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Skin, very great heat of, sometimes Skin, increased heat of, but not great; equal to exanthemata or pneumonia; less than in remittent fever; afterwards abdomen generally hotter than head; becomes cold; head the hottest part. picking of skin, especially of nostrils, corners of eyes, and mouth.

Paroxysms pretty regular; exacerbations towards night, remissions in morning.

Age: seldom occurs under three years, more frequent after fifth year; not influenced by sex or constitution.

Varies in intensity, but without any regularity.

Age: frequent under third year; seldom after fifth year; more frequent in boys and in scrofulous constitution; hereditary.

Hydrocephalus is, however, liable to arise in the course of remittent fever; which it does almost imperceptibly.

Dr. Schoepf Merci makes the following remark on the fever of children: "In almost all the fevers of children, headache and gastric disturbance are present, constituting often very prominent phenomena, and very frequently leading to an erroneous treatment, as their import is mistaken. Febrile headache, an obvious but . often little cared for symptom in the adult, almost always gives rise to serious apprehension in the minds of the parents of a sick child; and the medical attendant, frequently considering it as indicative of the commencement of meningitis, becomes prodigal of leeches and mercury. It may happen that diaphoresis follows, and that a case of meningitis is said to have been cured. But the result of such therapeutic interference is not always so favourable, for the organism of a delicate child very frequently becomes unable, from the effects of depletion, to pass through a natural crisis. No less an amount of mischief often follows, also, what may be termed the antigastric treatment. Both errors in practice are not uncommon, since slight soporosity, convulsions, or vomiting, are not unfrequently the prodromi of the acute fever of children. On the other hand, it must be confessed, the above-mentioned and other local affections sometimes complicate the course of the febrile disorder. It becomes, therefore, a matter of the highest importance to study the physical signs of this malady in children."

The treatment of remittent fever in children, like that of continued fever in

et the adult, should be chiefly expectant, medicine appearing to have no effect in

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cutting short even the mildest forms.

Rest in bed, cool drinks, sponging the surface of the body with lukewarm water, mild aperients if necessary are obviously indicated. In diarrhoea, with unhealthy evacuations, the combination of hydr. c. creta and Dover's powder is most effectual; if there is much pain over the right iliac region a warm poultice may be applied, and in the event of the pain not being removed, a few leeches should be put on. Cold should be applied to the head when delirium is present, and when considerable determination of blood to the head is manifest, attended by great restlessness and noisy delirium, depletion by leeches to the head may be practised. The vital powers should be supported by nutritious alimentation, and stimulants are necessary during the second and third weeks of the affection. West speaks highly of a mixture consisting of four minims of dilute hydrochloric acid, eight of compound spirit of sulphuric ether, and three drachms of camphor mixture every six hours for a child of five years old. The various complications should be treated in the manner directed in the various chapters on these subjects.

The convalescence is frequently exceedingly tedious, and in these cases change to sea air is most likely to prove beneficial.-P.H.B.]

BOOK XVII.

ON DISEASES OF THE SKIN.

The greater number of diseases of the skin are developed in children as well as in adults, and most of them present, at different ages, precisely similar anatomical characters. With respect to these, it is, consequently, useless to give a description of them which will be readily found in special treatises on cutaneous diseases. There are a certain number, on the contrary, which are only observed in children, or which, in the tender age, present differences which it is important to mention. These are gourmes, redness and fissures of the buttocks and thighs, simple pemphigus, erysipelas of infants, induration of the skin, &c.

CHAPTER I.

ON ERYTHEMA AND ULCERATION OF THE BUTTOCKS AND
MALLEOLI.

A slight cutaneous affection is often met with in young children; it was formerly termed intertrigo, that is to say, erosion, which sometimes becomes the origin of rather severe symptoms, and which is always the cause of acute pain. This disease is characterized by simple erythema of the buttocks, genital organs, internal parts of the thighs, Late 2 heels, or malleoli, an erythema followed by erosion and ulceration of these parts.

This disease is met with in children whose constitution is feeble and who have frequently diarrhoea, in those who have derangement of the digestive functions, and in those who, without the influence of these circumstances, are badly cared for and imperfectly attended to.

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Erythema of the thighs is the result of the irritation of the skin by the urine and excremental matters; the intensity which it may acquire may be readily imagined when it is considered that the evacuations are very numerous in diarrhoea, that the children are constantly moistened and that they sometimes remain much too long in the excrement, that the changes of linen are not sufficiently frequent,dition especially in the children of the poorer classes, and finally, that in this last-mentioned case, the linen of which the napkins are formed,

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is sometimes much too rough for the highly delicate skin of little children.

Erythema of the malleoli and of the heels also depends on the Max irritation of the skin produced by the excremental matters, but it is more especially the result of the friction of these parts against each other or against the clothes. Thus, when care is not taken to isolate the limbs of the little child by means of the first layer of linen which surrounds them, the internal malleoli are incessantly im rubbed together in the to and fro movements of the heels on the cloth. The result is, these parts become red, and lastly ulcerate to Aa greater or less extent.

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Erythema has been considered as a very unfavourable general symptom, and precursory of certain diseases of young children; thus M. Valleix is of opinion that it always precedes an attack of thrush. This may be; but it must be at the same time confessed that the children are at the time labouring under diarrhoea of one or more days' duration, a circumstance which it is absolutely necessary to bear in mind for the reasons we have but just mentioned.

