Impetigo Contagiosa. BY r GEORGE THOMAS JACKSON, M. D., CHIEF OF THE DERMATOLOGIC'WHWlC^'-COLLEGE OF PHYSICIANS AND SURGEONS ; INSTRUCTOR IN DERMATOLOGY, NEW YORK POST-GRAD- UATE MEDICAL SCHOOL AND HOSPITAL. REPRINTED FROM STtje Neta) Yorft HieUical journal for November 19, 1887. Reprinted from the New York Medical Journal for November 19, 1887. IMPETIGO CONTAGIOSA* By GEORGE THOMAS JACKSON, M. D., CHIEF OF THE DERMATOLOGICAL CLINIC, COLLEGE OF PHYSICIANS AND SURGEONS ; INSTRUCTOR IN DERMATOLOGY, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. A right understanding of this disease is important, be- cause, if recognized, its treatment is simple and its cure rapid. A proper diagnosis of its bullous form will enable the physician to give a good prognosis where otherwise he would regard the case as one of pemphigus, and therefore would be compelled to make a more or less grave one. Though the disease has been recognized for some time, and has been brought before the medical profession in its jour- nals and societies, errors in diagnosis are not infrequently made. Let this be my excuse for taking up your time to- night with this comparatively insignificant affection. By the term " impetigo " is now most often meant a disease with pustular lesions, just as we use the term " lichen " to indicate one with papular lesions. In so far the term impetigo contagiosa is justified, since it is a pus- tular disease. But it is not so from the beginning, for the primary lesion is a vesicle the contents of which soon be- come purulent. Vesico-pustules, then, are the characteristic * Read before the New York Academy of Medicine, Section in Ob- stetrics and Diseases of Women and Children, October 27, 1887. 2 IMPETIGO CONTAGIOSA. lesions of the disease, and in the vast majority of cases they will be the only ones present. They are of various sizes, but average that of a split pea. They are at first sur- rounded, in well-marked cases, with a red halo, which soon fades. They tend to increase slowly in size, and sometimes assume grotesque shapes. They are not fully distended, but flaccid, and not infrequently upon the hands will bear a strong resemblance to a burn of the second degree. If the covers of the vesicles or small bullae are not disturbed, their contents in a few days will dry up, and the vesico-pustule will change into a straw-yellow granular crust, which is placed superficially upon the skin with its edge somewhat detached, and, it may be, turned up. In fact, it looks " stuck on." When the crust is removed or falls of itself, there is exposed an erythematous spot, which in a short time will disappear and leave no trace of its existence. If the vesicles are torn by scratching, or if by any other means their covers are removed, we shall find very superficial losses of substance-a moist surface covered with a slight puru- lent secretion. Even this disappears and leaves no trace, passing through the erythematous stage in its course to re- covery. Such are the appearances presented in the majority of cases. Besides this usual and typical form we meet with an- other and rarer variety, in which, instead of vesico-pustules, there are large bullae. These are sometimes several inches in their long diameter, of irregular oval shape, not fully distended with fluid, and sometimes showing a slight de- pression in their centers. Their contents are at first serous, but soon become sero-purulent. They seem to be longer preserved than the vesicles, but otherwise run the same course. At first they have a slight zone of redness about them, but this soon disappears. They either are formed by two or more vesico-pustules running together, or spring IMPETIGO CONTAGIOSA. 3 up of themselves. They may attain their full size at once, or increase slowly. Rarely do they exist alone; generally the typical vesico-pustules will be found in their neighbor- hood or elsewhere on the body. It is this bullous form that is liable to be mistaken for pemphigus. Impetigo contagiosa is located principally upon the face, most often on the chin, and on the hands ; it may also occur upon the scalp, legs, and trunk, especially in infants. Ac- cording to my experience, the bullous form is most often seen upon the trunk. The lesions of both varieties are discrete; exceptionally two or more may run together. They are superficial, rarely very numerous, and tend to break out in crops. The bullous lesions are generally widely separated from one another. The outbreak of the disease may be preceded or accompanied by slight fever or some constitu- tional disturbance. My notes of sixteen cases contain no mention of any general disorder, so in them it must have been slight or wanting. Etiology.