THE

AMERICAN MEDICAL INTELLIGENCER.

Vol. III.

June 1, 1839.

No. 5.

ART. I.-CLINICAL LECTURE, ON ECZEMA IMPETIGINODES, AND REMARKS ON THE CONTAGIOUS AND NON-CONTAGIOUS PUSTULAR AFFECTIONS OF THE HEAD.

BY ROBERT CARSWELL, M. D.,"

Professor of Pathological Anatomy in University College, London; and of Clinical Medicine in University College Hospital.

Gentlemen:-Before relating to you the histories of two cases of eczema impetiginodes which have been under your observation, both patients having now left the hospital cured, I shall make a few remarks on the elementary characters of this cutaneous affection, that you may have a more clear con ception of those characters, as the only means of enabling you to recognise the disease when you meet with it, in its different forms, and on different parts of the body, and thereby distinguish it from other similar cutaneous diseases with which it is so frequently confounded, and from which it differs in one most essential particular, viz., its non-contagious nature; and this appears to me the more necessary because of the imperfect acquaintance which not only students, but even most medical men, possess of cutaneous diseases generally, and because of the importance of an accurate diagnosis, more especially as regards those pustular forms of cutaneous disease which are propagated by contagion.

In order to impress on your minds the importance of an accurate diagnosis of skin diseases, I may further observe that it is the first and most essential means of acquiring a knowledge of their history and treatment; for as it is, in general, by an accurate appreciation of their physical characters that you can obtain their respective designations and names, so is it from this latter circumstance that you can refer to those standard works in which you are to find the result of the experience of those who have studied these diseases in an especial manner. In this point of view alone an accurate diagnosis, if not as important as regards the issue of the case, as it always is in diseases affecting those organs essential to the maintenance of life, is often much more so as regards the reputation of the practitioner; as, for example, when he pronounces a disease of the skin to be non-contagious, which very soon after is communicated to other members of a family, or to the other inmates of a school; or, on the other hand, his pronouncing a disease to be contagious which is not so, and in consequence of his erroneous diagnosis giving rise to great disquietude, and inflicting too frequently a great injury on his patient, as happens to children at school, whose removal follows as a necessary consequence.

These latter observations apply more especially to the pustular and vesiculo-pustular affections of the scalp, some of which are contagious, others not, and which, although in almost all cases their special and distinc

1 Lancet, April 13, 1839, p. 97.

tive characters are sufficiently well marked to furnish us with the elements of an accurate diagnosis, are frequently, nay daily, confounded with each other.

However frequent the contagious forms of pustular affections of the head are believed to be, it is an important fact that the non-contagious forms are extremely frequent. Perhaps I would be justified in saying that they are much more frequent than the former; for among the considerable number of cases which I have had occasion to treat among the out-patients of this hospital, there have been extremely few of a contagious nature. Indeed, I believe I have had only two cases of contagious pustular disease of the head, viz., the porrigo scutulata, more commonly, but indefinitely called ringworm, and certainly not a single case of porrigo favosa.

As I shall, no doubt, have the opportunity of bringing under your notice, at some future period, the subject of pustular diseases of the skin, in their contagious forms, I shall not at present enter into a description of their special elementary characters. It will, besides, be sufficient for our present purpose to notice the distinctive characters of these as a means of giving precision and prominency to those which usually characterise the noncontagious pustular affections presented by the two patients whose cases I have to relate to you.

And, in the first place, what are the elementary characters of eczema impetiginodes? This disease, as the term implies, is a compound of two diseases, of eczema and of impetigo. Now, each of these, in its separate state, has its own elementary character-a vesicle in eczema, and a pustule in impetigo. In eczema impetiginodes we have both the vesicle and the pustule; the vesicle, however, being the primary element, and generally predominating during the early stage of the disease. And, besides, the pustular character of this affection always succeeds to the vesicular, and can easily be traced during its progress to a change in the contents of the vesicle, which consisting, at first, of a clear yellow-coloured serosity, afterwards becomes milky-looking, opaque, and puriform. In most cases, however, of eczema impetiginodes the pustular element is much less perfect than the vesicular, the contents of the former consisting of a sero-purulent, rather than of a purulent fluid. But in cases in which the inflammation is more severe than usual, the perfect impetiginous pustule is formed; that is to say, the small, psydraceous pustule, characteristic of impetigo, and even the large or phylaceous pustule, characteristic of ecthyma.

