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Book XVII, Chap. III.]

ON IMPETIGO.

627 Cure Shirts

the contrary, the impetigo of weak and scrofulous children, of ake Gradual.

strumous race, should be treated with more circumspection; it should be gradually eradicated, internal remedies, purgative and tonic, being

and bee

at the same time administered, in the aim of fortifying the constitution Combined

and of determining to the alimentary canal, the flux, salutary perhaps, from the cutaneous surface. We should, at the same time, always au keeping in view the diathesis alluded to, apply a supplemental drain at the arm, which should be kept open for several weeks. Nevertheless, alterative. if one is to decide between the employment of purgatives and of blisters, I should not hesitate to proscribe this last mentioned remedy which possesses the inconvenience of determining a fresh impetigo on the arm of those children which have really an impetiginous diathesis.

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Impetigo of the face and impetigo of the scalp require the use of the same remedies. At the commencement of the disease, cooling, acidulous drinks, baths, emollient lotions and slight purgatives, should be prescribed. Lotions have been recommended composed of woman's milk, the nurse being desired to squeeze the breast so as to wash ducous over the diseased parts. These lotions possess no advantage over the ordinary emollient lotions.

drinks

1 Baths

Purqutun

When impetigo has existed some length of time, and arrived at a chronic state, the use of topical astringents should be combined with/ that of purgatives. The crusts of the face and scalp are to be detached by means of poultices of bread crumbs or of linseed meal; the head should be shaved; alkaline lotions, with the bicarbonate of sodale prescribed, or with the sulphurous waters of Enghien, Barége, and Cotterets, with a weak solution of nitrate of silver, gr. j to 3 iss of felons. Lotions. distilled water, 'and lastly the liquor of Van Swieten; this last means is the most useful of all. I have seen it very frequently employed

by M. Trousseau, and I have always observed it succeed. This Yr of Chrenis

treatment should be ordered in the following manner: Detach the crusts; shave the head; apply lotions three times a day for a quarterl of an hour with linen moistened with the liquor of Van Swieten, diluted with an equal quantity of water. Care should be taken not

The Crusts

to make use of a sponge, which might, from its composition, change with poul.

the nature of the remedy employed. A slight purgative administered every other day should be added to this treatment.

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If the impetigo exists at the same time on the body, baths containing corrosive sublimate in the dose of from fifteen to sixty grains should be used according to the age of the patients. This plan of treatment, I repeat, is one of the most useful that can be employed, and it may uued. be prescribed with the utmost confidence, without fear of seeing any of the symptoms of mercurial poisoning supervene.

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CHAPTER IV.

ON PEMPHIGUS.

Pemphigus is a bullous disease of the skin, characterised by an eruption of rosy patches, followed by bullæ, filled with liquid, and 1 by thin lamellar crusts.

Pemphigus, which is observed in the adult under the acute or under the chronic form, is always developed in children at the LA 4 breast as an acute disease.

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There are two kinds of pemphigus; the simple infantine pemphigus, band and syphilitic pemphigus. This latter will become the object of a special chapter incorporated in the history of the syphilis of infants.

Simple pemphigus is never congenital; it appears one or several months after birth, under the form of more or less numerous bullæ, surrounded by a rosy areola, filled with clear serosity, either limpid or slightly opaline and diffused over the whole body on the surface of the skin, without involving its tissue under the form of ulceration. These characters may alone serve to distinguish simple pemphigus from syphilitic pemphigus, which is especially developed on the palms of the hands and on the soles of the feet; but there are in addition commemorative circumstances, which, by indicating in the parents the existence of a recent or distant infection, present a still more convincing element of proof.

Simple pemphigus is usually the result of poverty or of want of cleanliness.

Exanthematous patches are first observed on the skin, over all the body, then, at the end of twenty-four or forty-eight hours, bullæ are formed, at first discrete, but sometimes very numerous over the entire body. They are filled with clear serosity, of a yellowish colour, sometimes opaline, then they dry up and shrivel. Thence a small wound results which becomes covered with a thin, yellowish, lamellar crust, which adheres for some days and then falls off without leaving any traces except a reddish spot.

In young children, the eruption of pemphigus is apyretic, accom"panied with a more or less intense fever. It is usually apyretic. It lasts from seven to eight days, is not at all a serious disease, and always terminates in resolution.

Baths and diluent drinks constitute the whole of the treatment of pemphigus. pemphigus. If the bullæ are very large, they should be evacuated early with the point of a needle, so that the epidermis may become

The paleus of & mild

applied to the skin and hasten the cicatrization. Some spoonfuls of the compound syrup of chicory should be given to the children, or calomel in a purgative dose, and a spoonful of the syrup of bark should be administered every day.

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The erysipelas of infants and children at the breast is a very frequent disease and one which it is important should be well understood, in consequence of its singular progress and of its extreme

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desrase severity. It is more often met with in hospitals than in the city. 4peciali..

According to M. Baron, physician to the Hôpital des Enfants Trouvés, it appears that there are always one or several examples in the infirmary of this establishment.

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This disease has been described by F. Hoffman: Umbilicalem tuks. regionem in infantibus frequentius infestat, ac inde per abdomen spargitur cum gravibus pathematibus, funesto ut plurimum eventu Severe

by Underwood, Billard, M. Blache,* and M. Trousseau in an interesting monograph recently published.

CAUSES.

