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CHAPTER IV.

■ -i *umau OJf PEMPHIGUS.

Pemphigus is a bullous disease of the skin, characterised by an eruption of Tost patches, followed by bullae, filled with liquid, and -•-■•• i by thin lamellar crusts.

Pemphigus, which is observed in the adult under the acute or under the ckromic form, is always developed in children at the !.U«t H brea** as an acute disease.

t There are two kinds of pemphigus; the timple infantine pempkiptu,

"and typkiiitic pempkieu*. This latter will become the object of a

. .v ■ •'■-irn/ 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 bulla-.

* J"^"u*- 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.

> X'.i. /*; 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

. j _ ,v, '_ commemorative circumstances, which, by indicating in the parents the

existence of a recent or distant infection, present a still more convincing

'_ N element of proof.

... ^„..",.. Simple pemphigus is usually the result of poverty or of want of

cleanliness,

Exanthcmatous patches are first observed on the skin, over all the

• s. body, then, at the end of twenty-four or forty-eight hours, bulla;

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, accompanied with a more or less intense fever. It is usually apyretic. .' A •' *. ' , 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. If the bulls? are very large, they should be evacuated

* k ^ ear'v vr*ta t^6 point of a needle, so that the epidermis may become

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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.

CHAPTER V.

ON ERYSIPELAS.

The erysipelas of infants and children at the breast is a very - ° r^l ^•"^ frequent disease and one which it is important should be well under- > . stood, in consequence of its singular progress and of its extreme P*-*"^** severity. It is more often met with in hospitals than in the city, rjj i ^

According to M. Baron, physician to the Hopital des Enfants Trouves, / it appears that there are always one or several examples in the /. j^jvy infirmary of this establishment.'

This disease has been described by F. Hoffman: Umbilicalem [Juki regionem in infantibu* frequentitu infettat, ac inde per abdomen . ipargitur cum gravibu* patftematibus, funetto ut plurimum eventu :,}^ -jtivtQfby Underwood, Billard, M. Blache,* and M. Trousseau in an interesting monograph recently published.

Causes.

Erysipelas is nearly always the result of circumscribed inflammation .jLLiiUMmu of the skin; it succeeds the inflammation which surrounds the pustule _J of vaccination; impetigo of the scalp, eyes, or ears; fissures of the'-'*-'*■ V ,;(" thighs, scrotum, and lips; and lastly the inflammation which accom- r,. panics the detachment of the umbilical cord. The last of these is the most common cause; and it is to this that the greater number ZijuUxt-Lcj of cases of erysipelas of infants must be referred. ''

After having pointed out the occasional causes of erysipelas, namely: *f I4*! l ''cutaneous inflammations around the pustules of vaccination, around . , fissures of the buttocks and thighs, around the cicatrix of the umbilicus,tX*-CL I' <fec, it must be stated that these causes would be without result, did *- f- p i 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 there- ! '_/' fore possess a predisposition favourable to the development of the i,. / / disease. ,

This predisposition is determined by the bad hygienic conditions in k-'J. Ci <-*■'/ which the children of the poor are placed, by the deleterious influence - •

J*-t Ljljl'w V * Nouveau dlclionnairt de mMidn*. ^"^ ° 7

y 'kajl to which they are subjected in consequence of their over-crowding Id

J '• the hospitals for children, and lastly, by the epidemic constitution of

>,iA^r n-HVt ^.ne fa^ Thus, erysipelas is never more frequent than in the course 'JI i i °* *ne epidemics of puerperal fever. It is to this circumstance that the development of the cases of erysipelas is allied, and not to slight "!../. , J wounds which readily cicatrize in a more favourable hygienic consti

tution. It is to this epidemic influence that the fatality of the disease d-fLt. iDujiMt., should be referred.

Erysipelas is also sometimes the result of imperfect nourishment of pMMTi tne children, or of alimentation by a diseased milk; thus M. Raver

i\ ~ma "7?lttA nas 8een ^"a (^sease appc*1" m 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

■ £JV preceded by fever, save in some exceptional cases; when, for example,

z a violent inflammation of the arm around the pustules of vaccination

t It *> is the source of the evil. Sometimes, on the contrary, it presents

all the symptoms of a general disease which is announced by fever,

.. , /city Li\.l convulsions, icterus, <tc.

As soon as the erysipelas has declared itself, the fever is excited or

increases, and is easily recognized by the state of uneasiness, restless

"/ *jilijL ness, and want of sleep into which the young children are thrown, by

■ the thirst which consumes them, by the heat of skin and the degree

'-I "*'i li'iM, of the acceleration of the pulse.

— At the starting point of the erysipelas, on the abdomen, the head

i''^/>H«d or the limbs, whether this be the inflamed umbilical cicatrix, or the

'fissures of the skin, or the inflammatory areola of the pustules of

r vaccination, or lastly, the pustules of impetigo, we discover around

all these changes, the skin inflamed to a greater or less extent; it

'' ' '*#u' ' 1 's re^> 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

K.'■(,<Idij Lj rod colour.

