and one of its founding fathers. We have advanced melanoma. A discussion of congenital Zika virus infections has been
this text to be evidence based but full of our tips for the diagnosis added, as have expanded discussions of therapy for infantile heman-
and treatment of pediatric skin diseases in the four editions since giomas, newer approaches for other vascular tumors and malforma-
Dr. Hurwitz “passed the baton” after writing the first and second editions, and the expanding spectrum of genetic mutations and clinical
tions. In this Paller/Mancini text, we have maintained the focus on presentations of vascular disorders and syndromes. We have expanded
educating and enlightening pediatricians, dermatologists, family the discussions of pediatric vasculitides, as well as factitial disorders
practitioners, medical students, residents, fellows, nurses, and other and delusional infestation in children.
allied pediatric care providers with a book that is practical, relevant, Several new tables have been added or updated in this edition, in-
and user friendly in both its online and paper formats. cluding the evaluation of suspected neonatal infection with herpes
What lies between these covers will be familiar but with many addi- simplex virus, a discussion of monitoring for comorbidities in psoriasis,
tions. The field of pediatric dermatology has continued to expand new classifications for ectodermal dysplasias and epidermolysis bullosa
since our last edition. The molecular bases for many established skin that focus on a molecular basis, fixed-dose combination therapies
diseases continue to be elucidated, and several new disease and syn- for acne vulgaris, contraindications to combined oral contraceptives,
drome associations have been described. The therapeutic armamen- clinical features of polycystic ovary syndrome, the RASopathies, gene
tarium for cutaneous disease has broadened, with many new forms of polymorphisms and pigmentation, the epidermal necrolysis classifica-
pathogenesis-based therapy available for patients, including through tion, diagnostic criteria for hemophagocytic lymphohistiocytosis, an
new classes of drugs. We have strived to maintain a book that repre- update on the contemporary classification of pediatric histiocytoses,
sents a balance between narrative text, useful tables, and vivid clinical consensus-derived PHACES syndrome criteria, the updated ISSVA clas-
photographs. sification of vascular anomalies, updated treatment recommendations
Several new features have been added to this sixth edition, includ- for herpes simplex virus infections, revised Jones criteria for acute
ing a downloadable e-book with the printed edition and more than rheumatic fever, and features of juvenile dermatomyositis.
350 new clinical images. We have updated the sections on atopic As with our last edition, the references have again been extensively
dermatitis, psoriasis, connective tissue diseases, and autoinflamma- updated in our companion online edition, leaving only some excellent
tory disorders to reflect our growing armamentarium of new medica- reviews and landmark articles to allow for more complete textual
tions. Our sections on the ichthyoses, hair and ectodermal dysplasias, content for our readers of the print version.
genetic blistering disorders, and mosaic gene disorders have grown We continue to be indebted to several individuals, without whom
based on so many new discoveries of underlying causes. New direc- this work would not have been possible. First and foremost, we thank
tions, such as the use of stem cell and cell therapy, as well as recombi- Dr. Sidney Hurwitz, whose vision, dedication, and enthusiasm for the
nant protein, for treating epidermolysis bullosa are also mentioned. specialty of pediatric dermatology lives on as a legacy in this text, ini-
Our discussion of treatment for pediatric head lice reflects the mul- tially published in 1981. We are indebted to Teddy Hurwitz, his wife,
titude of new therapy options, and we have expanded the discussion who entrusted to us the ongoing tradition of this awesome project; to
of viral exanthematous diseases, including the resurgence in measles Dr. Alvin Jacobs, a “father” of pediatric dermatology, who kindled the
infections and the broadened scope of manifestations related to flame of the specialty in both of us through his teaching at Stanford; to
infection with human herpesviruses and enteroviruses. There are Dr. Nancy B. Esterly, the “mother” of pediatric dermatology, whose
vi
Preface vii
superb clinical acumen and patient care made her the perfect role a daily basis and place their trust in us to provide them care; to the
model for another female physician who yearned to follow in her foot- clinicians who referred many of the patients seen in these pages; to
steps; and to Dr. Alfred T. Lane, who believed in a young pediatric intern our pediatric dermatology fellows (especially Dr. Ayelet Ollech),
and mentored him through the process of becoming a mentor himself. nurses, and office staff (especially Melissa Jones and Giuliana Wells),
We are also indebted to the staff at Elsevier, most notably Charlotta who contributed enormously through assistance with literature
Kryhl, Melissa Rawe, Kathleen Nahm, and Janish Paul, who worked searches and the taking and archiving of our many clinical photo-
tirelessly through this edition to again meet the many demands of two graphs; and to our families, whose understanding, sacrifice, support,
finicky academicians; to our patients, who continue to educate us on and unconditional love made this entire endeavor possible.
Contents
Dedication, v 13 Bullous Disorders of Childhood, 369

Preface, vi
14 Bacterial, Mycobacterial, and Protozoal Infections
1 An Overview of Dermatologic Diagnosis and of the Skin, 391
Procedures, 1
15 Viral Diseases of the Skin, 420
2 Cutaneous Disorders of the Newborn, 11
16 Exanthematous Diseases of Childhood, 444
3 Eczematous Eruptions in Childhood, 42
17 Skin Disorders Caused by Fungi, 467
4 Papulosquamous and Related Disorders, 82
18 Infestations, Bites, and Stings, 497
5 Hereditary Disorders of Cornification
(the Ichthyoses and Palmoplantar 19 Photosensitivity and Photoreactions, 520
Keratodermas), 108 20 Urticarias and Other Hypersensitivity
6 Hereditary Disorders of the Dermis, 139 Disorders, 541
7 Disorders of Hair and Nails, 160 21 Vasculitic Disorders, 572

8 Acne Vulgaris and Other Disorders of the 22 Collagen Vascular Disorders, 588
Sebaceous and Sweat Glands, 205 23 Endocrine Disorders and the Skin, 623
9 Cutaneous Tumors and Tumor Syndromes, 227 24 Inborn Errors of Metabolism, 644
10 Histiocytoses and Malignant Skin Diseases, 268 25 Skin Signs of Other Systemic Diseases, 662
11 Disorders of Pigmentation, 287 26 Abuse and Factitial Disorders, 690
12 Infantile Hemangiomas, Vascular Malformations, Index, 705
and Other Vascular Disorders of Infancy and
Childhood, 326
viii
1 An Overview of Dermatologic
Diagnosis and Procedures
CHAPTER OUTLINE Configuration of Lesions Racial Variations in the Skin and Hair
Distribution and Morphologic Patterns of Procedures to Aid in Diagnosis
Common Skin Disorders Therapeutic Procedures
Changes in Skin Color
Accurate diagnosis of cutaneous disease in infants and children is a Lesions that tend to merge are said to be confluent. Confluence of
systematic process that requires careful inspection, evaluation, and lesions is seen, for example, in childhood exanthems, Rhus dermatitis,
some knowledge of dermatologic terminology and morphology to erythema multiforme, tinea versicolor, and urticaria.
develop a prioritized differential diagnosis. The manifestations of Lesions localized to a dermatome supplied by one or more dorsal
skin disorders in infants and young children often vary from those ganglia are referred to as dermatomal. Herpes zoster classically occurs
of the same diseases in older children and adults. The diagnosis may in a dermatomal distribution.
be obscured, for example, by different reaction patterns or a ten- Discoid is used to describe lesions that are solid, moderately raised,
dency toward easier blister formation. In addition, therapeutic and disc shaped. The term has largely been applied to discoid lupus
dosages and regimens often differ from those of adults, with medi- erythematosus, in which the discoid lesions usually show atrophy and
cations prescribed on a “per kilogram” (/kg) basis and with liquid dyspigmentation.
formulations. Discrete lesions are individual lesions that tend to remain separated
Nevertheless, the same basic principles that are used to detect disor- and distinct. Eczematoid and eczematous are adjectives relating to in-
ders affecting viscera apply to the detection of skin disorders. An ade- flamed, dry skin with a tendency to thickening, oozing, vesiculation,
quate history should be obtained, a thorough physical examination and/or crusting; although atopic dermatitis is a classic eczematous
performed, and, whenever possible, the clinical impression verified by disorder, other examples of eczema are contact, nummular, and dys-
appropriate laboratory studies. The easy visibility of skin lesions all too hidrotic forms.
often results in a cursory examination and hasty diagnosis. Instead, Grouping and clustering are characteristic of vesicles of herpes
the entire skin should be examined routinely and carefully, including simplex or herpes zoster, insect bites, lymphangioma circumscriptum,
the hair, scalp, nails, oral mucosa, anogenital regions, palms, and soles, contact dermatitis, and bullous dermatosis of childhood.
because visible findings often hold clues to the final diagnosis. Guttate or drop-like lesions are characteristic of flares of psoriasis in
The examination should be conducted in a well-lit room. Initial children and adolescents that follow an acute upper respiratory tract
viewing of the patient at a distance establishes the overall status of the infection, usually streptococcal.
patient and allows recognition of distribution patterns and clues to Gyrate refers to twisted, coiled, or spiral-like lesions, as may be seen
the appropriate final diagnosis. This initial evaluation is followed by in patients with urticaria and erythema annulare centrifugum.
careful scrutiny of primary and subsequent secondary lesions in an Iris or target-like lesions are concentric ringed lesions characteristic
effort to discern the characteristic features of the disorder. of erythema multiforme. The classic “targets” in this condition are
Although not always diagnostic, the morphology and configuration composed of a central dusky erythematous papule or vesicle, a periph-
of cutaneous lesions are of considerable importance to the classifica- eral ring of pallor, and then an outer bright red ring.
tion and diagnosis of cutaneous disease. A lack of understanding of Keratosis refers to circumscribed patches of horny thickening, as
dermatologic terminology commonly poses a barrier to the description seen in seborrheic or actinic keratoses, keratosis pilaris, and keratosis
of cutaneous disorders by clinicians who are not dermatologists. Ac- follicularis (Darier disease). Keratotic is an adjective pertaining to kera-
cordingly, a review of dermatologic terms is included here (Table 1.1). tosis and commonly refers to the epidermal thickening seen in chronic
The many examples to show primary and secondary skin lesions refer dermatitis and callus formation.
to specific figures in the text that follows. The Koebner phenomenon or isomorphic response refers to the appear-
ance of lesions along a site of injury. The linear lesions of warts and
molluscum contagiosum, for example, occur from autoinoculation of
Configuration of Lesions virus from scratching; those of Rhus dermatitis (poison ivy) result from
the spread of the plant’s oleoresin. Other examples of disorders that
A number of dermatologic entities assume annular, circinate, or ring show a Koebner phenomenon are psoriasis, lichen planus, lichen niti-
shapes and are interpreted as ringworm or superficial fungal infections. dus, pityriasis rubra pilaris, and keratosis follicularis (Darier disease).
Although tinea is a common annular dermatosis of childhood, there Lesions in a linear or band-like configuration appear in the form of
are multiple other disorders that must be included in the differential a line or stripe and may be seen in epidermal nevi, Conradi syndrome,
diagnosis of ringed lesions, including pityriasis rosea, seborrheic der- linear morphea, lichen striatus, striae, Rhus dermatitis, deep mycoses
matitis, nummular eczema, lupus erythematosus, granuloma annu- (sporotrichosis or coccidioidomycosis), incontinentia pigmenti, pig-
lare, annular psoriasis, erythema multiforme, erythema annulare ment mosaicism, porokeratosis of Mibelli, or factitial dermatitis. In
centrifugum, erythema migrans, secondary syphilis, sarcoidosis, urti- certain genetic and inflammatory disorders, such linear configura-
caria, pityriasis alba, tinea versicolor, lupus vulgaris, drug eruptions, tions represent the lines of Blaschko, which trace clones of embryonic
and cutaneous T-cell lymphoma. epidermal cells and, as such, represent a form of cutaneous mosa-
The terms arciform and arcuate refer to lesions that assume arc-like icism. This configuration presents as a linear pattern on the extremi-
configurations. Arciform lesions may be seen in erythema multiforme, ties, wavy or S-shaped on the lateral trunk, V-shaped on the central
urticaria, pityriasis rosea, bullous dermatosis of childhood, and some- trunk, and varied patterns on the face and scalp.
times epidermolysis bullosa simplex. Text continued on p. 7
2 1 • An Overview of Dermatologic Diagnosis and Procedures
Table 1.1 Glossary of Dermatologic Terms