Such are the special and distinctive characters of eczema impetiginodes. The pustular character of this form of eczema distinguishes it from the other forms of the disease, viz., from the eczema simplex, which is a purely vesicular eruption, neither preceded nor accompanied by redness of the skin; and from eczema rubrum, which is always distinguishable by the bright-red colour of the skin, and the number of minute vesicles by which it is covered. To distinguish eczema impetiginodes from some other diseases of the skin is not always so easily accomplished, and this is more especially the case in that form of scabies, called scabies purulenta, affecting the fingers and hands, parts, also, often affected with eczema impetiginodes. But as these parts were not affected in either of our patients, I shall notice only those circumstances which distinguish this disease more especially from porrigo of the scalp, and on other parts of the body. But I shall first read to you the short case of Charlotte Fuller, admitted on the 1st of January, with eczema impetiginodes. She was a female child, two years of age, in general good health, and about a month before was said to have had ringworm, which was followed by an eruption on the head and nates. When examined the following were the appearances observed:-Scalp thickly covered with an eruption and dried incrustation. In some parts vesicles, in others pustules, with an inflamed basis and a raised centre. Behind the ears, erythematous redness, accompanied by a considerable discharge. Besides these appear

ances of the head and ears there were also redness, swelling, and excoriation of the nates. There was little or no disturbance of the general health. This is an extremely simple and obvious case of two forms of eczema, viz., eczema impetiginodes of the scalp, and of eczema rubrum of the ears and nates. The vesiculo-pustular eruption of the scalp, in the first stage of the disease, and the incrustations formed by the discharge of the secreted fluids in the second stage, were well marked, and without those complications which arise from the long duration of the disease, a bad state of the general health, and neglect of cleanliness. The characters of the eczema rubrum behind the ears and on the nates were less perfect, as the vesicular element was absent; as generally happens on the decline of the disease, there remaining only the bright-red colour of the skin from which it derives its name, with a few thin, laminated, transparent incrustations, formed by the morbid secretion of the inflamed cutis deprived of the epidermis. In this stage of the affection it resembles and is sometimes denominated, intertrigo, which, however, is only a variety of erythema, produced by friction of contiguous parts, as between the thighs and nates of fat children, for example.

This case terminated favourably in about three weeks after the admission of the little patient, under the use of a mild antiphlogistic treatment, such as is always indicated and required in recent cases of this nature. After the removal of the hair, poultices were employed with a twofold intention, viz., to facilitate the removal of the incrustations and diminish the inflammatory excitement which accompanies the eruption. This latter intention was also fulfilled by water-dressings behind the ears. The bowels were regulated, at first, by means of calomel and rhubarb, and afterwards by the compound decoction of aloes and tincture of senna. The local affection improved daily, and the redness and slight discharge that still remained were nearly removed by the application of a lotion of the dilute liquor plumbi, when the child was removed at the desire of her mother.

