The cure of erysipelas, that is to say, the resolution of the inflammation, is very rarely observed; death is much more frequently the consequence. Thus, in thirty children of from one day to one year old attacked with erysipelas, Billard 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 A of the newly-born should be regarded, according to the observations of MM. Blache, 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 1% 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, especially in newly-born children.) Peritonitis, of greater or less extent, is almost always observed; and sometimes, according to M. Rayer, inflammation , of the umbilical vein.)

It will 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.

[Several cases are related (American Journal of Medical Science; N.S., No. xl, p. 318) of erysipelas after vaccination, in which some of the children died, and we should be cautious of vaccinating during 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 Hospital, bullæ 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 always 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 Erysipelas, in the library of the College of Surgeons, for which the Jacksonian prize was awarded in 1849.-P.H.B.]

PATHOLOGICAL ANATOMY.

We shall not dwell long on the pathological anatomy of erysipelas, ty

for it does not present much matter of interest.

The affected parts are the seat of a more or less considerable oedema, which is especially well marked at the extremity of the limbs. The cellular tissue is here infiltrated with a considerable quantity of serum.

Pus is sometimes found infiltrated in the meshes of the cellular tissue,

ww the without being collected into a distinct deposit. We met with this Cellular appearance in a child three weeks old, which died after fifteen days' illness. This infiltration existed in the cellular tissue of the anterior Tiss me abdominal wall and in the cellular tissue of the scalp. The same child had besides, in the peritoneum, a rather large quantity of purulent au serosity, and on the viscera albuminous false membranes, very delicate and very easily detached.

Underwood has remarked the same alterations in the bodies of several children: adhesions between the different viscera which were covered with a plastic exudation precisely resembling that which is

met with on the viscera of women who have died from puerperal fever.

As already remarked, peritonitis is, according to M. Baron, one of the most constant alterations in young children who die from the disease we are now considering.

In the post mortem examinations we have made, we did not observe in the other organs any change which deserves to be mentioned.

TREATMENT.

Although the erysipelas of infants is very fatal, we should not on that account idly look on. We should endeavour from the commencement to allay the inflammation of the skin by means of energetic treatment.

We should endeavour to prevent it by carefully attending to the cicatrization of the umbilical cord, and by not vaccinating children too early, provided we are not obliged to do so in consequence of an epidemic of small pox raging at the time.

Jusions

Local abstraction of blood, by means of one or two leeches applied✰ at the circumference of the primary seat of the erysipelas, should be put in force, provided the power of the constitution of the children permits.hug In the contrary case, we must rest satisfied, as is done at the Hôpital des Enfants Trouvés, in prescribing emollient fomentations, baths, and frequent applications of lard and mercurial ointment.

Hamilton Bell and Charles Bell, of Edinburgh, treated these cases

of erysipelas by the tincture of the muriate of iron, two drops in a

tablespoonful of sweetened water every two hours, and in addition by v

a mild purgation with castor oil or calomel.

The attempt has also been made to destroy the erysipelas by means

"

of topical astringents, such as astringent fomentations of tannin, sulphate of iron and corrosive sublimate, or by means of baths with these substances in solution. Underwood employed fomentations of the acetate of lead, and baths of bark combined with aromatic herbs. The sublimate may be employed in solution, according to Dr. Schott, of Philadelphia, in the dose of gr. j to 3 iss of distilled water. Fifteen, or at most thirty grains, are sufficient to put into the bath. These experiments have not been followed by all the results expected from them, and it has been discovered that all these means were insufficient to arrest in any decided manner the progress of the disease.

Some have recommended the separation of the healthy from the erysipelatous parts by a strip of blistering plaster, in the hope of circumscribing the disease and of destroying it at the very place of its origin. I have seen M. Trousseau make use of this plan of treatment without any good resulting; and the same was the case with cauterizations with the actual cautery made with the same intention, on the limits of the cutaneous inflammation. The erysipelas has always passed the barriers one would oppose to it, and continued its onward march as above described.

Lastly, we would allude to a plan of treatment mentioned by M. Blache, and which M. Meigs has proposed as very advantageous in the disease we are now considering. This physician has treated many cases of erysipelas in infants who quickly recovered under the use of Kentish's liniment (a mixture of basilicum ointment and spirits of turpentine), applied several times a day on the diseased part.

APHORISMS.

314. The erysipelas of infants is very common at the time of epidemics of puerperal fever, and often results from this epidemic influence.