Lesion Description Illustration Examples
PRIMARY LESIONS
The term primary refers to the most representative, but not necessarily the earliest, lesions; it is distinguished from the cutaneous features of
secondary changes such as excoriation, eczematization, infection, or results of previous therapy.
Macule Flat, circumscribed change of the skin. It Ephelides; lentigo (see Fig. 11.45);
may be of any size, although this term is flat nevus (see Fig. 9.1); and tinea
often used for lesions ,1 cm. A macule may versicolor (see Fig. 17.40)
appear as an area of hypopigmentation or
as an area of increased coloration, most
commonly brown (hyperpigmented) or red
(usually a vascular abnormality). It is usually
round but may be oval or irregular; it may
be distinct or may fade into the
surrounding area.
Patch Flat, circumscribed lesion with color Congenital dermal melanocytosis

change that is .1 cm in size. (see Fig. 11.65); port wine stain (see
Fig. 12.63); nevus depigmentosus
(see Fig. 11.24); larger café-au-lait
spot (see Fig. 11.49); and areas
of vitiligo (see Figs. 11.2–11.10)
Papule Circumscribed, nonvesicular, Elevated nevus (see Fig. 9.4);

nonpustular, elevated lesion that verruca (see Fig. 15.20);
measures ,1 cm in diameter. The molluscum contagiosum (see
greatest mass is above the surface of the Fig. 15.40); perioral dermatitis
skin. When viewed in profile, it may be (see Fig. 8.23); and individual
flat topped, dome shaped, acuminate lesions of lichen planus (see
(tapering to a point), digitate (finger- Fig. 4.54)
like), smooth, eroded, or ulcerated. It
may be covered by scales, crusts, or a
combination of secondary features.
Plaque Broad, elevated, disk-shaped lesion that Psoriasis (see Fig. 4.6); lichen
occupies an area of .1 cm. It is commonly simplex chronicus
formed by a confluence of papules. (neurodermatitis, see Fig. 3.43);
granuloma annulare (see Fig. 9.62);
nevus sebaceus (see 9.43–9.46);
and lesions of lichen planus
(see Fig. 4.55)
1 • An Overview of Dermatologic Diagnosis and Procedures 3
wTable 1.1 Glossary of Dermatologic Terms (Continued)

Nodule Circumscribed, elevated, usually solid Erythema nodosum (see
lesion that measures 0.5–2 cm in Fig. 20.45); pilomatricoma (see
diameter. It involves the dermis and may Figs. 9.50 and 9.51);
extend into the subcutaneous tissue subcutaneous granuloma
with its greatest mass below the surface annulare (see Fig. 9.64); and
of the skin. nodular scabies (see
Figs. 18.9 and 18.10)
Tumor Deeper circumscribed solid lesion of Deep hemangioma (see Fig. 12.8)
the skin or subcutaneous tissue that and plexiform neurofibroma
measures .2 cm in diameter. It may be (see Fig. 11.56)
benign or malignant.
Wheal Distinctive type of elevated lesion Darier sign of mastocytosis (see

characterized by local, superficial, Fig. 9.59); urticarial vasculitis (see
transient edema. White to pink or pale Fig. 21.15); and various forms of
red, compressible, and evanescent, they urticaria (see Figs. 20.2–20.7)
often disappear within a period of hours.
They vary in size and shape.
Vesicle Sharply circumscribed, elevated, fluid- Herpes simplex (see Figs. 15.8
containing lesion that measures #1 cm and 15.12); hand-foot-and-
in diameter. mouth disease (see Fig. 16.32);
pompholyx (see Fig. 3.47);
varicella (see Fig. 16.1);
and contact dermatitis
(see Fig. 3.65, B)
Continued on following page
Table 1.1 Glossary of Dermatologic Terms (Continued)

Bulla Larger, circumscribed, elevated, fluid- Blistering distal dactylitis (see
containing lesion that measures .1 cm Fig. 14.22); bullous pemphigoid
in diameter. (see Fig. 13.33); chronic bullous
disease of childhood (see
Fig. 13.37); bullous flea bite
reaction (see Figs. 18.33 and
18.34); and epidermolysis bullosa
(see Fig. 13.4)
Pustule Circumscribed elevation ,1 cm Folliculitis (see Fig. 14.11); transient

in diameter that contains a purulent neonatal pustular melanosis (see
exudate. It may be infectious or sterile. Fig. 2.22); pustular psoriasis (see
Fig. 4.30); and neonatal cephalic
pustulosis (see Fig. 2.16), neonatal
S. aureus pustulosis (see Fig. 2.21),
and infantile acropustulosis (see
Fig. 2.24)
Abscess Circumscribed, elevated lesion .1 cm Staphylococcal abscess (in a

in diameter, often with a deeper neonate, see Fig. 2.5; in a patient
component and filled with purulent with hyperimmunoglobulinemia
material. E, see Fig. 3.41)
OTHER PRIMARY LESIONS

Comedone Plugged secretion of horny material Acne comedones (see Figs. 8.3
retained within a pilosebaceous follicle. It and 8.4) and nevus comedonicus
may be flesh colored (as in closed (see Fig. 9.47)
comedone or whitehead) or slightly raised
brown or black (as in open comedone or
blackhead). Closed comedones, in
contrast to open comedones, may be
difficult to visualize. They appear as pale,
slightly elevated, small papules without a
clinically visible orifice.
Burrow Linear lesion produced by tunneling of Scabies (see Fig. 18.3) and
an animal parasite in the stratum cutaneous larva migrans
corneum. (creeping eruption, see Fig. 18.41)
Telangiectasia Persistent dilation of superficial venules, Spider angioma (see Fig. 12.97);
capillaries, or arterioles of the skin. periungual lesion of
dermatomyositis (see Figs. 22.26
and 22.29); CREST syndrome (see
Fig. 22.45); and focal dermal
hypoplasia (see Fig. 6.18)

