.A. CASIE OF Ringworm ot the Scalp, COMPLICATED BY PUSTULAH ECZEMA-CUHE. ”“Y~ \/ A. H. OHMANN-DUMESN1L, PROFESSOR OF DERMATOLOGY, ST. LOUIS COLLEGE OF PHYSI- CIANS AND SURGEONS. Reprint from tlie June Number of Tiie Cincinnati Medicai. News. Although pustular eczema of the scalp is an ordinary affection, tinea capitis is rather infrequent in this city, and a complication of both diseases, attacking the same locality, is unusual. My purpose in reporting the following case is simply to call attention to the care which must sometimes be exercised in the examination of such cases, as well as in the treatment and management, the last being perhaps as important as any feature if not more so. Case.—C , a well-nourished boy, a little over seven years of age, has parents in well-to-do circumstances. He is a blonde, well nourished, apparently, and is a child of marked intelligence and quick perceptions. He is well developed for his age. His hairy system, however, is some- what deficient in quantity and his teeth give evidence of malnutrition in earlier life. Upon inquiry is developed the fact that his general health is not good. There is a want of power in assimilation and weakness on the side of the digestive apparatus. He is more or less dyspeptic. Besides this, he has a ravenous appetite and is permitted by his par- ents to indulge in “stuffing.” The result of this is the dys- peptic condition accompanied by an irritable disposition and “nervousness.” In addition to this, so-called malarial symp- toms exist. The local condition when I first saw the patient, who had been referred to me by Dr. Love, of this city, was about as follows : The scalp was the seat of a pustular eczema of 2 RINGWORM OF THE SCALP, ETC. some standing. Yellowish crusts varying in size from the small finger nail to a silver dollar, were disseminated over the scalp. Several of these had a marked circular form, notably one in the median line, an inch posteriorly to the edge of the hair in front. Pustules were also discreetly dis- tributed. Underneath a number of the crusts, which were from two to four lines in thickness, a collection of pus could be found. The subjective symptoms accompanying this condition were extreme tenderness upon pressure and an intolerable itching. The pruritus was so great that it pre- vented the patient from sleeping and, in consequence, increased the nervous irritability which was present. The peculiar configuration of some of the crusts aroused my suspicions as to the presence of tinea tonsurans, more especially as the patient’s sister was the subject of this latter affection, at the time. A few hairs were extracted, and upon microscopic examination, showed the well known in- filtration with the spores of the tricophyton. Thus much being determined, the question which now arose was as to the best method of local treatment to adopt. The first thing to be done was to remove the crusts. While it might appear to be a comparatively easy matter, it proved to be quite a task, on account of the irritability of the patient. Olive oil was freely applied to the entire scalp, and, in a few days, the crusts began to separate, showing raw, bleeding and suppurating surfaces beneath. Then began the routine treatment of eczema of the scalp. This was unsuccessful, in so far as it permitted the crusts to re-form and did not in the least alleviate the intense itching which was present. Having continued this for about two weeks, I decided upon a radical change in treatment, and, as the result proved, a successful one. The crusts were again drenched with oil and removed with forceps, despite the outcries of the patient. Immediately thereafter the entire scalp was freely painted with campho-phenique, this opera tion being repeated morning and evening. From this time on, the crusts returned very slowly and in diminished numbers, the extreme tenderness of the scalp became less, as also the itching, and the suppurative process markedly decreased in quantity. In about two weeks the condition was practically cured, the scalp was clean, and all objective as well as subjective symptoms referable to it had lisappeared. A number of bald spots showed themselves in the locality where the ringworm had existed and a fine RINGWORM OK THE SCALP, ETC. 3 growth of hair soon manifested itself upon them. Micro- scopic examination of the young hairs failed to reveal the spores of trichopyton, so that my conclusion was that it was cured. The general treatment and management of the case, I have no doubt, exercised a marked influence upon the suc- cessful termination of the condition. In regard to the gen- eral treatment, I had but little to |do, it being conducted upon general principles. Anodynes were given at night to secure rest. I ordered alkalies and a restriction of the diet. Oat-meal mush in the morning and but a small quantity; a little meat at noon, with plain vegetables, and bread and milk at night. The patient rebelled at this dietary, more especially as all pastry and sweets were prohibited and coffee stricken off his bill of fare. The results, however, were such as to show the advantages following such a regi- men. The stomach obtained tone, the nervous excitability disappeared, factitious strength gave way to vigor, and the child was in every respect one with a new constitution. This latter result, however, was not attained until some time after I had dismissed him from my care. Remarks.—One of the interesting points in connection with this case is the fact of the cure of the ringworm. No particular attention was paid to this, as it was my object to first rid the patient of the inflammatory trouble which existed and then turn my attention to the tinea. I was more than agreeably disappointed when I saw that the par- asitic trouble had disappeared, as it is a well-known fact what a difficult matter it is to eradicate tinea tonsurans, some cases only disappearing spontaneously in years in spite of all the treatment. The question which naturally arises is, how did it disappear? In my opinion, the suppurative process of the eczema penetrated the hair follicles, and by rapid inflammatory action destroyed the hair bulbs, thereby removing the trychophyton with its pabulum. Croton oil vesication is one of the methods of treatment of ringworm, the object being to produce just such a condition as the eczema produced in this case. That the campho-phenique exercised a certain amount of influence on the condition is also probable. Being a parasiticide, it, no doubt, destroyed any lingering spores; or at least prevented their prolifer- ation. During the whole course of treatment the head was cov- ered with a close fitting skull-cap made of knit material, this 4 RINGWORM OF THE SCALP, ETC. precaution being adopted for a two-fold purpose—first, to avoid disseminating the parasite; and, second, to prevent external irritants from reaching the scalp, as well as to render less destructive the scratching indulged in by the patient. Another point I wish to refer to in reference to the last drug employed, is that it prevented suppuration to a great extent and also acted as a local anaesthetic. It acted admir- ably in this case, as it does in all cases of pustular eczema, and was rapid in its action on account of the general treat- ment which was added to it. One important feature in the entire treatment was that no washing of the scalp was indulged in except upon two occasions, when tincture of green soap was used. Note.—As it is customary among many to report suc- cessful cases and fail to record results observed at some more or less remote period, I take this opportunity of add- ing this appendix to the history nearly two years after the apparent cure (May, 1890). The boy has grown in height and weight, but weighs comparatively less to his height than when first seen prior to treatment. His scalp is not only perfectly healthy, but he has acquired a splendid suit of hair. He is in better health than he ever was before, a sojourn at the sea-shore last autumn having greatly benefited him. This places the cure of the ringworm beyond a doubt, and the fact that the bald spots have entirely disappeared also proves the suppurative process to have been of that super- ficial nature characteristic of eczema.