Erythema is certainly in relation with the state of the constitution in children; it preferably develops itself in subjects who are weak and of bad constitution. But this circumstance would be of little value if there was not at the same value if there was not at the same time derangement of the lulu alimentary canal characterized by a commencement of diarrhoea. The disease appears very rapidly in children of bad constitution. It requires a much longer time to develop itself in those who are strong and robust and who have only fallen ill accidentally.

It is observed in the course of all diseases of infants at the breast, when there is an increase in the number of stools and when the children's linen is not changed sufficiently often. It is a disease which is especially in relation with diseases of the alimentary canal. constitutes the most constant complication of thrush and of enterocolitis.

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Erythema of the buttocks and the thighs is, in the first instance, characterized by a simple redness of the integuments. The redness extends to the genital organs, and down the entire length of the alindés a limbs to the heels. Small reddish papulæ, more or less confluent, quickly form, and each of these becomes the seat of an erosion of the epidermis. Thence results a great number of superficial ulcerations of the skin, the base of which, red, raw, and bleeding, is observed

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on a level with the circumference. These ulcerations extend in size and in depth; they coalesce with the adjoining ulcerations and sometimes acquire a considerable diameter. Their appearance undergoes an insensible change; the surface is rough, reddish, and presents a * Clinique des maladies des enfants. Paris, 1838; p. 337.

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greyish speckling formed by the exudation of plastic matter around the orifice of the absorbent vessels. Each of these points extends, coalesces with its neighbours, and thence a false membrane results which covers the ulcer and becomes organized so as to constitute the dermis. Thus their cicatrization is brought about. The work of reparation does not take place as in ordinary wounds; so far from being effected by the circumference, it commences by the centre and takes place by means of the false membrane to which we have just alluded, which becomes organized and is covered with a fresh epidermis. After cicatrization, reddish, copper coloured spots remain which n might be easily mistaken for papular syphilis if we were not aware of their origin.

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Reddish The erythema of the malleoli and of the heels is also the result of irritation of the skin by irritant matters; but we must take into Copps consideration the repeated frictions of these parts, which slightly re changes the nature of the inflammation.

The erythema is only observed on both heels and on the internal malleoli, that is to say on those parts which are reciprocally rubbed in the movements of the child. This redness rapidly gives place to deep ulcerations, with a greyish, dry base, and irregular edges, which Course, is project and are of a phlegmonous redness. The ulcerations of the buttocks, thighs, and genital organs, persist but les as long as the cause which originates them; they are kept up by the

irritation produced by the excrementitious matters and they begin to

long

cicatrise when the frequency of the alvine evacuations is lessened. However, there is one circumstance which is very much opposed to as the the cicatrization of these wounds; I refer to the repeated frictions Carusele. to which they are subjected. In fact the patient requires to be changed as soon as the linen is soiled; it is unswathed and the wounds are maine. necessarily interfered with. The dressings, which adhere more or less to the ulcerations, are disturbed, the adhesions are broken, blood flows, and this happens every time the child has to be cleaned. It is impossible that amidst such manoeuvres cicatrization can readily take place.

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These ulcerations are sometimes the cause of swelling and inflammation of the scrotum, gangrene of the vulva, and erysipelas in very holes young children. They must be most carefully attended to in order to avoid such accidents and to ease the pain which they occasion. Attention to cleanliness is of the utmost importance to bring about the cure of erythema and ulceration of the buttocks, thighs, and hone malleoli. Bathing the child, washing it with decoctions of aromatic herbs, changing it as soon as the linen is soiled, powdering the wounds with lycopodium, and the application of soft linen rag, are the principalĈi means of treating this disease. Perfumed lycopodium powder is the

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best to sprinkle over the fissures of the skin of children. It •protects them in the most perfect manner, for it is not pervious to liquids, and water runs off its surface. Powdered starch, on the contrary, becomes moistened and forms a crust which becomes

cult to remove. Care should be taken not to make use of metallic powders, the salts of lead for example, as has been sometimes done, at the risk of bringing on lead cholic in children (Chaussier.) Most of these substances are very active, and although insoluble, they may be absorbed, and determine the most serious symptoms. I may here instance the terrible case of a child inadvertently poisoned by the mother sprinkling over a fissure in the inguinal region a pinch of corrosive sublimate. There was not time for the eschar produced to become detached; for the child died on the eighth day in a state of the most complete mercurial cachexia, with gangrenous stomatitis and gangrene of the mouth, accompanied with loss of all the teeth.

If these ulcerations of the thighs are large and numerous, and if it appears insuficient to treat them by emollients and powders, they should be protected by a simple dressing, which should be renewed as soon as it has become soiled. Cerate is the best application to make use of. It should be spread upon a piece of lint and kept applied by a bandage; but this is not absolutely useful, for its place may be perfectly supplied by the first layer of the swathing. It is however more appropriate to employ it so as not to allow all the child's clothing to be soiled.

Ulcerations of the internal malleoli require the same care as those. we have just alluded to; only it is necessary, in order to favour their cure, to prevent the reciprocal friction of these parts. The first layer of the swathing is sufficient to ensure this result. It should be employed to envelop each limb so as to isolate it from its fellow, and the other clothing applied above as usual.

CHAPTER II.

ON INTERTRIGO, OR THE FISSURES WHICH ARE FORMED DEEP IN THE FOLDS OF THE SKIN.

Fissures of the skin form a variety of the intertrigo of the ancients. They are met with in very fat children; are seated in the folds of the groin, thighs, and neck; are more especially observed in the situations where the skin forms deep folds, when two cutaneous surfaces are continually in contact; they commence by a slight redness accompanied by mucous moisture, and followed by erosion of the dermis.

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