SECONDARY LESIONS
Secondary lesions represent evolutionary changes that occur later in the course of the cutaneous disorder. Although helpful in dermatologic
diagnosis, they do not offer the same degree of diagnostic aid as that afforded by primary lesions of a cutaneous disorder.
Crust Dried remains of serum, blood, pus, or Herpes simplex (see Fig. 15.5);
exudate overlying areas of lost or weeping eczematous dermatitis
damaged epidermis. Crust is yellow (see Fig. 3.1); and dried
when formed by dried serum, green honey-colored lesions of
or yellowish-green when formed by impetigo (see Fig. 14.1)
purulent exudate, and dark red or
brown when formed by bloody
exudative serum.
Scale Formed by an accumulation of compact Seborrheic dermatitis (greasy

desquamating layers of stratum and yellowish, see Fig. 3.3);
corneum as a result of abnormal psoriasis (silvery and mica-like,
keratinization and exfoliation of see Fig. 4.1); lichen striatus (fine
cornified keratinocytes. and adherent, see Fig. 3.52); and
lamellar ichthyosis (large and
adherent, see
Fig. 5.16)
Fissure Dry or moist, linear, often painful Angular cheilitis (see Fig. 17.46)
cleavage in the cutaneous surface that and dermatitis on the palmar
results from marked drying and long- aspect of the fingers (see
standing inflammation, thickening, and Fig. 3.58) or the plantar aspect
loss of elasticity of the integument. of the foot (see Fig. 3.69)
Erosion Moist, slightly depressed vesicular or Herpes simplex (see Figs. 3.31
bullous lesions in which part or all of and 15.3); epidermolytic
the epidermis has been lost. Because ichthyosis in a neonate (see
erosions do not extend into the Fig. 5.6); and superficial forms of
underlying dermis or subcutaneous epidermolysis bullosa (see
tissue, healing occurs without Fig. 13.5)
subsequent scar formation.
Continued on following page

Excoriation Traumatized or abraded (usually self- Atopic dermatitis (see Fig. 3.9)
induced) superficial loss of skin caused and acne excoriée (see
by scratching, rubbing, or scrubbing of Fig. 8.22)
the cutaneous surface.
Ulcer Necrosis of the epidermis and part or all Pyoderma gangrenosum (see
of the dermis and/or the underlying Fig. 25.18) and ulcerated
subcutaneous tissue. hemangioma of infancy (see
Figs. 12.15 and 12.26)
Atrophy Cutaneous changes that result in Anetoderma (see Fig. 22.63);

depression of the epidermis, dermis, or morphea (see 22.54 and 22.56);
both. Epidermal atrophy is characterized steroid-induced atrophy (see Fig.
by thin, almost translucent epidermis, a 3.36); and focal dermal
loss of the normal skin markings, and hypoplasia (see Fig. 6.19)
wrinkling when subjected to lateral
pressure or pinching of the affected
area. In dermal atrophy, the skin is
depressed.
Lichenification Thickening of the epidermis with Atopic dermatitis (see Fig. 3.8);
associated exaggeration of skin chronic contact dermatitis (see
markings. Lichenification results Fig. 3.61, B); and lichen simplex
from chronic scratching or rubbing chronicus (see Fig. 3.43)
of a pruritic lesion.

