These fissures are prevented and cured by attention to cleanliness, baths, and by powdering with starch, or better still with lycopodium, the parts as soon as they are observed to become red.

Fr. Keep

clean 4

apply Stard и дуговом diuino

CHAPTER III.

ON GOURMES.

Yourmes

The term gourmes was formerly applied to certain eruptions of the face, eyelids, and scalp, with or without swelling of the glands of the neck; it was considered that these diseases were salutary and destined to expel from the economy certain deleterious principles a grueni contained in all children. It was a matter of necessity that the ! gourmes should come out, and should not be interfered with, under pain of determining serious symptoms at some future time.

"Meaning Аниребері

This term has now lost all its value in the eyes of the medical world, who look upon gourmes as a very complex disease, as frequently a local as a general one, and which we should sometimes endeavour to cure and sometimes leave alone in consequence of the bad state of the un constitution of the children. It is now only the vulgar who systematically would leave gourmes to themselves so as not to lead to the injury of their children's health. Under the term of gourmes must be ranked impetigo and eczema, that it is to say all the eczematous and impetigenous diseases of the skin, face, eyelids, scalp, and several scrofulous affections of the glands of the neck.

1ST. ON IMPETIGO.

Impetigo is characterized by the presence of cutaneous pustules, of hara small size, irregularly scattered, most frequently close together, and which generally form thick, irregular, yellowish crusts.

The impetigo of children is observed on the face and scalp. It is very important to distinguish between this difference of seat, for the disease presents different characters in each of these regions. The impetigo of the face preserves its ordinary characteristics; but the impetigo which is developed on the scalp is so much modified that it has been confounded with another disease of the pericranium which has been ranked amongst the group of tinea. The term tinea mucosa was applied to it, to distinguish it from ordinary tinea.

On impetigo of the face. It appears at first under the form of red patches, more or less distinct, slightly elevated, which become covered with small pustules slightly projecting above the surface of the skin. These pustules burst and become covered with a drop of liquid which

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dries and forms a semi-transparent yellowish crust. The eruption may usu, be more or less extended, and formed of more or less numerous pustules. It is sometimes sufficiently confluent to form a large surface, in which pt is impossible to recognize the primary element of the disease. This Yigurata portion of the skin is covered with soft, yellowish, semi-transparent which out crusts, termed crusta lactea, which are very easily detached and are almost immediately reproduced.) The circumference is reddish, as if herysipelatous, and pustules of unbroken impetigo are often observed, which soon become united with those which are already agglomerated. It is thus that the disease extends further every day.

one.

When the pustules have coalesced so as to form a rather circumscribed dysurface, the disease is termed impetigo figurata; the epithet sparsa, on the contrary, is applied to that variety in which the pustules are scattered and disseminated over the face.

blul Impetigo of the face attacks the cheeks, lips, back of the ears, and eyelids. That which occupies this region is the most serious, for it is sometimes the origin of ciliary blepharitis, and often causes acute temples inflammation of the conjunctiva.

This eruption is accompanied by slight pain, itching, and a very may disagreeable sensation of considerable heat. disagreeable sensation of considerable heat. It does not sometimes last more than from fifteen days to three weeks; at other times it is prolonged for several months; in this case it is almost always allied to a bad constitution, the strumous diathesis, for example. When the impetigenous crusts are completely detached, the skin preserves for a long time a reddish tint, which finally disappears, and which sufficiently indicates the seat and form of the disease. Co-Impetigo of the face is not of itself a serious disease, for it is very easily cured; it is only of importance when it becomes developed in scrofulous children, and when it affects the eyes or ears. It then becomes the origin of interminable scrofulous ophthalmia, and is the cause of swelling of the glands at the side and back of the neck, in the same manner as excoriation of the toes occasions enlargement of the inguinal glands. This complication is a very serious one, for the enlargement of the cervical glands of a scrofulous child disappears very slowly and often does not disappear at all. The glands remain swollen, and become transformed into tubercular matter, and thence cold abscesses result, which opening externally, leave on the neck ill-conditioned wounds and indelible cicatrices.

2ND. ON IMPETIGO OF THE SCALP-MUCOUS TENIA. There are two varieties of impetigo of the scalp; impetigo larvalis, and impetigo granulata.

1st. When the pustules of impetigo are developed on the head and when they are very numerous at the same spot, they cause a very

Pathology crusts form and cover the surface of the scalp; they cause agglutination pusof the hair under the form of large irregular layers which mask the tulisare

abundant mucus oozing which exhales a very nauseous odour; yellow

subjacent raw surface. This is what is termed impetigo larvalis.

It is accompanied by rather acute pains and insupportable itching, y deu and it may be, like impetigo of the face, the cause of inflammation merousm and suppuration of the neighbouring glands. When it extends from the head to the ears and face, it assumes the character of the preceding variety, and, like it, it becomes the origin of otitis and very severe ophthalmia.