315. The erysipelas of infants almost always originates in a wound of the skin, and especially in that which results from the detachment of the umbilical cord.

316. The erysipelas of infants is a fatal disease.

317. The erysipelas of children becomes less and less serious in proportion as the child grows older.

CHAPTER VI.

ON NÆVI AND ERECTILE TUMOURS.

The term nævus is applied to certain spots or cutaneous marks with which children are born and which always remain. These are what are called mother-marks, or nævi materni.

Nævi present several forms, which it is important to separate and which are otherwise easy to recognise. Some are superficial, but slightly vascular, and not susceptible of degeneration; others involve the skin to a greater extent, are very vascular, becoming every day more so, and rapidly constitute so many erectile tumours. To the first, I apply the term of superficial pigmentary novus, and to the

others the term of erectile nævus.

The production of these nævi is generally referred by the vulgar' to flights of the imagination, to impressions or to unsatisfied caprices of the mother. The occasional singular form of this cutaneous alteration, in which some put on the appearance of cherries, raspberries, mulberries, strawberries, the head of an animal or of any other object, would appear to justify this more than dubious etiology. But there is nothing in this respect which has been clearly proved, and all that has been stated on this point is only fantasy and pure credulity. Without in any way denying the all-powerful influence of the mother over the physical dispositions of the foetus, of which there is now no want of proof, we must wait for sufficient motives of belief in order to admit the reality of this intervention. In the present state of science we are entirely ignorant of the cause of the development of nævus.

Superficial pigmentary nævus presents itself in every part of the body, but more frequently on the face, eyelids, and lips; it is usually well defined under the form of limited or very extended patches, it is not sensibly raised above the surface of the skin; its uniform colour varies from a bistre to a deep brown, from a dull red to a blackish blue; it changes slightly during the movements of expiration and during the cries of the child. Its surface is tolerably level, usually smooth; sometimes covered with silky, fine hairs. These patches do not generally increase in size, they remain stationary both t as regards structure and volume; they extend in proportion to the parts which support them. They are not susceptible of degeneration if they are not irritated, and they thus remain during the whole duration of life.

They are formed by a superficial alteration of the skin which does not extend into its thickness. Well supplied with vessels and with pigment, as MM. de Blainville and Rayer have proved them to be, and who term them pigmentary patches, they appear to occupy the mucous tissue of Malpighi.

As the superficial nevus does not cause pain, and possesses no other inconvenience than that of deformity, we should leave it alone and not yield to the advice of those who would cause their disappearance by means of the suppuration of a blister and of a superficial scarification by Plenck's paste, composed of equal parts of quicklime and Venice soap. This paste, which is to be kept applied for twelve hours in order to produce a sufficient eschar, possesses the serious inconvenience of producing acute inflammation, and of often leaving behind a cicatrix of greater deformity than the spot to be destroyed.

There is scarcely more than one appropriate means to be employed in causing the disappearance of one of these spots, and this is tattooing; but this is only useful in a very limited number of cases, when the spot is very superficial, and of a not very great extent of surface. The skin is to be rather deeply pricked at slight intervals, and in each puncture oxide of zine or calcined magnesia, mixed with a little minium, is to be introduced. This is to be repeated several times, and thus a pink and white colouring of the skin is obtained, so as very much to improve its appearance and to hide the deep red morbid tinge of the integuments.

The erectile nærus, which M. Rayer includes in the category of vascular spots, is a more dangerous cutaneous alteration, and may sometimes be the origin of serious symptoms.

Several of these may be observed on the same individual, but generally, erectile nærus exists alone. It is developed on all parts of the body, but is more frequently observed on the face, the head, and the neck. It may exist in a high state of development at the time of birth, or simply under the form of an imperceptible spot, resembling a fleabite, which increases in size on the following days. Its form is that of a spot or speck of a red or blackish brown colour, in other cases, on the contrary, of a reddish livid blue patch, sometimes granulated, flabby. It at length presents itself under the form of a ...tumour, more or less well defined, of the size of a nut or a walnut, sometimes very projecting and almost pedicellate, occasionally occupying the whole of the dermis and extending itself beneath it. This is what characterizes the true erectile tumour. I have drawn, for A. Bérard, one of these congenital nævi in a woman thirty-two years old, whom I daily meet near my dwelling. This venous nævus had invaded the whole of the right side of the face, had become tubercular, 7 like an elephantiasis, and had given rise to an erectile appendix on