:

Erysipelas is nearly always the result of circumscribed inflammation tutuma. of the skin; it succeeds the inflammation which surrounds the pustule of vaccination; impetigo of the scalp, eyes, or ears; fissures of the thighs, scrotum, and lips; and lastly the inflammation which accompanies the detachment of the umbilical cord. The last of these is the most common cause; and it is to this that the greater numberustules, of cases of erysipelas of infants must be referred.

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After having pointed out the occasional causes of erysipelas, namely: cutaneous inflammations around the pustules of vaccination, around fissures of the buttocks and thighs, around the cicatrix of the umbilicus, &c., it must be stated that these causes would be without result, did not a totally different influence come in aid of their action. In fact, we every day observe children who present similar morbid changes without erysipelas being the consequence. The individual must therefore possess a predisposition favourable to the development of the thi

disease.

This predisposition is determined by the bad hygienic conditions in which the children of the poor are placed, by the deleterious influence

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+ inal to which they are subjected in consequence of their over-crowding in Sidumie the hospitals for children, and lastly, by the epidemic constitution of the time. Thus, erysipelas is never more frequent than in the course of the epidemics of puerperal fever. It is to this circumstance that the development of the cases of erysipelas is allied, and not to slight wounds which readily cicatrize in a more favourable hygienic constitution. It is to this epidemic influence that the fatality of the disease , should be referred.

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Erysipelas is also sometimes the result of imperfect nourishment of the children, or of alimentation by a diseased milk; thus M. Rayer has seen this disease appear in a child who for several days was suckled by a nurse labouring under dysentery. It is not at all impossible that milk altered in its source by unwholesome food, muscles for example, may produce this cutaneous disease.

SYMPTOMS.

This disease usually commences as a local affection, without being preceded by those general disturbances of the alimentary canal which are observed so frequently in the erysipelas of adults. It is not preceded by fever, save in some exceptional cases; when, for example, a violent inflammation of the arm around the pustules of vaccination is the source of the evil. Sometimes, on the contrary, it presents all the symptoms of a general disease which is announced by fever,

ally los convulsions, icterus, &e.

As soon as the erysipelas has declared itself, the fever is excited or increases, and is easily recognized by the state of uneasiness, restlesse ness, and want of sleep into which the young children are thrown, by 1 the thirst which consumes them, by the heat of skin and the degree of the acceleration of the pulse.

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At the starting point of the erysipelas, on the abdomen, the head lants or the limbs, whether this be the inflamed umbilical cicatrix, or the fissures of the skin, or the inflammatory areola of the pustules of vaccination, or lastly, the pustules of impetigo, we discover around all these changes, the skin inflamed to a greater or less extent; it is red, tense, shining, and very hot. Pressure with the finger is very painful, it leaves a slight depression, and causes a whitish colouring which ceases with the pressure, to be rapidly replaced by the usual red colour.

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From this point the cutaneous inflammation invades the neighbouring utuse parts; from the abdomen it extends to the pubes, the buttocks, and the lower limbs; from the neck and arms it diffuses itself over the It remains stationary

Shed, Gut head, the trunk, and lastly the lower limbs.

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in the same spot from twelve to twenty-four hours, and it is only when it has extended onwards that the parts first invaded lose their

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Fears on pressure

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ON ERYSIPELAS.

is ther followed 631 by a

Book XVII, Chap. V.]
colour and swelling, and assume a yellowish tint before presenting o
desquamation of the epidermis.

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The erratic progress of this inflammation is perfectly well characterized, 4 desys, and every one may follow it by carefully observing the young children Kammating who are attacked by it. It propagates itself from one place to another, and it every day occupies a fresh part until it has run over the entire surface of the body.

Sometimes, as M. Trousseau has remarked in the work we have

Severally

cited, when the disease has become general, this progression is not traves

Over the

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entirely the same. The erysipelas returns to the parts which it has already occupied, but then it commences in a spot at some distance from its seat without having run over the intermediate parts. The Entire erysipelatous inflammation thus occupies several parts of the body at the same time, but this peculiarity is very rare. (In young children the red colour which erysipelas presents is not very manifest except on the trunk and on the upper part of the limbs. When it extends to the feet and hands the redness is very faint and scarcely to be detected. There is only a slight pink colouring observed not? there.)

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on the The parts attacked by erysipelas are always swollen, as the impression left by pressure of the fingers testifies. This oedema is not always a David7 very decided on the trunk, but is, on the contrary, very considerable on the hands and feet, which are very much enlarged and sometimes transparent, as in the cases of general serous effusion. When the face is the seat of the disease, which is seldom the case, it is very bloated, but the swelling is not to be compared to that which is observed in the erysipelas of adults.)

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Such are the local symptoms of the erysipelas of infants and of Ichildren at the breast. The general symptoms at the commencement of the disease have been partly indicated, but they insensibly assume h a much greater intensity. The face is exceedingly pale and the lips colourless. The restlessness is very great; continual cries give proof of the suffering experienced by the patients; the pulse is excessively frequent and feeble. Vomiting or diarrhoea are then observed, and sometimes convulsions, which put an end to the existence of these Svon become Typhoid

unfortunate children.

DURATION-TERMINATIONS.

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The duration of the erysipelas is very variable. We have not bulsions

observed a sufficiently large number of cases to give a decided opinion on this point. Nevertheless, we should fix, from our observations and in an approximative manner, the duration of this disease between four and five weeks, a result similar to that which has been obtained by M. Trousseau.

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