Scar A permanent fibrotic skin change that Keloid (see Fig. 9.93); healed
develops after damage to the dermis. areas of recessive dystrophic
Initially pink or violaceous, scars are epidermolysis bullosa (see
permanent, white, shiny, and sclerotic as Fig. 13.26); post-hemangioma
the color fades. Although fresh scars often scarring (see Fig. 12.21);
are hypertrophic, they usually contract congenital erosive and vesicular
during the subsequent 6–12 months dermatosis with reticulated
and become less apparent. Hypertrophic supple scarring (see Fig. 2.21, B);
scars must be differentiated from keloids, and amniocentesis scars (see
which represent an exaggerated response Fig. 2.4)
to skin injury. Keloids are pink, smooth,
and rubbery and are often traversed by
telangiectatic vessels. They tend to
increase in size long after healing has
taken place and can be differentiated from
hypertrophic scars by the fact that the
surface of a keloidal scar tends to extend
beyond the area of the original wound.
Moniliform refers to a banded or necklace-like appearance. This is vertebrae. The fifth cranial nerve commonly is involved, and only
seen in monilethrix, a hair deformity characterized by beaded nodu- rarely are lesions seen below the elbows or knees.
larities along the hair shaft. Lichen planus often affects the limbs (see Figs. 4.54, 4.55, and
Multiform refers to disorders in which more than one variety or shape 4.58). Favorite sites include the lower extremities, the flexor surface of
of cutaneous lesions occurs. This configuration is seen in patients with the wrists, the buccal mucosa, the trunk, and the genitalia.
erythema multiforme, urticaria multiforme, early Henoch–Schönlein The lesions of lupus erythematosus most commonly localize to the
purpura, and polymorphous light eruption. bridge of the nose, malar eminences, scalp, and ears, although they
Nummular means coin shaped and is usually used to describe num- may be widespread (see Figs. 22.3 and 22.4). Patches tend to spread
mular dermatitis. at the border and clear in the center with atrophy, scarring, dyspig-
Polycyclic refers to oval lesions containing more than one ring, as mentation, and telangiectases. The malar or butterfly rash is neither
commonly is seen in patients with urticaria. specific for nor the most common sign of lupus erythematosus; telan-
A reticulated or net-like pattern may be seen in erythema ab igne, giectasia without the accompanying features of erythema, scaling,
livedo reticularis, cutis marmorata, cutis marmorata telangiectatica or atrophy is never a marker of this disorder other than in neonatal
congenita, and lesions of confluent and reticulated papillomatosis. lupus.
Serpiginous describes the shape or spread of lesions in a serpentine Molluscum contagiosum is a common viral disorder characterized
or snake-like configuration, particularly those of cutaneous larva by dome-shaped, skin-colored to erythematous papules, often with a
migrans (creeping eruption) and elastosis perforans serpiginosa. central white core or umbilication (see Figs. 15.41 through 15.47).
Umbilicated lesions are centrally depressed or shaped like an umbi- These papules most often localize to the trunk and axillary areas. Al-
licus or navel. Examples include lesions of molluscum contagiosum, though molluscum lesions can be found anywhere, the scalp, palms,
varicella, vaccinia, variola, herpes zoster, and Kaposi varicelliform and soles are rare sites of involvement.
eruption. Photodermatoses are cutaneous disorders caused or precipitated by
Universal (universalis) implies widespread disorders affecting the exposure to light. Areas of predilection include the face, ears, anterior
entire skin, as in alopecia universalis. V of the neck and upper chest, dorsal aspect of the forearms and
Zosteriform describes a linear arrangement along a nerve, as typified hands, and exposed areas of the legs. The shaded regions of the upper
by lesions of herpes zoster, although herpes simplex infection can also eyelids, subnasal, and submental regions tend to be spared. The major
manifest in a zosteriform distribution. photosensitivity disorders are lupus erythematosus, dermatomyositis,
polymorphous light eruption, drug photosensitization, phototoxic
reactions, and porphyria (see Chapter 19).
Distribution and Morphologic Patterns Photosensitive reactions cannot be distinguished on a clinical basis
of Common Skin Disorders from lesions of photocontact allergic conditions. They may reflect in-
ternal as well as external photoallergens and may simulate contact
The regional distribution and morphologic configuration of cutane- dermatitis from airborne sensitizers. Lupus erythematosus can be dif-
ous lesions are often helpful in dermatologic diagnosis. ferentiated by the presence of atrophy, scarring, hyperpigmentation or
Acneiform lesions are those having the form of acne, and an acne- hypopigmentation, and periungual telangiectases. Dermatomyositis
iform distribution refers to lesions primarily seen on the face, neck, with swelling and erythema of the cheeks and eyelids should be dif-
chest, upper arms, shoulders, and back (see Figs. 8.3 through 8.8). ferentiated from allergic contact dermatitis by the heliotrope hue and
Sites of predilection of atopic dermatitis include the face, trunk, and ex- other associated changes, particularly those of the fingers (periungual
tremities in young children; the antecubital and popliteal fossae are the most telangiectases and Gottron papules).
common sites in older children and adolescents (see Figs. 3.1 through 3.11). Pityriasis rosea begins as a solitary round or oval scaling lesion known
The lesions of erythema multiforme may be widespread but have a as the herald patch in 70% to 80% of cases, which may be annular and is
distinct predilection for the hands and feet (particularly the palms and often misdiagnosed as tinea corporis (see Fig. 4.49). After an interval of
soles) (see Figs. 20.35 through 20.37). days to 2 weeks, affected individuals develop a generalized symmetric
Lesions of herpes simplex may appear anywhere on the body but eruption that involves mainly the trunk and proximal limbs. The clue to
have a distinct predisposition for the areas about the lips, face, and diagnosis is the distribution of lesions, with the long axis of these oval le-
genitalia (see Figs. 15.1 through 15.14). Herpes zoster generally has sions parallel to the lines of cleavage in what has been termed a Christmas-
a dermatomal or nerve-like distribution and is usually but not neces- tree pattern (see Figs. 4.50, 4.51, and 4.53). A common variant, inverse
sarily unilateral (see Figs. 15.15 through 15.17). More than 75% pityriasis rosea, often localizes in the inguinal region (see Fig. 4.52), but
of cases occur between the second thoracic and second lumbar the parallel nature of the long axis of lesions remains characteristic.
Psoriasis classically consists of round, erythematous, well-marginated more typical of postinflammatory hypopigmentation, pityriasis alba,
plaques with a rich red hue covered by a characteristic grayish or tinea versicolor, leprosy, nevus achromicus, tuberous sclerosis, and
silvery-white mica-like (micaceous) scale that on removal may result the hypopigmented streaks of pigment mosaicism. A generalized de-
in pinpoint bleeding (Auspitz sign) (see Figs. 4.1 through 4.16). crease in pigmentation can be seen in patients with albinism, un-
Although exceptions occur, lesions generally are seen in a bilaterally treated phenylketonuria, and Menkes syndrome. The skin of patients
symmetric pattern with a predilection for the elbows, knees, scalp, and with Chédiak–Higashi and Griscelli syndromes takes on a dull silvery
lumbosacral, perianal, and genital regions. Nail involvement, a valu- sheen and may show decreased pigmentation.
able diagnostic sign, is characterized by pitting of the nail plate, discol-
oration, separation of the nail from the nailbed (onycholysis), and an
accumulation of subungual scale (subungual hyperkeratosis). A Racial Variations in the Skin and Hair
characteristic feature of this disorder is the Koebner or isomorphic
response in which new lesions appear at sites of local injury. The skin of Black and other darker-skinned children varies in several
Scabies is an itchy disorder in which lesions are characteristically ways from that of lighter-skinned children based on genetic back-
distributed on the wrists and hands (particularly the interdigital ground and customs (see Chapter 11). The erythema of inflamed
webs), forearms, genitalia, areolae, and buttocks in older children and black skin may be difficult to see and likely accounts for the purport-
adolescents (see Figs. 18.1 through 18.12). Other family members edly decreased incidence of macular viral exanthems such as ery-
may be similarly affected or complain of itching. In infants and young thema infectiosum. Erythema in Black children commonly has a
children, the diagnosis is often overlooked because the distribution purplish tinge that can be confusing to unwary observers. The skin
typically involves the palms, soles, and often the head and neck. Oblit- lesions in several inflammatory disorders such as in atopic dermatitis,
eration of demonstrable primary lesions (burrows) because of vigor- pityriasis rosea, and syphilis commonly show a follicular pattern in
ous hygienic measures, excoriation, crusting, eczematization, and Black children.
secondary infection is particularly common in infants. Postinflammatory hypopigmentation and hyperpigmentation oc-
Seborrheic dermatitis is an erythematous, scaly or crusting erup- cur readily and are more obvious in darker-skinned persons, regard-
tion that characteristically occurs on the scalp, face, and postauricu- less of racial origin. Pityriasis alba and tinea versicolor are more
lar, presternal, and intertriginous areas (see Figs. 3.3, 3.44, and commonly reported in darker skin types, perhaps because of the easy
3.45). The classic lesions are dull, pinkish-yellow, or salmon colored visibility of the hypopigmented lesions in marked contrast to unin-
with fairly sharp borders and overlying yellowish greasy scale. Mor- volved surrounding skin. Lichen nitidus is more apparent and report-
phologic and topographic variants occur in many combinations and edly more common in Black individuals; lichen planus is reported to
with varying degrees of severity from mild involvement of the scalp be more severe, leaving dark postinflammatory hyperpigmentation.
with occasional blepharitis to generalized, occasionally severe ery- Vitiligo is particularly distressing to patients with darker skin types,
thematous scaling eruptions. The differential diagnosis may include whether Black or Asian, because of the easy visibility in contrast with
atopic dermatitis, psoriasis, various forms of diaper dermatitis, Lang- surrounding skin.
erhans cell histiocytosis, scabies, tinea corporis or capitis, pityriasis Although darker skin may burn, sunburn and chronic sun-induced
alba, contact dermatitis, Darier disease, and lupus erythematosus. diseases of adults such as actinic keratosis and carcinomas of the skin
Warts are common viral cutaneous lesions characterized by the ap- induced by ultraviolet light exposure (e.g., squamous cell carcinoma,
pearance of skin-colored small papules of several morphologic types keratoacanthoma, basal cell carcinoma, and melanoma) generally
(see Figs. 15.19 through 15.37). They may be elevated or flat lesions have an extremely low incidence in Blacks and Hispanics. Congenital
and tend to appear in areas of trauma, particularly the dorsal surface melanocytic nevi also tend to have a lower tendency to transform to
of the face, hands, periungual areas, elbows, knees, feet, and genital malignancy in darker-skinned individuals. Café-au-lait spots are more
or perianal areas. Close examination may reveal capillaries appearing numerous and seen more often in Blacks, although the presence of six
as punctate dots scattered on the surface. or more should still raise suspicion about neurofibromatosis. Derma-
tosis papulosa nigra commonly develop in adolescents, especially
those who are female, of African descent. Mongolian spots occur more
Changes in Skin Color often in persons of African or Asian descent. Physiologic variants in
children with darker skin include increased pigmentation of the gums
The color of skin lesions commonly assists in making the diagnosis and tongue, pigmented streaks in the nails, and Voigt–Futcher lines,
(see Chapter 11). Common disorders of brown hyperpigmentation lines of pigmentary demarcation between the posterolateral and
include postinflammatory hyperpigmentation, pigmented and epi- lighter anteromedial skin on the extremities.
dermal nevi, café-au-lait spots, lentigines, incontinentia pigmenti, Qualities of hair may also differ among individuals of different
fixed drug eruption, photodermatitis and phytophotodermatitis, me- races. Black hair tends to tangle when dry and becomes matted when
lasma, acanthosis nigricans, and Addison disease. Blue coloration is wet. As a result of its naturally curly or spiral nature, pseudofolliculi-
seen in congenital dermal melanocytosis, blue nevi, nevus of Ito and tis barbae is more common in Blacks than in other groups. Tinea ca-
nevus of Ota, and cutaneous neuroblastomas. Cysts, deep hemangio- pitis is particularly common in prepubertal Blacks; the tendency to
mas, and pilomatricomas often show a subtle blue color, whereas the use oils because of hair dryness and poor manageability may obscure
blue of venous malformations and glomuvenous malformations is the scaling of tinea capitis. Pediculosis capitis, in contrast, is rela-
often a more intense, dark blue. Yellowish discoloration of the skin tively uncommon in this population, possibly related to the diameter
is common in infants, related to the presence of carotene derived and shape of the hair shaft. Prolonged continuous traction on hairs
from excessive ingestion of foods, particularly yellow vegetables con- may result in traction alopecia, particularly with the common prac-
taining carotenoid pigments. Jaundice may be distinguished from tice of making tight cornrow braids. The use of other hair grooming
carotenemia by scleral icterus. Localized yellow lesions may repre- techniques such as chemical straighteners, application of hot oils,
sent juvenile xanthogranulomas, nevus sebaceous, xanthomas, or and hot combs increases the risk of hair breakage and permanent
mastocytomas. Red lesions are usually vascular in origin, such as alopecia. Frequent and liberal use of greasy lubricants and pomades
superficial hemangiomas, spider telangiectases, and nevus flammeus produces a comedonal and sometimes papulopustular form of acne
(capillary malformations), or inflammatory, such as the scaling (pomade acne).
lesions of atopic dermatitis or psoriasis. Keloids form more often in individuals of African descent, often as
Localized lesions with decreased pigmentation may be hypopig- a complication of a form of inflammatory acne, including nodulocys-
mented (decreased pigmentation) or depigmented (totally devoid of tic acne and acne keloidalis nuchae. Other skin disorders reportedly
pigmentation); Wood lamp examination may help to differentiate seen more commonly are transient neonatal pustular melanosis, in-
depigmented lesions, which fluoresce a bright white, from hypopig- fantile acropustulosis, impetigo, papular urticaria, sickle cell ulcers,
mented lesions. Localized depigmented lesions may be seen in vitiligo, sarcoidosis, and dissecting cellulitis of the scalp. Atopic dermatitis
Vogt–Koyanagi syndrome, halo nevi, chemical depigmentation, pie- and Kawasaki disease have both been reported most often in children
baldism, and Waardenburg syndrome. Hypopigmented lesions are of Asian descent.
Hair plucks tend to be traumatic for children and often cause

