General Remarks.
In many very different diseases of the skin pus is present, and if the term pustular were used in its widest sense a large number of diseases would have to be included under it; for instance, acne; favus; scabies; pemphigus; variola; farcy; varicella; and so on. But in the diseases just named the presence of pus is often not a primary or even essential condition, and its importance is thrown into the shade by the prominence of other features. In those affections which may more strictly be called pustular, the suppuration is the leading and the primary condition, the particular morbid condition the practitioner has to recognize and to remedy. Now under the term pustular diseases, thus defined, are usually comprised impetigo, ecthyma, and furuncular affections, -the later term including furunculus, or boil; anthrax or carbuncle; and pustular maligna, or malignant boil. Delhi boil would come under this division, but, owing to its rarity in this country, will not be treated of.
Impetigo Contagiosa.
This disease is characterized by the appearance of mild pyrexial symptoms, followed in two or three days by the appearance of one or more small vesicles. They slowly enlarge, but soon dry into thin, light-yellow crusts, or scabs. These lesions may be few or numerous, and successive outbreaks may prolong the affection for several months. The affection is unquestionably contagious, and when it once appears upon an individual, other members of the family, either children or adults, may contract it. In not a few instances the eruption has appeared within a couple of weeks or so after vaccination. If the crust, which has the appearance of being “stuck on”, is removed, a slightly reddened but not eroded surface is revealed, from which but little or no moisture is exuded.
The disease is seen amongst children of the lower orders especially, probably in great measure because the disease spreads by contagion freely amongst them. It occurs also in those who have all the advantages of social position and good hygiene.
The eruption in the disease in the majority of cases appears first of all on the face, sometimes on the top or back of the head, and in the form of “little watery heads” (vesicles) that enlarge into flat bullae if they are not injured by scratching. Sometimes the hands are attacked at the outset, and look as if burnt here and there; phlyctenae may also arise out of and around the remnants of vaccinia, or about cuts or bruises. The disease then extends to other parts, the back of the neck, buttocks, feet, etc. The vesicles are always isolate. In five or six days the bullae may reach the size of a sixpence or shilling unless ruptured, and are then flat and depressed in the centre, their contents becoming turbid. Usually the vesico-pustule is the size of a large split-pea or there -abouts. The secretion consists of lymph-like fluid, granular cells, and subsequently pus-cells.
Scabs commence to form a few days after the appearance of the disease. They are characteristics of the disease, varying in size from that of a split pea to a shilling; they are flat, straw-colored, dry, and granular-looking, and appear as if “stuck on” to the part; they present as a rule, no inflammatory areola around their circumferences, though this is the case in severe instances of the disease. If removed, little sores are observed beneath, more or less filled in by gummy-like secretion, or a little pellet of plastic lymph, and when the scabs fall off there is an erythematous base left behind, the hue of which gradually fades away. The disease may be spread from spot to spot by direct inoculation with its secretion in the act of scratching. The crop of vesicles is to some extent successive, though the majority of the places “come out” in the first week or so.
In some instances the disease resembles vaccinia very slowly. There is always a uniformity about it; it always commences by vesicles; there are no papules present at the height of the disease. On the face the spots may be confluent, and then the disease resembles eczema impetiginodes; but the patches are made up of the elements described above. On the scalp the disease consists of circular, mostly isolated, flat-scabbed spots about the top and back of the head, the hair being matted by the crusts. Usually, no pediculi and no offensive smell are present. Now it is very important to note that an eczema may be readily excited in fair children by scratching or the irritation of the discharge, in connection with impetigo contagiosa-and then the characteristic features of the latter disease are masked. The result of neglecting to attend to this point is that the practitioner regards the disease present as solely and entirely an eczema. The error, too is a very common one.
The mucous membranes of the eye and the nose are sometimes implicated; then inflammation is produced by the development of little ulcers, that take their origin in the formation apparently of vesico-pustules, identical with those seen on the surface of the skin. The eye may look as though affected by slight purulent ophthalmia, but soon recovers itself.
The disease may complicate eczema, scabies, and other affections, and vice versa.
Diagnostic features are-its apparently epidemic character in many cases; the antecedent febrile condition; its attacking children; the origin from isolated vesicles, which tend to enlarge into blebs and to become pustular, the bleb having a depressed centre, and, it may be, a well-defined, slightly raised, rounded edge; the isolation of the spots; the uniform character of the eruption, and its general and scattered condition; its frequent seat and commencement about the face or head; the circular, flat, granular, yellow crusts looking as if stuck on; its contagious nature and inoculability; its frequent following in the wake of vaccination; the absence of pain, and especially troublesome itching at night.
Contagious impetigo may be confounded with eczema; but the history is altogether different, and the isolation, the small scabbed patch, the characters of the crusts, and the facility of cure at once distinguish it. Impetigo sparsa does not arise from a vesiculation, but is primarily pustular, made up of aggregated pustules; it does not phlyctenoid; it is not contagious nor inoculable; it does not run a definite course; it is not confined to the young; it is not so amenable to treatment.
Pemphigus.
In this disease the blebs are larger, more persistent, oval, and distended; the contents are watery and acid. Pemphigus is non-contagious; it does not occur especially on the face or the head; it is less inflammatory, and wants the characteristic scabs. Ecthyma.-This is primarily a pustular disease; it is seen also in adults; there are more induration and swelling, and a good deal of pain in connection with the formation of pustules; it is non-contagious; the scabs are heaped-up and dark. Pustular scabies.-This is the disease with which contagious impetigo is at times confounded. It must be remembered that the two diseases may coexist. In children both attack the buttocks frequently; both may exist about hands and feet; but the distinctions are really very clear.
In scabies there is no febrile condition; the eruption is multiform. If there be ecthymatous pustules, like impetigo contagiosa, they are covered by dark thick crusts; there are plenty of characteristic vesicles, with cuniculi and papules. If the impetigo contagiosa begins about the buttocks, it appears presently on the face or the head, or both. There is no irritation, nor are the effects of scratching visible about the body as in scabies; the bullous origin of the disease is distinct, and the scabs are characteristic. The hands are not specially affected in scabies in the child, but even impetigo contagiosa may attack the hands and feet markedly; still there is no multiform eruption, and there are no cuniculi in the latter.
When a correct diagnosis is made, the treatment is easy. The natural course of the disease is a short and definite one. The secretion is an active agent, by means of inoculation self- practiced by the patient in scratching, in transmitting the disease from one part to another. Therefore it is of first importance to destroy the activity of the pus, and to alter the behavior of the surface that secretes it. A very active agent in procuring this result is an ointment containing five grains of the ammonio-chloride of mercury, and apply it to surface beneath the scabs, which must be removed by poulticing or fomentation with warm water. A sulphur ointment is also beneficial. The patient must be well-nourished, and strict hygienic treatment adopted. Cleanliness is all-important.
The old-school rely principally upon the external applications.
The indications for the internal remedies are:
Antimon. crud-This is the principal internal remedy. Eruption forming thick, heavy yellow crusts, with burning; eruption about face; worse from bathing the parts; better in open air; chronic cases.