-The disease is comparatively rare, or at least it seldom comes under the notice of the dermatologist. Thus, the statistics of the American Dermatological Associ- ation for 1886 show but 91 cases in 14,984. During the last two years I have met with it only 16 times in about 2,200 dispensary and hospital cases. It is, as its name in- dicates, very contagious, and often occurs in epidemics. When one case is met with in dispensary service; several more may be expected in children of the same family or neighborhood. It is readily inoculable both on the subject of the disease and on others. Not infrequently we see a mother or other attendant of a child with the characteristic lesions of impetigo contagiosa upon the arms, derived from carrying the child suffering with the same disorder. What the contagious element may be is not yet determined with certainty, though various investigators have described sev- 4 IMPETIGO CONTAGIOSA. eral parasites as the cause of the disease. We know that all pus is under certain circumstances hioculable, and hence it has been maintained that there is no such disease, prop- erly speaking, as contagious impetigo. But when we suc- ceed in inoculating from an ordinary impetigo pustule, we produce an ordinary impetigo pustule, not the characteristic vesico-pustule of impetigo contagiosa. It has been stated by some authorities that the disease is due to lice on the head. In some cases phtheiriasis capitis may be present, because both diseases occur with special frequence in chil- dren of the poor. In my own experience no such relation- ship could be traced. A number of cases have been re- ported of the occurrence of contagious impetigo shortly after the fall of vaccine crusts, and thus has been suggested the possible connection between impetigo and vaccinia. It is more frequent in the warm months than in the cold. Thus, of my sixteen cases, one occurred in May, three in June, one in July, three in August, and five in September- thirteen in all. Children furnish the vast majority of the cases. My oldest patient was ten years of age, though I have seen the disease in adults from contact with children under their care. The duration of the disease is short, rarely more than a few weeks. Two months is the longest duration I have met with before the child was presented for treatment. Diagnosis.-Impetigo contagiosa is diagnosticated by the presence of discrete, partially distended vesico-pustules, which are located upon the exposed parts-head, face, and hands-in most cases; these are sometimes grouped, run an acute course, and dry up into straw-yellow "stuck-on' crusts. It is sometimes preceded by slight constitutional disturbances, and accompanied by a slight amount of itching. It must be differentiated from simple impetigo, pustular ec- zema, varicella, scabies, pemphigus, and possibly ecthyma. IMPETIGO CONTAGIOSA. 5 The lesions of simple impetigo are pustules from the start, while those of impetigo contagiosa are first vesicles and then vesico-pustules. The pustules of impetigo are prominently raised, and run no definite course. The vesico- pustules of impetigo contagiosa are flattened, and run a rather definite course. The crusts of impetigo are gener- ally greenish, while those of the contagious form are yel- lowish. Impetigo is not so readily inoculable as impetigo contagiosa, and is much more widely disseminated, as a rule. Simple impetigo is a deeper process than the contagious form. Pustular eczema is often itchy ; its pustules tend to break down quickly, run together, and form large patches, which soon become covered with a greenish or blackish crust. These phenomena are entirely foreign to impetigo contagi- osa. Eczema does not present vesico-pustules nor bullae, as a rule, and shows slight tendency to spontaneous recovery. Varicella is an acute* contagious disease, with constitu- tional symptoms in most cases. Its vesicles are smaller than those of impetigo contagiosa, and they run a definite course peculiar to themselves. They are widely distributed over the whole surface, usually appear first on the trunk, sometimes occur upon the fauces, and not infrequently leave pitted sears. Contagious impetigo is in most cases limited to the exposed parts, it never occurs upon the fauces, and its lesions leave no trace. The crusts of varicella are small, while those of contagious impetigo are large. The diagnosis from scabies offers little difficulty. In fact, the location of both diseases upon the back of the hands is their strongest point of resemblance. When we bear in mind that scabies is very itchy, that it occurs usually as a copious eruption upon the hands, wrists, and forearms, about the umbilicus, on the nipples of females and the geni- tals of males, that scratched papules and pustular lesions are more characteristic of it than vesicles, and that it presents 6 IMPETIGO CONTAGIOSA. the pathognomonic furrows, we should