To make any remarks on the distinctive characters of this case of eczema impetiginodes of the head, and other diseases of this part of the body, would certainly be superfluous as regards the diagnosis of this individual case, so simple and obvious were the elementary characters which it presented. But, had this same disease presented itself under more unfavourable circumstances; had the vesicular or vesiculo-pustular character entirely disappeared, and the hair been matted together by the repeated accumulation of the morbid secretion of the inflamed cutis, its real nature might not have been so easily determined. The probability is, that it would have been classed among the porrigos, and suspicions entertained of its contagious nature. And here I may with propriety introduce a few observations on the special and distinctive characters of the contagious forms of pustular affections of the scalp, in order to simplify the means of discriminating between them and other non-contagious pustular eruptions of the impetiginous kind. In the case which I have relatedno doubt could be entertained, as I have already said, regarding its nature, not only on account of the presence of the vesicles, but from the form of the pustule, which the reporter of the case has taken care to state, presented a raised centre. This circumstance alone is sufficient to separate the non-contagious from the contagious pustular eruptions of the scalp,-the form of the pustule, besides other equally important characters, being the very reverse of the former, viz., having a depressed centre. But, in order to render this subject more precise and intelligible, let me state, in outline only, the pustular affections of the scalp. These are four in number: two of them have for their elementary character what is called the favous pustule; the two others the achores pustule. Now there can be no doubt that the favous pustule is one sui generis, and essentially contagious, and includes two forms of porrigo,-the porrigo favosa, and the porrigo scutulata, the true ringworm of authors, if not of the vulgar. The achores pustules, on the other hand, if they do not characterise a special disease of the scalp, are certainly not susceptible of transmission by contagion, and hence an im

portant distinction between the diseases to which they give rise and those of the favous character. The diseases of the scalp, however, arising in the achores pustule, have been included under the porrigos, and present two varieties, the porrigo larvalis and the porrigo granulata. I am, however, disposed to think, with Biett, that they might be separated from the porrigos, from the circumstance of their non-contagious nature, and also from their bearing a strong resemblance to impetigo or eczema impetiginodes, of which they are probably only modifications, owing to a difference in the seat which they occupy. But, be this as it may, it is obvious that our great object ought to be to be able to distinguish the contagious pustular eruptions from every other pustular affection of the scalp; and this may be accomplished in by far the greater number of cases either at first sight, or after watching the progress of the disease for a few days. The characters, then, by means of which we distinguish the two forms of contagious pustular diseases of the scalp, the porrigo favosa and the porrigo scutulata,-are the following; and, first, of those of porrigo favosa: the favous pustule is formed by the deposition of a minute quantity of pus, which concretes almost immediately into a pale yellow or straw-coloured substance, having a defined circular edge, hardly, if at all, rising above the surface of the skin, and surrounded by a slight blush of red. The successive effusion and concretion of the matter proceeds from the centre towards the circumference, in which direction it accumulates, thereby raising the circular edge of the crust, and giving to it that cupshaped form by which it is so readily recognised. The size of these concrete pustules varies from one to two lines, to half or three quarters of an inch in diameter. They are distinct at the commencement, but become confluent during their formation, and are sometimes confounded together into a large, dry, brittle mass, resembling a mixture of sulphur and plaster. Even in this state, however, of agglomeration, traces of the primitive character of the disease are perceptible, viz., numerous round or irregular depressions, indicating the situation and number of the original favi.

In the second form, viz., the porrigo scutulata, the favous pustules, instead of being distinct, as in the former, are confluent from the commencement, and form patches of various extent, around the circumference of which they are much more numerous than at the centre. Patches of this kind may be seen on various parts of the scalp, but, however much they may increase in extent, by the accumulation of the concrete effused matter, and although, from this circumference the alveolar depressions may become effaced, the projecting, defined, circular edges of the favi are always to be observed around the circumference of the patches, and serve to point out the nature of the affection. The concrete matter of the patches resembles plaster, is of a dirty-gray colour, rather than a yellow tinge, as in the porrigo favosa. Such is a general outline of the physical and distinctive characters of what may be regarded as the true porrigos,-the porrigo favosa and scutulata,— and by means of which we are enabled to distinguish them from other pustular affections of the scalp with which they are confounded, that is to say, with impetigo, eczema impetiginodes, and still more so with the porrigo larvalis and porrigo granulata. I have already said that these two latter pustular affections have not the favous but the achores pustule for the basis of their classification, and that it is extremely probable that the achores pustule is merely a modification of the pustule of impetigo, affected by its locality, and constitute, when seated in the scalp, varieties of impetigo and eczema impetiginodes. The achores pustules, however, which constitute the porrigo larvalis and granulata, are larger than those of the porrigo favosa and scutulata at their commencement. They are situated superficially, instead of being sunk deep in the cutis, as is the case in the latter; they are, in fact, prominent, instead of being depressed; are surrounded by an inflamed basis; are scattered over the head or other parts of the body; and instead of the puriform fluid concreting when effused within a defined circumscribed space, it is spread over the surrounding surface in the form of laminated,