From this point the cutaneous inflammation invades the neighbouring

J ti.U-u^4, *-Pai°ts; from the abdomen it extends to the pubes, the buttocks, and

>< >I > n, /*newer limbs; from the neck and arms it diffuses itself over the

"head, the trunk, and lastly the lower limbs. It remains stationary

X! ,'''•/,, in the same spot from twelve to twenty-four hours, and it is only

1 when it has extended onwards that the parts first invaded lose their

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colour and swelling, and assume a yellowish tint before presenting yxUjf^T desquamation of the epidermis. CUjti^iiirtU

The erratic progress of this inflammation is perfectly well characterized, a W^j* and every one may follow it by carefully observing the young children 1.1 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 t. surface of the body. VitLtA^*^

Sometimes, as M. Trousseau has remarked in the work we have ~cited, when the disease has become general, this progression is not ^/lA^-v-W entirely the same. The erysipelas returns to the parts which it has *> . JT already occupied, but then it commences in a spot at some distance from its seat without having run over the intermediate parts. The Zcjuajl. erysipelatous inflammation thus occupies several parts of the body at the same time, but this peculiarity is very rare. CUT-^

(\n young children the red colour which erysipelas presents is not very manifest except on the trunk and on the upper part of the limbs. (T^ *. 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 fff" AuX*..

there.j , 01c &*

The parts attacked by erysipelas are always swollen, as the impression v

left by pressure of the fingers testifies. This oedema is not always Auuhto J very decided on the trunk, but is, on the contrary, very considerable kttM> on the hands and feet, which are very much enlarged and sometimes ^ transparent, as in the cases of general serous effusion. /When the (w>t\la{m. face is the seat of the disease, which is seldom the case, it is very , ., bloated, but the swelling is not to be compare3 lo that which is observed W in the erysipelas of adults. \ UcA 8*.*.'i I

Such are the local symptoms of the erysipelas of infants and of ^ ... ,. children at the breast. The general symptoms at the commencement of the disease have been partly indicated, but they insensibly assume }iti «i <£<) a much greater intensity. The face is exceedingly pale and the lips «> . i colourless. The restlessness is very great; continual cries give proof *■ of the suffering experienced by the patients; the pulse is excessively w A I frequent and feeble. Vomiting or diarrhoea are then observed, and sometimes convulsions, which put an end to the existence of these fa-tUlJj.i'-Q unfortunate children. S&0-U. 4<.t*'H4.<_ shs W.ooi - £i&t,U't*

DurationTerminations. ft" UjtJ- *

The duration of the erysipelas is very variable. We have not IhuMnj >•. /, 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 ^jtil-A '' <>\

four and five weeks, a result similar to that which has been obtained y. ,

bv M. Trousseau. Q. U ^.

hi 1 *V .

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The core of erysipelas, that is to say, the resolution of the inflammation, b Terr rarely observed; death is much more frequently the consequence. Thus, in thirty children of from one day to one year old attacked with erysipelas, Bfllard has reckoned sixteen cases of death. But here it is necessary to establish a distinction between the newlyborn, properly so called, and the child of several months; the erysipelas ■«• <•<■<. t of the newly-born should be regarded, according to the observation* of MM. Blacbe, Baron, and Trousseau, as inevitably fatal; whilst, on the contrary, the erysipelas of children of more advanced age is sometimes cured. I have met with two instances of this favourable ■ ■ termination.

(^ Nevertheless, death is not constantly the result of simple erysipelas. It is equally the result of the suppuration and of the mortification of the skin, which appears as a complication of this disease, especiallv in newly-born children.) Peritonitis, of greater or less extent, is almost always observed; and sometimes, according to M. Bayer, inflammation •^i of the umbilical vein. \

It wiD be seen that the erysipelas of young children is a very serious

. disease. All the newly-born die. Subjects of a more advanced age

are the only ones who can resist it and recover. Of these there are

still very few indeed in whom we can succeed in triumphing over

these symptoms.

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1 '"* [Several eases are related {American Journal of Medical Science; N.S., Xo. xl,

p. 318) of erysipelas after vaccination, in which some of the children died, and we ahoold be camions of vaccinating daring an epidemic of erysipelas.

Dr. Doepp states expressly that he has found erysipelas most frequent in infants when they had been vaccinated with lymph taken from a highly inflamed pustule or vesicle, and he has been able to affirm this with greater certainty from the results of the practice he has long followed of vaccinating each child in both arms, but with different lymph, and he constantly produced erysipelas in that arm which had been . . vaccinated with lymph from a highly inflamed vesicle.

In nearly all the children born for several months in Queen Charlotte's Lying-in '/ r Hospital, bulls occurred, which Dr. Copeland says was evidently referable to a more than usually superficial, slight, and uniform kind of erysipelas, which affected the whole surface in many instances, and not any one part in preference to another. The accompanying fever is usually at first of an inflammatory character, attended with much derangement of the alimentary canal, the secretions being ahravs much - depravated; but the fever soon becomes typhoid, and the local and general symptoms give evidence of deficient power. Dr. Bromfield mentions the case of a child born with erysipelas who perfectly recovered. The cases of inflammation and ulceration of the pudenda of young children described by Kinder Wood appear to be instances of this disease in its aggravated form.

For further information on the erysipelas of children see my MSS. Essay on • ■, -1 Erysipelas, in the library of the College of Surgeons, for which the Jacksonian prize was awarded in 1849.—P.H.B.]

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