Procedures to Aid in Diagnosis hair shaft distortion, but gentle-traction hair pulling yields hair
that is appropriate for determining whether alopecia areata is still
BETTER VISUALIZATION active (hair-pull test) and for microscopic evaluation of the telogen
Although most lesions are diagnosed by clinical inspection, several bulbs of telogen effluvium and the distorted bulb and ruffled cuti-
techniques are used to aid in diagnosis. The Wood lamp (black light) is cle of loose anagen syndrome (see Chapter 7). Cutting the hair
an ultraviolet A (UVA)-emitting device with a peak emission of 365 nm. shafts may suffice for seeking hair shaft abnormalities via a micro-
With the room completely dark and the light held approximately scopic trichogram (which may require polarizing light such as to
10 cm from the skin, the examiner can see (1) more subtle differences detect trichothiodystrophy) and detecting nits of pediculosis versus
in pigmentation and the bright whiteness of vitiligo lesions based on hair casts (see Chapter 18).
the strong absorbance of the light by melanin, and (2) characteristic Patch testing is key to determining or confirming triggers of delayed-
fluorescence of organisms such as the pink-orange fluorescence of type hypersensitivity reactions in children with allergic contact derma-
urine in porphyria (see Chapter 19), the coral red fluorescence of ery- titis (see Chapter 3). Round aluminum (Finn) chambers are taped to
thrasma, the yellow-orange fluorescence of tinea versicolor, the green the back for 48 hours, and reactions are detected immediately after
fluorescence of ectothrix types of tinea capitis (e.g., Microsporum) (see removal and generally twice thereafter to capture late reactivity. Al-
Chapter 17), and sometimes Pseudomonas infection. False-positive as- though a ready-to-apply system is available (TRUE test), many impor-
sessments can result from detection of other fluorescent objects, such tant potential allergens are missing; thus expanded testing is often
as lint, threads, scales, and ointments. necessary to comprehensively evaluate possible triggers and is usually
Diascopy involves pressing a glass microscope slide firmly over a le- best performed by dermatologists who have expertise in patch testing
sion and watching for changes in appearance. Purpura, which does more comprehensively.
not blanch with diascopy because the erythrocytes have leaked into Although swabs of mucosae and of purulent skin material are ap-
tissue, can be distinguished from erythema caused by vasodilation, propriate for microbial cultures, obtaining biopsy material for special
which blanches because the pressure from the slides forces the eryth- stains and cultures of suspected deep fungal or mycobacterial infec-
rocytes to move out of the compressed vessels. The yellow-brown tions is better for pathogen detection (see Therapeutic Procedures
(“apple jelly”) color of granulomatous lesions (e.g., granuloma an- section). Biopsies are also important for making a diagnosis based on
nulare, sarcoidosis) persists during diascopy, and the constricted blood routine histopathologic, immunofluorescent, and/or immunohisto-
vessels of nevus anemicus blend in with surrounding skin during di- chemical evaluation. For example, immunofluorescent testing is used
ascopy and do not refill when the slide is lifted after diascopy (as do the to delineate the level of cleavage and absent skin proteins in epider-
surrounding normal areas). molysis bullosa (see Chapter 13), as well as to define the immune de-
Magnification using a lens or lighted devices such as the otoscope, posits and patterning in immunobullous disorders (see Chapter 13)
ophthalmoscope, or dermatoscope can be used to more easily visual- and Henoch–Schönlein purpura (see Chapter 21); in contrast, im-
ize lesions such as nailfold capillaries, especially after swabbing the munohistochemistry is important for confirming the diagnosis of
skin with alcohol or applying a drop of oil.1,2 Indeed, dermoscopy (also Langerhans cells in histiocytosis (see Chapter 10) and a variety of
known as dermatoscopy or epiluminescence microscopy) refers to ex- cutaneous lymphoproliferative disorders. Clinicopathologic correla-
amination of the skin with a dermatoscope, a handheld magnifier tion is important, however, and the pathologic result should be ques-
with an embedded light source. Dermoscopy provides more than just tioned (or repeated) if not consistent with clinical findings.
magnification, because it allows the viewer to visualize dermal diag-
nostic clues. In pediatric patients, dermoscopy can be particularly
useful for reassurance regarding the benign nature of pigmented Therapeutic Procedures
nevi,3 visualization of vascular lesions, and hair disorders ranging
from shaft defects to alopecia areata.4–8 Reflectance confocal micros- The most common therapeutic procedures in pediatric dermatology
copy9–11 is a noninvasive technology for in vivo imaging of skin at are (1) treatment of warts with cryotherapy, (2) treatment of mollus-
nearly histologic resolution. Although largely used currently to dis- cum with cantharidin or curettage, (3) lesional biopsy or excision, and
tinguish benign lesions from skin cancer, it has also been used to (4) laser therapy. These techniques should only be performed by
identify skin accumulation of cysteine for diagnosis of infantile ne- trained, experienced practitioners. Phototherapy with ultraviolet B
phropathic cystinosis.12 (UVB) light, narrow-band UVB, and UVA/UVA1 light is used occasion-
Several diagnostic techniques involve procedures to obtain scales or ally in children and is discussed in Chapter 19.
discharge (by scraping or swabbing) for analysis. Scraping can be Cryotherapy involves the application of liquid nitrogen to lesional
performed with a sterile surgical blade, Fomon blade, or even less skin, which causes direct injury. It is most commonly used for warts
costly small metal spatula. An endocervical brush (Cytobrush)13 or (see Chapter 15) but can be selectively applied to keloids and mollus-
moistened swab can be used for obtaining scales and broken hairs for cum contagiosum. Although spray delivery is possible, application
fungal cultures and may be less frightening for young children (see with a cotton swab that is adapted with extra cotton to fit the size of
Chapter 17). Vesicular lesions can be scraped for Tzanck smears and the lesion allows better retention of the liquid nitrogen, provides bet-
obtaining epidermal material for direct fluorescent analysis and viral ter avoidance of nonlesional skin, and is less frightening for young
(primarily herpes) cultures or to show the cellular content such as children. More pedunculated lesions (or filiform warts) can be treated
eosinophils in the vesicular lesions of incontinentia pigmenti. Poten- by grasping the lesion with a forceps and freezing the forceps close
tial scabies lesions, especially burrows, can be dotted with mineral oil to the lesion rather than the lesion directly. Generally, freezing is
and scraped vigorously for microscopic analysis, which may reveal live performed until there is a white ring around the lesion, often with two
mites, eggs, or feces (see Chapter 18). When looking for superficial to three freeze-thaw cycles. Cryotherapy is painful and as a result is
fungi, both potassium hydroxide (KOH) wet-mount preparations and generally reserved for children 8 years of age and older. Alternative
cultures are often performed, although KOH examination should be cryotherapy agents that contain dimethyl ether or chlorodifluoro-
performed in a Clinical Laboratory Improvement Amendments methane achieve temperatures considerably warmer than liquid
(CLIA)-approved setting (see Chapter 17). For skin lesions, the blade or nitrogen and are not as effective. Potential complications include
Cytobrush should scrape the active lesional border. For possible tinea hypopigmentation and atrophic scarring.
capitis, it is important to obtain broken (infected) hairs and scales. The Cantharidin is an extract from the blister beetle, Cantharis vesicatoria,
Cytobrush technique has been shown to be more effective than scrap- that leads to epidermal vesiculation after application to molluscum
ing,13 and vigorously rubbing with a moistened cotton swab (either contagiosum lesions (see Chapter 15). Although traditionally requir-
with tap water or the Culturette transport medium) before inoculation ing compounding and administration using a wooden applicator, a
into fungal culture medium is well tolerated, easy, and reliable. Nail single-use applicator with cantharidin is in development. Because the
scrapings and subungual debris can also be obtained for evaluation; extent of blistering cannot be controlled (with some children develop-
nail clippings can be sent for histopathologic evaluation with special ing extensive blisters and others virtually none), lesions near the eyes,
stains to demonstrate fungal elements. on mucosae, and near other sensitive areas should not be treated with
cantharidin. In addition, lesions should not be occluded. Blistering Light amplifications by stimulated emission of radiation (lasers)
occurs in 24 to 48 hours, and crusting clears within about a week. produce intense light energy at a specific wavelength that can be emit-
Associated discomfort is variable, but application is painless. ted as a pulse or continuous wave to target tissue components for de-
Curettage is a scraping technique used most commonly after topical struction. After absorption of the light, heat is generated and the target
anesthetic application for physical removal of molluscum contagio- tissue is selectively destroyed. This process of selective destruction has
sum, especially for larger lesions for which cantharidin is less effective. been called selective photothermolysis and carries the benefit of destruc-
Curettage can also be used after electrodesiccation (with a hyfrecator) tion of the target chromophores (substances that absorb specific wave-
to remove the desiccated tissue, most commonly for removal of a pyo- lengths of light) with minimal damage to surrounding tissues.13
genic granuloma (see Chapter 12). Many pediatric dermatologists By far the most common laser used in children is the pulsed-dye laser
avoid the use of curettage in younger patients, given the associated (PDL; wavelength 585 to 595 nm), which targets hemoglobin and is used
discomfort. for a variety of vascular lesions, including capillary malformations (port
Biopsies and excisions are performed in pediatric patients as inter- wine stains, salmon patches), macular (flat) infantile hemangiomas, ul-
vention, not just for diagnosis. The decision to remove a lesion thera- cerated hemangiomas (in which case it helps speed reepithelialization),
peutically should be based on the indication and urgency for removal, spider telangiectasias, and even small pyogenic granulomas. PDL has also
the age and maturity of the pediatric patient, the location, and the been used (with more variable response) for inflammatory linear verru-
expected cosmetic result. Careful explanation of the procedure to the cous epidermal nevus, erythematous striae, warts14,15, acne,16 and even
parents and child is important to allay concerns and manage expecta- some inflammatory dermatoses such as psoriasis and eczema.
tions. If possible, the area to be biopsied, excised, or injected with an- The response of a port wine stain to PDL therapy is variable and
esthesia can be treated initially with a topical anesthetic cream (e.g., may depend on the depth of the dermal capillaries, location of the
4% lidocaine or 2.5% lidocaine/2.5% prilocaine) under a clear occlu- stain (e.g., central facial stains classically respond less to PDL therapy
sive film (e.g., waterproof transparent dressing [Tegaderm] or Glad than lesions on the forehead or peripheral face, in part likely related to
Press’n Seal wrap, which adheres more effectively than traditional the more superficial depth of laterally located dilated capillaries),17
plastic cling wrap). Buffering the lidocaine with sodium bicarbonate size of the stain, and age at the time treatment is initiated. Sequential
and use of a 30-gauge needle also help to decrease the pain of injec- treatment sessions are often necessary (generally at 4- to 8-week in-
tion; once buffered, lidocaine with epinephrine must either be kept tervals), and multiple treatments may be necessary to achieve signifi-
refrigerated or discarded after a week because of accelerated epineph- cant improvement.18 Port wine stains located on the extremities tend
rine degradation. Regional nerve blocks can be used selectively for to require more treatments than those located elsewhere, and those
larger excisions or cryotherapy. Distraction techniques such as con- associated with early-onset hypertrophy have a poorer response and
versation, listening to music, watching a video, or applying vibrations higher complication rate after PDL treatment.19 Recent studies in
to a contiguous area can also allay fear at almost any age. Punch bi- adults with facial port wine stains suggest that the effect of the
opsy is most useful for removing lesions smaller than 6 mm in diam- combination of topical rapamycin and PDL may be greater and more
eter. For larger lesions and in cosmetically sensitive areas, an elliptical persistent than PDL alone.20
excision is preferred. Elliptical excisions ideally have their long axis Other lasers used in pediatric patients include neodymium:yttrium-
following skin lines to minimize tension on the wound and to optimize aluminum-garnet (Nd:YAG; 1064 nm),21 alexandrite (755 nm),22 di-
the ultimate cosmetic appearance of the scar. Shave biopsies are ap- ode (810 nm), Q-switched ruby (694 nm), and intense pulsed light
propriate for the superficial removal of skin tags (acrochordons) and (555 to 950 nm) lasers, which have shown variable benefit in port
more protuberant small nevi that are cosmetically problematic; how- wine stains, venous malformations, deeper hemangiomas, and pig-
ever, shave removal can be followed by lesional regrowth and should mented lesions (mongolian spots, nevus of Ota, Becker melanosis).13,23
not be performed if there is any concern about lesional atypia or ma- The xenon-chloride excimer laser (308 nm) provides a wavelength
lignancy. Surgical wounds of 4 mm or larger in diameter should be similar to narrow-band UVB therapy, with the advantage of being able
closed with suture; wounds that are 3 mm or less can be left to heal via to selectively treat a more targeted area of the skin. It has been
secondary intention after hemostasis (including with insertion of demonstrated to be useful in psoriasis, vitiligo, nevus depigmentosus,
Gelfoam), although suturing of any lesion often gives a better cos- pityriasis alba, and postinflammatory hypopigmentation.24–28
metic result. Although octylcyanoacrylates such as Dermabond are
appropriate for closure of lacerations, the cosmetic result of their use The complete list of 28 references for this chapter is available
in elective procedures may be suboptimal and they are generally not online at http://expertconsult.inkling.com.
recommended. Deep sutures are often required to close the deeper
space of larger or deeper wounds (e.g., .6 mm in diameter) using
buried absorbable suture materials. Although a variety of methods Key References
are available for closing at the surface, interrupted or running subcu-
ticular suturing with nonabsorbable suture material is most often Haliasos EC, Kerner M, Jaimes-Lopez N, et al. Dermoscopy for the pediatric derma-
tologist. Part I. Dermoscopy of pediatric infectious and inflammatory skin lesions
used. Adhesive wound closure strips such as Steri-Strips are often used and hair disorders. Pediatr Dermatol 2013;30:163–71.
to further protect the wound from dehiscence. Haliasos EC, Kerner M, Jaimes N, et al. Dermoscopy for the pediatric dermatologist. Part
The most common complications of biopsies and surgical excisions II. Dermoscopy of genetic syndromes with cutaneous manifestations and pediatric
are wound infection, dehiscence, postoperative bleeding, and hema- vascular lesions. Pediatr Dermatol 2013;30:172–81.
toma (especially on the scalp). Contact dermatitis may also occur, es- Haliasos EC, Kerner M, Jaimes N, et al. Dermoscopy for the pediatric dermatologist.
Part III. Dermoscopy of melanocytic lesions. Pediatr Dermatol 2013;30:281–93.
pecially in reaction to adhesives or topical antibiotics; many surgeons Rudnicka L, Olszewska M, Waskiel A, et al. Trichoscopy in hair shaft disorders.
use petrolatum alone after skin surgery to avoid the risk of contact Dermatol Clin 2018;36(4):421–30.
dermatitis. Parents should be given clear, written postoperative in- Bonifaz A, Isa-Isa R, Araiza J, et al. Cytobrush-culture method to diagnose tinea
structions about keeping dressings in place (and the wound com- capitis. Mycopathologia 2007;163(6):309–13.
pletely dry) for the first 48 hours, appropriate wound care thereafter, Cordisco MR. An update on lasers in children. Curr Opin Pediatr 2009;21:499–504.
Craig LM, Alster TS. Vascular skin lesions in children: a review of laser surgical and
limitation in physical activity (generally 4 weeks without sports or medical treatments. Dermatol Surg 2013;39:1137–46.
gym if an excision), managing potential complications, and when to Dinulos JGH. Cosmetic procedures in children. Curr Opin Pediatr 2011;23:395–8.
have sutures removed (typically 7 days for the face and 10 to 14 days Franca K, Chacon A, Ledon J, et al. Lasers for cutaneous congenital vascular lesions:
on the body and extremities). a comprehensive overview and update. Lasers Med Sci 2013;28:1197–204.
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Title: History of the United States of America, Volume 5 (of 9)

