Sir R. Brodie had treated small subcutaneous nævi, in situations where it was advisable to avoid the scars which would follow the use of the ligature or the knife, in the following way :-He melted some nitrate of silver in a platinum spoon, and dipped into it the blunt points of two or three probes, which, being withdrawn in the space of a few seconds, were found to be coated with the caustic; he then made one, two, or three punctures, according to circumstances, in the nævus, by means of a small instrument resembling a lancet, and into these punctures he inserted the armed probes, and allowed them to remain for a minute or two, until the nitrate became decomposed by acting on the structure of the nævus; he had a little oil in readiness in order to counteract the too violent effect of the caustic. In this way inflammation was set up, and the tumour became consolidated. In general one operation was sufficient to effect a cure, in other instances the proceeding required to be repeated twice, or more frequently, the pain attending which was very slight. In the case of a child who had a large nævus extending over the greater part of the face, and in which a variety of means had been resorted to, the application of nitric acid among the rest, he had pursued the above plan in a part of the tumour; in the other portion he had broken up the net-work of vessels, by adopting the proceeding recommended by Dr. M. Hall. A perfect cure ensued, although an ugly scar remained on the part to which the nitric acid had been applied. He had also treated successfully, by this mode, a case of an ugly subcutaneous cellular nævus situate at the extremity of the nose. He punctured it in several parts, and then introduced the probes. Some slight puckering of the skin where the caustic had been inserted were the only marks which remained. Whilst speaking on this subject, he might also allude to another kind of marks very commonly found upon the face, and consisting of little stellated patches of blood-vessels. Generally speaking these went away when left alone, but persons in high life frequently complained of them as blemishes, and requested means to be adopted for their removal. When looking at these spots through a glass it was easy to discover one or two larger vessels entering into and supplying the net-work, which spread out like the web of a spider. Having found the supplying vessel or vessels, he placed on them the end of a small probe, and if he found that the red spot entirely disappeared, he proceeded thus: he divided the vessel by a minute puncture, and then destroyed it by inserting a piece of caustic potash, scraped to a very fine point; he then introduced a small quantity of vinegar, in order to prevent the caustic extending its influence beyond a certain limit.

Mr. Cæsar Hawkins, in allusion to the use of steel needles as recommended by the author of the paper, in the treatment of nævi by ligature, suggested that the old silver needles would not require the nipping off of their ends, and would not, therefore, be so likely to produce irritation. Nævi generally consisted of a mixture of arteries and veins; occasionally, however, they were entirely venous. He had seen a congenital case of this kind, in which the disease occupied the back of the head and neck, and extended down as low as the scapula,-the tumour consisted of branches given off from the post-aural, occipital, and lingual veins. There was no discoloration of the capillaries, and no pulsation. The child was now seven years of age, and the tumour increasing.

Mr. T. B. Curling rose to notice one of the objections which the author of the paper had advanced against the treatment of nævi by setons, and which consisted in the fear he entertained of the occurrence of dangerous homorrhage. Now he (Mr. C.) had used the seton in a great number of cases of nævi, no hemorrhage, except such as was readily stopped, taking place; he thought, indeed, the great advantage of the treatment by setons consisted in its freedom from the occurrence of hemorrhage. The treatment by ligature was objectionable; for, even though it might cure, it left an ugly scar, and was not free from danger. In a case in which the crossed

ligatures were applied, the child perished in a few days, from the occurrence of great constitutional irritation. The mode of treatment by injection, he believed was originally proposed by Mr. Lloyd. There was one source of danger from this proceeding, for as it was necessary that very strong caustic should be employed, there was fear of its making such an impression on the larger vessels as to be attended with danger. In a case treated on this plan the patient died almost instantly, probably from the above cause. In what way did Mr. Tyrrell guard against the occurrence of such an accident? Mr. Lloyd, for this purpose, had recommended the use of a piece of pasteboard with a piece the size of the disease removed from it.

Mr. Tyrrell considered that the explanation given in the paper, of the precautions he took for preventing the occurrence alluded to by Mr. Curling, was sufficient. He (Mr. T.) had there stated that he invariably consolidated the surrounding cellular tissue before he interfered with the tumour itself. In two cases in which he had employed the injection the disease was much reduced in size before he touched it, proving the influence of the consolidation around. He thought this plan quite as successful as the one recommended by Mr. Lloyd. He (Mr. T.) did not bring forward his plans as perfect, but merely as the result of his own experience. He regretted that in the reading of the paper the secretary had left out the most important case, which had been treated by the application of nitric acid. In this instance the nævus was cutaneous, occupying part of the superior eyelid, the whole of the left cheek, half of the upper lip, and extended up to the septum nasi. Tartar emetic had been employed, and part of the disease had been destroyed by it, but it was extending in other directions. He circumscribed the boundary line in this case, the nævus being very large, at two distinct periods. This proceeding was followed by no extension of the disease. He then painted over the surface, piecemeal, with a brush dipped in the acid, and touched the neighbouring portion to the last, at each successive application. In this way hemorrhage was avoided, and, after five or six applications, the disease was removed, there being only here and there a slight contraction of the skin, consequent upon the use of the tartar emetic.

Medical Department of Cincinnati College.-The number of students in this institution during the last session was 112; of whom 52 were from Ohio; 14 from Alabama; 11 from Kentucky; 10 from Indiana; 2 from Illinois; 1 from New York; 1 from Louisiana; 7 from Mississippi; 5 from Tennessee; 4 from Virginia; 2 from Pennsylvania; 1 from Arkansas; 1 from Missouri, and 1 from England.

The number of graduates was 27.

Medical Department of Transylvania University-At the last session 211 students matriculated; of whom 106 were from Kentucky; 25 from Tennessee; 19 from Alabama; 10 from Mississippi; 8 from Virginia; 7 from Georgia; 5 from North Carolina; 5 from Missouri; 4 from South Carolina; 4 from Maryland; 3 from Arkansas; 4 from Illinois; 3 from Indiana; 2 from Ohio; 2 from Louisiana; 2 from Pennsylvania; 1 from New York, and 1 from Texas.

The number of graduates was 54.

Great efforts are making by proper buildings, an infirmary, &c., to render the instruction in medicine even yet more effective.

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 srutulata, 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