brittle incrustations, of a yellowish-green, yellowish-brown, or brown colour. The dry, irregular incrustations, independent of the colour, of these two non-contagious forms of porrigo, cannot be confounded with the solid circular patches, with depressed centres, of porrigo favosa and scutulata, the only two pustular diseases from which, as I have already said, it is of importance that they should be distinguished.

We We now come to the consideration of the second case of eczema impetiginodes, which is one of considerable interest, even in a diagnostic point of view, owing to the unusually obscure and complicated appearance which it presented. I shall first read you the history of this case, taken from the case-book, before offering you the explanatory observations which it suggests. History of Case.-John Smith, æt. 35, admitted December 4th, 1838, formerly a groom, but for the last three years has been employed as a gardener; he is of a sanguine temperament, tall and muscular, married, and of regular habits; parents are living, and generally healthy; his own health has always been remarkably good. Fourteen years ago (before his marriage) he contracted gonorrhea, and got well in about a fortnight by the use of internal remedies. He declares he never had any venereal complaint since, nor, indeed, ever been in "harm's way." In the summer, six years ago, he had an eruption of small pimples all over his body, on glans penis, and scrotum, as well as on other parts. These were attended with very little itching and died away spontaneously towards winter; they have returned every summer about June. The eruption was supposed, by his medical attendant, to be syphilitic, and the patient was salivated three times within the twelve months, three years ago. At this time he states that he had a small swelling in the groin, which, however, soon subsided after leeching and rest. After the first salivation the eruption assumed a new form; the pimples broke and discharged a yellow fluid, which concreted into thick scabs. Similar pimples now began to appear on the scalp and face, being preceded by severe headachs. Each pimple broke, enlarged, joined with neighbouring ones, and formed large discharging surfaces, which afterwards gradually healed at the centre, on various parts of the head, trunk, and extremities. His throat became sore; there were large ulcers formed in it, and it continued in this state for two months. He became gradually worse and worse, and was, as stated, admitted the 4th December.

Present Symptoms. His face is nearly covered with the eruption; the patches are irregular in size, but generally assume a circular form; some parts are erythematous, covered with a furfuraceous desquamation, and around the margins of these patches which have healed in various degrees in the centre, the still discharging eruption forms scabs and crusts of a yellow colour, by the concreting of the matter furnished by the pustules. There are numerous patches on the head, behind the ears, &c. &c.; the margins of the patches are not raised, but the skin around is red and shining; the eruption heals in the centre of the patches, and the parts, once the seat of the disease, do not again become affected. The affected parts are hot, itch, and smart, and heat only makes them worse. There are several large patches on the back, and on the front of the chest, one on the left scapula, and one on the right breast, forming a complete ring. Another very large one is situated just below the knee, healed in the centre, the skin there being of the natural colour, and another patch under the left thigh, four inches in breadth. There are small red papulæ, containing fluid of a yellow colour, like impetiginous pustules, diffused over the body in various parts.

The upper lip is much swollen and protruded; the eyelids are thickened, there is lippitudo and coryza; the sight is dim and impaired, and the eyeballs blood shot.

The skin is, at times, very hot and dry; he is very much weakened by the disease; appetite is pretty good; thirst; sleep bad; very little perspiration; bowels regular; urine high coloured, and rather increased in quantity; tongue clean and natural.