During the first administration of James Madison
Author: Henry Adams
Release date: January 9, 2024 [eBook #72668]
Language: English
Original publication: New York: Charles Scribner's Sons, 1889
Credits: Richard Hulse, Karin Spence and the Online Distributed

Proofreading Team at https://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive/American Libraries.)
*** START OF THE PROJECT GUTENBERG EBOOK HISTORY OF

THE UNITED STATES OF AMERICA, VOLUME 5 (OF 9) ***
THE FIRST ADMINISTRATION
OF
JAMES MADISON
1809–1813
HISTORY OF THE UNITED STATES.
BY
HENRY ADAMS.
Vols. I. and II.—The First Administration of Jefferson. 1801–
1805.
Vols. III. and IV.—The Second Administration of Jefferson.
1805–1809.
Vols. V. and VI.—The First Administration of Madison. 1809–
1813.
Vols. VII., VIII., and IX.—The Second Administration of Madison.
1813–1817. With an Index to the Entire Work. (In Press.)
HISTORY
OF THE
UNITED STATES OF AMERICA

DURING THE FIRST ADMINISTRATION OF
JAMES MADISON
By HENRY ADAMS
Vol. V.
NEW YORK
CHARLES SCRIBNER’S SONS
1890
Copyright, 1890
By Charles Scribner’s Sons.
University Press:
John Wilson and Son, Cambridge.
CONTENTS OF VOL. V.
CHAPTER PAGE
I. Subsidence of Faction 1
II. Alienation from France 22
III. Canning’s Concessions 42
IV. Erskine’s Arrangement 66
V. Disavowal of Erskine 87
VI. Francis James Jackson 109
VII. Napoleon’s Triumph 133
VIII. Executive Weakness 154
IX. Legislative Impotence 176
X. Incapacity of Government 199
XI. The Decree of Rambouillet 220
XII. Cadore’s Letter of August 5 241
XIII. The Marquess Wellesley 262
XIV. Government by Proclamation 289
XV. The Floridas and the Bank 316
XVI. Contract with France 338
XVII. Dismissal of Robert Smith 359
XVIII. Napoleon’s Delays 380
XIX. Russia and Sweden 404
HISTORY OF THE UNITED STATES.
CHAPTER I.
The “National Intelligencer,” which called public attention only to
such points of interest as the Government wished to accent, noticed
that President Madison was “dressed in a full suit of cloth of
American manufacture” when he appeared at noon, March 4, 1809,
under escort of the “troops of cavalry of the city and Georgetown,”
amid a crowd of ten thousand people, to take the oath of office at the
Capitol. The suit of American clothes told more of Madison’s
tendencies than was to be learned from the language of the
Inaugural Address, which he delivered in a tone of voice so low as
not to be heard by the large audience gathered in the new and
imposing Representatives’ Hall.[1] Indeed, the Address suggested a
doubt whether the new President wished to be understood. The
conventionality of his thought nowhere betrayed itself more plainly
than in this speech on the greatest occasion of Madison’s life, when
he was required to explain the means by which he should retrieve
the failures of Jefferson.
“It is a precious reflection,” said Madison to his anxious audience,
“that the transition from this prosperous condition of our country to the
scene which has for some time been distressing us, is not chargeable
on any unwarrantable views, nor as I trust on any voluntary errors, in
the public councils. Indulging no passions which trespass on the rights
or the repose of other nations, it has been the true glory of the United
States to cultivate peace by observing justice, and to entitle
themselves to the respect of the nations at war by fulfilling their
neutral obligations with the most scrupulous impartiality. If there be
candor in the world, the truth of these assertions will not be
questioned; posterity at least will do justice to them.”
Since none of Madison’s enemies, either abroad or at home,