Нибиш

брок

Eder

2nd. Impetigo granulata is characterized by the presence of small, whitish pustules, isolated, developed on the scalp, at the base of the the org hairs which cover it. Greyish crusts succeed these pustules when perus they have burst; they dry up, and form round several united hairs, crusts, small dry granulations of a greyish colour, of a greater or less size, and moveable at the base, when a pedicle is observed which is only the hair. These crusts are sometimes in very great number, and Granulata the head is covered with them; they easily become detached, and are very rapidly reproduced.

The dance Like the preceding, this variety is accompanied with intolerable path. Chane

itching. Like it, also, it is the cause of inflammation and suppuration of the glands of the neck. It exhales from the head a nauseous Except its odour of such a disagreeable nature, that in children imperfectly this daily looked after, it is impossible to remain near them. This odour is not present when care is taken to wash and properly cleanse the heads of the patients.

The hair is not always destroyed in impetigo of the scalp; it falls off, but reappears after the cure of the disease. Impetigo larvalis hair and impetigo granulata only invade the surface of the skin; they do not extend into the interior of the cul-de-sacs, in which the

hair bulbs are found, and which are not affected.

The two varieties of impetigo, which constitute mucous tinea, are observed in young children. The first is most frequent in infancy

at the period of the first dentition, and the other variety preferably be up. attacks children of more advanced age, who are approaching the cand second dentition. It is also as much observed in strong and vigorous subjects as in those whose constitution is bad or ill-conditioned. The disince Mucous tinea is a rather tedious disease which lasts several months dos no at least, and sometimes continues beyond a year. In this case it is the fault of the parents, who will not give attention to this/ disease, and who encourage it in the intention of purging the children of the humours which they suppose exist in their organism. Thus, impetigo left to itself is a very tedious disease, which heals with difficulty. On the contrary, when the proper plan of treatment

R R

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1

is applied, it disappears very rapidly. The cure of it is generally easy, and is accomplished in three or four weeks at most.

TREATMENT.

The treatment of impetigo involves one of the most serious medical questions, and one of the most difficult to resolve. Ancient writers made scruple of curing this disease, in the fear of bringing on serious morbid symptoms in the children; some moderns, on the ecctrary, very decidedly declare for the impunity of this cure.

What are we to believe, and which of these opinions must we ad.pt? If we consult facts, which, in truth, should constitute the law in such a case, we should endeavour to cure the impetigo, for no immediate unfavourable symptom ever results from its disappearance; besides, we get rid of a rather serious disease which is incessantly extending itself, and which determines otitis, ophthalmia, inflammatory enlargement of the glands of the neck, a very unfavourable circumstance in scrofulous children.

But we must not only consider the results of the moment, we mast follow up the patients in the course of their existence in order to determine if the cure of the impetigo is not the origin, as has been stated, of a vitiation of the organism, revealed by serious 1, lesions, such as scrofula of the neck, articulations, lungs, &c.

a difficult matter to form this appreciation, for we lose sight of Wide the patients, and those with whom we meet again are not in sufcient number to decide the question. Now, supposing that several children become scrofulous, there is nothing to prove that the cure of the impetigo is the cause of it; for a great many children become scrofulous and have pulmonary tubercles without having had gourmes; and besides, impetigo itself is sometimes a manifestation of the scrofulous disease. Moreover, in these last, the development of the scrofula is very evidently independent of the cure # of the impetigo.

Observation has not then demonstrated that the cure of gourmes is the sure cause of the approaching development of scrofula. This is not even probable, and when it manifests itself, it is because the children previously, by reason of their constitution, were liable to this disease, of which impetigo was only one of the first symptoms. On the contrary, it is proved that the cure of impetigo is not cat et followed by immediate unfavourable symptoms, and that it preserves the children from the development of a host of very serious diseases. Impetigo should, then, be cured.

However, in order to reconcile the various opinions, I would say, that the impetigo of strong and robust children, born of healthy parents, may be cured without fear of future bad symptoms. On

Book XVII, Chap. III.]

ON IMPETIGO.

627 Cure Shanti

а

the contrary, the impetigo of weak and scrofulous children, of ake Grustual

course.

strumous race, should be treated with more circumspection; it should be gradually eradicated, internal remedies, purgative and tonic, being and be at the same time administered, in the aim of fortifying the constitution Lond Солоний 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, literative 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. Impetigo of the face and impetigo of the scalp require the use of 7 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 washiducous over the diseased parts. These lotions possess no advantage over the ordinary emollient lotions.

When impetigo has existed some length of time, and arrived at a

Cooling

drinks. chronic state, the use of topical astringents should be combined with artis 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 Purquter. should be shaved; alkaline lotions, with the bicarbonate of sodadlem? prescribed, or with the sulphurous waters of Enghien, Barége, and

This &r of Chrenic

Cotterets, with a weak solution of nitrate of silver, gr. j to 3 iss of felons. 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. 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

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

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

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 hand. be prescribed with the utmost confidence, without fear of seeing any of the symptoms of mercurial poisoning supervene.