not confound it with impetigo contagiosa, which has none of these symptoms. Further, impetigo will, in almost all cases, occur upon the face at the same time with the hands, and that location is very rarely attacked by the itch mite. The diagnosis from pemphigus is the most important one to be made, for the reasons stated in the first part of this paper. Nor is the distinction between the two diseases by any means always easy. The occurrence of the bullous form of contagious impetigo is so rare that it is no wonder it is mistaken for pemphigus. Indeed, it is probable that not a few of the cases reported as acute pemphigus in chil- dren, which possessed apparent contagious qualities, were instances of this bullous form of impetigo. I have had opportunity to observe but four well-developed cases of the bullous form of this disease. Three of these occurred at the Nursery and Child's Hospital, some font years ago, in the service of your chairman and my friend, Dr. E. L. Partridge, who kindly asked me to look at them. In these cases the upper part of the chest and the neck were chiefly affected ; the subjects were all infants; and a focus of con- tagion was ready at hand in the person of a fourth infant, who had well-marked impetigo-contagiosa. The fourth case I saw recently at the Roosevelt Hospital, in the out-patient service, through the kindness of my friend, Dr. W. T. Daw- son. In this case the trunk of the infant had some half a dozen bullae upon it, and the diagnosis would have been difficult if it were not that an older sister and brother pre- sented symptoms characteristic of impetigo contagiosa. I cite these cases to show that when we meet with an acute bullous eruption in children we must always think of the possibility of impetigo contagiosa, and seek for a focus of contagion. The diagnosis between the two diseases can scarcely be made with certainty by the appearances of the IMPETIGO CONTAGIOSA. 7 bullae alone ; we must also take into consideration the gen- eral course of the disease. The differential diagnosis may be given as follows : Pemphigus. 1. Occurs chiefly in adults. 2. No source of contagion can be found. 3. No particular sites of pref- erence ; if anything, it is most frequent on the ex- tremities. 4. Chronic in its course ; marked by frequent re- lapses ; may return from year to year. 5. Bullae are fully distended with a clear fluid, so that their covers appear tense. They often spring up out of the sound skin with- out areola. 6. Lesions often occur in great numbers, so as to cover the whole body, and at times are prurigi- nous. 7. Disease obstinate to treat- ment, and prognosis usu- ally grave. Impetigo Contagiosa (Bullous form). 1. Occurs chiefly in children. 2. A source of contagion can usually be found. 3. Met with most often upon the trunk; sometimes it may occur on the face, hands, or extremities. 4. Acute in its course, rarely lasting more than a few weeks. 5. Bulla? not fully distended, but flaccid, and contain sero-purulent fluid. They have a well-marked red halo while slowly attain- ing their full size. Char- acteristic vesico-pustules are generally present else- where at the same time. 6. Lesions, few in number, do not involve the whole body, and itch but little, if at all. 7. Disease yields readily to treatment; prognosis uni- formly good. 8 IMPETIGO CONTAGIOSA. Ecthyma should not be mistaken for impetigo contagi- osa. It occurs in broken-down subjects, affects by prefer- ence the lower extremities, is seen most often in adults, and its lesions are deep pustules, which are highly inflammatory and painful. It is non-contagious, and inoculable with difficulty. These symptoms will sufficiently distinguish the two diseases. Prognosis.-The prognosis of impetigo contagiosa is always good ; so readily is it cured that the patients seldom present themselves a third time at the dispensary. Treatment.-The treatment of the usual form is to direct the affected parts to be scrubbed with warm water and soap, and covered with a 5-per-cent. carbolized vaseline, or with oxide-of-zinc ointment with carbolic acid in the same strength. If there is a good deal of crusting, the crusts may readily be removed by soaking them with oil or hot water, after which the applications mentioned may be made, or a very mild mercurial ointment used. In the bullous form it is well to prick the bull;® at their most dependent part, and let the fluid escape, after which the lesions may be treated as just indicated. 14 East Thirty-first Street. % ft REASONS WHY Physicians Should MRB/L Subscri be F°R The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,* Published by D. APPLETON & CO., 1, 3, & 5 Bond St. i. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medical men of this country. 4. 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