intended to show him candor, his only hope was in posterity; yet the
judgment of posterity depended chiefly on the course which the new
President might take to remedy the misfortunes of his predecessor.
The nation expected from him some impulse toward the end he had
in mind; foreign nations were also waiting to learn whether they
should have to reckon with a new force in politics; but Madison
seemed to show his contentment with the policy hitherto pursued,
rather than his wish to change it.
“This unexceptionable course,” he continued, “could not avail
against the injustice and violence of the belligerent Powers. In their
rage against each other, or impelled by more direct motives, principles
of retaliation have been introduced equally contrary to universal
reason and acknowledged law. How long their arbitrary edicts will be
continued, in spite of the demonstrations that not even a pretext for
them has been given by the United States, and of the fair and liberal
attempt to induce a revocation of them, cannot be anticipated.
Assuring myself that under every vicissitude the determined spirit and
united councils of the nation will be safeguards to its honor and
essential interests, I repair to the post assigned me, with no other
discouragement than what springs from my own inadequacy to its
high duties.”
Neither the actual world nor posterity could find much in these
expressions on which to approve or condemn the policy of Madison,
for no policy could be deduced from them. The same iteration of
commonplaces marked the list of general principles which filled the
next paragraph of the Address. Balancing every suggestion of
energy by a corresponding limitation of scope, Madison showed only
a wish to remain within the limits defined by his predecessor. “To
cherish peace and friendly intercourse with all nations having
corresponding dispositions” seemed to imply possible recourse to
war with other nations; but “to prefer in all cases amicable discussion
and reasonable accommodation of differences to a decision of them
by an appeal to arms” seemed to exclude the use of force. “To
promote by authorized means improvements friendly to agriculture,
to manufactures, and to external as well as internal commerce” was
a phrase so cautiously framed that no one could attack it. “To
support the Constitution, which is the cement of the Union, as well in
its limitations as in its authorities,” seemed a duty so guarded as to
need no further antithesis; yet Madison did not omit the usual
obligation “to respect the rights and authorities reserved to the
States and to the people, as equally incorporated with, and essential
to, the success of the general system.” No one could object to the
phrases with which the Address defined Executive duties; but no one
could point out a syllable implying that Madison would bend his
energies with sterner purpose to maintain the nation’s rights.
At the close of the speech Chief-Justice Marshall administered
the oath; the new President then passed the militia in review, and in
the evening Madison and Jefferson attended an inauguration ball,
where “the crowd was excessive, the heat oppressive, and the
entertainment bad.”[2] With this complaint, so familiar on the
occasion, the day ended, and President Madison’s troubles began.
About March 1, Wilson Cary Nicholas had called on the President
elect to warn him that he must look for serious opposition to the
expected appointment of Gallatin as Secretary of State. Nicholas
had the best reason to know that Giles, Samuel Smith, and Leib
were bent on defeating Gallatin.
“I believed from what I heard he would be rejected,” wrote Nicholas
two years afterward;[3] “and that at all events, if he was not, his
confirmation would be by a bare majority. During my public service but
one event had ever occurred that gave me as much uneasiness: I
mean the degradation of the country at that very moment by the
abandonment of [the embargo].”
The two events were in fact somewhat alike in character. That
Gallatin should become Secretary of State seemed a point of little
consequence, even though it were the only remaining chance for
honorable peace; but that another secretary should be forced on the
President by a faction in the Senate, for the selfish objects of men
like Samuel Smith and Giles, foreboded revolution in the form of
government. Nicholas saw chiefly the danger which threatened his
friends; but the remoter peril to Executive independence promised
worse evils than could be caused even by the overthrow of the party
in power at a moment of foreign aggression.
The effort of Giles and Smith to control Madison had no excuse.
Gallatin’s foreign birth, the only objection urged against him,
warranted doubt, not indeed of his fitness, but of difficulty in obliging
European powers to deal with a native of Geneva, who was in their
eyes either a subject of their own or an enemy at war; but neither
Napoleon nor King George in the year 1809 showed so much regard
to American feelings that the United States needed to affect delicacy
in respect to theirs; and Gallatin’s foreign birth became a signal
advantage if it should force England to accept the fact, even though
she refused to admit the law, of American naturalization. Gallatin’s
fitness was undisputed, and the last men who could question it were
Giles and Samuel Smith, who had been his friends for twenty years,
had trusted their greatest party interests in his hands, had helped to
put the Treasury under his control, and were at the moment keeping
him at its head when they might remove him to the less responsible
post of minister for foreign affairs. Any question of Gallatin’s
patriotism suggested ideas even more delicate than those raised by
doubts of his fitness. A party which had once trusted Burr and which
still trusted Wilkinson, not to mention Giles himself, had little right to
discuss Gallatin’s patriotism, or the honesty of foreign-born citizens.
Even the mild-spoken Wilson Cary Nicholas almost lost his temper at
this point. “I honestly believe,” he wrote in 1811, “if all our native
citizens had as well discharged their duty to their country, that we
should by our energy have extorted from both England and France a
respect for our rights, and that before this day we should have
extricated ourselves from all our embarrassments instead of having
increased them.” The men who doubted Gallatin’s patriotism were
for the most part themselves habitually factious, or actually dallying
with ideas of treason.
Had any competent native American been pressed for the
Department of State, the Senate might still have had some pretext
for excluding Gallatin; but no such candidate could be suggested.
Giles was alone in thinking himself the proper secretary; Samuel
Smith probably stood in the same position; Monroe still sulked in
opposition and discredit; Armstrong, never quite trusted, was in
Paris; William Pinkney and J. Q. Adams were converts too recent for
such lofty promotion; G. W. Campbell and W. H. Crawford had
neither experience nor natural fitness for the post. The appointment
of Gallatin not only seemed to be, but actually was, necessary to
Madison’s Administration.
No argument affected the resistance of Giles and Samuel Smith,
and during the early days of March Madison could see no means of
avoiding a party schism. From that evil, at such a stage, he shrank.
While the subject still stood unsettled, some unknown person
suggested a new idea. If Robert Smith could be put in the Treasury,
his brother Samuel would vote to confirm Gallatin as Secretary of
State. The character of such a transaction needed no epithet; but
Madison went to Robert Smith and offered him the Treasury.[4] He
knew Smith to be incompetent, but he thought that with Gallatin’s aid
even an incompetent person might manage the finances; and
perhaps his astuteness went so far as to foresee what was to
happen,—that he should deal with the Smiths on some better
occasion in a more summary manner. Madison’s resemblance to a
cardinal was not wholly imaginary.[5]
While Robert Smith went to inquire into the details of Treasury
business before accepting the offered post, the President consulted
with Gallatin, who rejected the scheme at once. He could not, he
said, undertake the charge of both departments; the President would
do better to appoint Robert Smith Secretary of State, and leave the
Treasury as it was. Madison seized this outlet of escape. He
returned to Robert Smith with the offer of the State Department,
which Smith accepted. In making this arrangement Madison knew
that he must himself supply Smith’s deficiencies; but stronger wills
than that of Madison had yielded to party discontent, and he gained
much if he gained only time.
The true victim of the bargain was Gallatin, who might wisely
have chosen the moment for retiring from the Cabinet; but after
declining an arrangement in his favor, he could not fairly desert the
President, who had offered to sacrifice much for him, and he was too
proud to avow a personal slight as the motive of his public action.
Weakened already by the unexpected decline of his influence in the
Senate, his usefulness was sure to be still further lessened by the
charge of clinging to office; but after weighing the arguments for
retirement he decided to remain,[6] although he could not, even if he
would, forget that the quarrel which had been forced upon him must
be met as vigorously as it was made.
The War and Navy Departments remained to be filled. Dearborn,
who had continued in the War Department chiefly to oblige President
Jefferson, retired in the month of February to become Collector of
the port of Boston. As his successor, Madison selected William
Eustis, of Boston, who had served in Congress during Jefferson’s
first Administration. Eustis was about fifty-six years old; in the
Revolutionary War he had filled the post of hospital surgeon, and
since the peace he had practised his profession in Boston. Little
could be said of the appointment, except that no other candidate was
suggested who seemed better qualified for the place.[7]
To succeed Robert Smith at the Navy Department, Madison
selected Paul Hamilton, of South Carolina. Nothing was known of
Hamilton, except that he had been governor of his State some ten
years before. No one seemed aware why he had attracted the
President’s attention, or what qualities fitted him for the charge of
naval affairs; but he appeared in due time at Washington,—a South
Carolinian gentleman, little known in society or even to his
colleagues in the government, and little felt as an active force in the
struggle of parties and opinions.
From the outset Madison’s Cabinet was the least satisfactory that
any President had known. More than once the Federalist cabinets
had been convulsed by disagreements, but the Administration of
Madison had hardly strength to support two sides of a dispute.
Gallatin alone gave it character, but was himself in a sort of disgrace.
The Secretary of State, the Secretary of War, and the Secretary of
the Navy, overshadowed in the Cabinet by Gallatin, stood in a
position of inevitable hostility to his influence, although they
represented neither ideas nor constituents. While Gallatin exacted
economy, the army and navy required expenditures, and the two
secretaries necessarily looked to Robert Smith as their friend.
Toward Robert Smith Gallatin could feel only antipathy, which was
certainly shared by Madison. “We had all been astonished at his
appointment,” said Joel Barlow two years afterward;[8] “we all
learned the history of that miserable intrigue by which it was
effected.” Looking upon Robert Smith’s position as the result of a
“miserable intrigue,” Gallatin could make no secret of his contempt.
The social relations between them, which had once been intimate,
wholly ceased.
To embroil matters further, the defalcation of a navy agent at
Leghorn revealed business relations between the Navy Department
and Senator Samuel Smith’s mercantile firm which scandalized
Gallatin and drew from him a sharp criticism. He told Samuel Smith
that the transactions of the firm of Smith and Buchanan were the
most extraordinary that had fallen within his knowledge since he had
been in the Treasury, and had left very unfavorable impressions on
his mind.[9] Smith was then struggling for a re-election to the Senate,
and felt the hand of Gallatin as a chief obstacle in his way. The feud
became almost mortal under these reciprocal injuries; but Samuel
Smith gained all his objects, and for the time held Gallatin and
Madison at his mercy. Had he been able to separate them, his
influence would have had no bounds, except his want of ability.
Yet Madison was always a dangerous enemy, gifted with a quality
of persistence singularly sure in its results. An example of this
persistence occurred at the moment of yielding to the Smiths’
intrigues, when, perhaps partly in the hope of profiting by his
sacrifice, he approached the Senate once more on the subject of the
mission to Russia. February 27, the nomination of William Short to
St. Petersburg had been unanimously rejected. March 6, with the
nominations of Robert Smith and William Eustis to the Cabinet,
Madison sent the names of J. Q. Adams as minister at St.
Petersburg, and of Thomas Sumter as minister to Brazil. He asked
the Senate to establish two new missions at once. March 7 the
Senate confirmed all the other nominations, but by a vote of
seventeen to fifteen, adhered to the opinion that a mission to Russia
was inexpedient. Both Giles and Samuel Smith supported the
Government; but the two senators from Pennsylvania, the two from
Kentucky, together with Anderson of Tennessee and William H.
Crawford, persisted in aiding the Federalists to defeat the
President’s wish. Yet the majority was so small as to prove that
Madison would carry his point in the end. Senators who rejected the
services of Gallatin and John Quincy Adams in order to employ
those of Robert Smith, Dr. Eustis, and Governor Hamilton could not
but suffer discredit. Faction which had no capacity of its own, and
which showed only dislike of ability in others, could never rule a
government in times of danger or distress.
After thus embarrassing the President in organizing his service
the Senate rose, leaving Madison in peace until May 22, when the
Eleventh Congress was to meet in special session. The outlook was
more discouraging than at the beginning of any previous
Administration. President Jefferson had strained his authority to
breaking, and the sudden reaction threw society as well as
government into disorder. The factiousness at Washington reflected
only in a mild form the worse factiousness elsewhere. The
Legislature of Massachusetts, having issued its Address to the
People, adjourned; and a few days afterward the people, by an
election which called out more than ninety thousand votes,
dismissed their Republican governor, and by a majority of two or
three thousand chose Christopher Gore in his place. The new
Legislature was more decidedly Federalist than the old one. New
Hampshire effected the same revolution. Rhode Island followed. In
New York the Federalists carried the Legislature, as they did also in
Maryland.
Even in Pennsylvania, although nothing shook the fixed political
character of the State, the epidemic of faction broke out. While the
legislatures of Massachusetts and Connecticut declared Acts of
Congress unconstitutional, and refused aid to execute them, the
legislature of Pennsylvania authorized Governor Snyder to resist by
armed force a mandate of the Supreme Court; and when the United
States marshal attempted to serve process on the person of certain
respondents at the suit of Gideon Olmstead, he found himself
stopped by State militia acting under orders.
In a country where popular temper had easier means of
concentrating its violence, government might have been paralyzed
by these proofs of low esteem; but America had not by far reached
such a stage, and dark as the prospect was both within and without,
Madison could safely disregard dangers on which most rulers had
habitually to count. His difficulties were only an inheritance from the
old Administration, and began to disappear as quickly as they had
risen. At a word from the President the State of Pennsylvania
recovered its natural common-sense, and with some little sacrifice of
dignity gave way. The popular successes won by the Federalists
were hardly more serious than the momentary folly of Pennsylvania.
As yet, the Union stood in no danger. The Federalists gained many
votes; but these were the votes of moderate men who would desert
their new companions on the first sign of a treasonable act, and their
presence tended to make the party cautious rather than rash. John
Henry, the secret agent of Sir James Craig, reported with truth to the
governor-general that the Federalist leaders at Boston found
disunion a very delicate topic, and that “an unpopular war ... can
alone produce a sudden separation of any section of this country
from the common head.”[10] In public, the most violent Federalists
curbed their tongues whenever the Union was discussed, and
instead of threatening to dissolve it, contented themselves by
charging the blame on the Southern States in case it should fall to
pieces. Success sobered them; the repeal of the embargo seemed
so great a triumph that they were almost tempted into good humor.
On the people of New England other motives more directly selfish
began to have effect. The chief sources of their wealth were shipping
and manufactures. The embargo destroyed the value of the shipping
after it had been diminished by the belligerent edicts; the repeal of
the embargo restored the value. The Federalist newspapers tried to
prove that this was not the case, and that the Non-intercourse Act,
which prohibited commerce with England, France, or their
dependencies, was as ruinous as embargo itself; but the shipping
soon showed that Gottenburg, Riga, Lisbon, and the Spanish ports
in America were markets almost as convenient as London or Havre
for the sale of American produce. The Yankee ship-owner received
freights to Europe by circuitous routes, on the accumulations of two
years in grain, cotton, tobacco, and timber, of the whole United
States, besides the freights of an extended coast-trade.
Massachusetts owned more than a third of the American registered
tonnage, and the returns for 1809 and 1810 proved that her profits
were great. The registered tonnage of Massachusetts employed in
foreign trade was 213,000 tons in 1800, and rose to 310,000 tons in
1807 before the embargo; in 1809 it rose again to 324,000; in 1810 it
made another leap to 352,000 tons. The coasting trade employed in
1807 about 90,000 tons of Massachusetts shipping which was much
increased by the embargo, and again reduced by its repeal; but in
1809 and 1810 this enrolled shipping still stood far above the
prosperous level of 1807, and averaged 110,000 tons for the two
years.[11]
Such rapid and general improvement in shipping proved that New
England had better employment than political factiousness to occupy
the thoughts of her citizens; but large as the profits on freights might
be, they hardly equalled the profits on manufactures. In truth, the
manufactories of New England were created by the embargo, which
obliged the whole nation to consume their products or to go without.
The first American cotton mills, begun as early as 1787, met with so
little success that when the embargo was imposed in 1807, only
fifteen mills with about eight thousand spindles were in operation,
producing some three hundred thousand pounds of yarn a year.
These eight thousand spindles, representing a capital of half a
million dollars, were chiefly in or near Rhode Island.
The embargo and non-importation Acts went into effect in the last
days of 1807. Within less than two years the number of spindles was
increased, or arrangements were made for increasing it, from eight
thousand to eighty thousand.[12] Nearly four million dollars of capital
were invested in mills, and four thousand persons were in their
employ, or expected soon to be employed in them. The cotton cost
about twenty cents a pound; the yarn sold on an average at about
$1.12½ a pound. Besides these mills, which were worked mostly by
water but partly by horsepower, the domestic manufacture of cotton
and linen supplied a much larger part of the market. Two thirds of the
clothing and house-linen used in the United States outside of the
cities was made in farm-houses, and nearly every farmer in New
England sold some portion of the stock woven every year by the
women of his household. Much of this coarse but strong flaxen
material, sold at about fifteen or twenty cents a yard by the spinner,
was sent to the Southern States.[13]

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Dedication, v 13 Bullous Disorders of Childhood, 369

7 Disorders of Hair and Nails, 160 21 Vasculitic Disorders, 572

Table 1.1 Glossary of Dermatologic Terms

Patch Flat, circumscribed lesion with color Congenital dermal melanocytosis

Papule Circumscribed, nonvesicular, Elevated nevus (see Fig. 9.4);

wTable 1.1 Glossary of Dermatologic Terms (Continued)

Wheal Distinctive type of elevated lesion Darier sign of mastocytosis (see

Continued on following page

Table 1.1 Glossary of Dermatologic Terms (Continued)

Pustule Circumscribed elevation ,1 cm Folliculitis (see Fig. 14.11); transient

Abscess Circumscribed, elevated lesion .1 cm Staphylococcal abscess (in a

OTHER PRIMARY LESIONS

Table 1.1 Glossary of Dermatologic Terms (Continued)

Scale Formed by an accumulation of compact Seborrheic dermatitis (greasy

Continued on following page

Table 1.1 Glossary of Dermatologic Terms (Continued)

Atrophy Cutaneous changes that result in Anetoderma (see Fig. 22.63);

Table 1.1 Glossary of Dermatologic Terms (Continued)

Hair plucks tend to be traumatic for children and often cause

Title: History of the United States of America, Volume 5 (of 9)

Author: Henry Adams

Release date: January 9, 2024 [eBook #72668]

Original publication: New York: Charles Scribner's Sons, 1889

Credits: Richard Hulse, Karin Spence and the Online Distributed

*** START OF THE PROJECT GUTENBERG EBOOK HISTORY OF

UNITED STATES OF AMERICA

Since none of Madison’s enemies, either abroad or at home,

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