CHAPTER IX.

POMPHOLIX.

characters.

POMPHOLIX or Pemphigus is known by an eruption General of bullæ, which at first are very minute, and resemble ordinary vesicles. In their progress they vary considerably. Generally hemispherical, they may, by their confluence, assume great irregularity in shape, and attain a diameter of several inches in extent. The fluid in the bullæ is always clear and transparent at an early period; it may maintain this character throughout its course, but more frequently becomes turbid or sero-purulent, or mixed with flakes of lymph. At either extreme of life, or in unhealthy subjects, the same secretion is sometimes tinged with blood. The walls of the bullæ are thin, and easily yield to the pressure of their contents or to slight force.

composition

The fluid, as long as it is limpid, is neutral or Chemical alkaline. It readily coagulates by heat, and becomes of the fluid. nearly solid on the addition of nitric acid. An analysis has been made by Simon and Haller, who agree in the large proportion of water it contains, being no less than 940 or 955.80 in 1,000 parts. As might be expected, albumen is present in much quantity, and together with the earthy phosphates is estimated by Simon at 48 parts in 1,000, which leaves only 12 to include the fat, cholesterine, extractive and other matters.

As an acute affection, pompholix is generally local, and Acute pomappears on the hands, face, or soles of the feet; bullæ are

pholix.

General pompholix.

rapidly developed, and their growth is commonly completed in twenty-four or thirty-six hours. Previous to their formation the skin is sometimes stained with red patches, which are the seat of considerable irritation. Having reached a certain size, many of the bullæ remain separate, or they coalesce with others; in either case, if the skin be unbroken, crusts are formed on the surface, of varying consistence, thickness, and colour, according to the nature of the secretion. Should they have burst spontaneously at an early stage, the bleb is often reduced to a thin piece of shrivelled cuticle, and the surface beneath is red and tender, especially if the bullæ have been torn. Left to itself, the skin soon regains its natural state, the preparatory change being denoted by a cuticular desquamation. Sometimes pompholix is ushered in by symptoms of constitutional disturbance, and occasional bullæ will often arise after the original blebs have disappeared. In the course of three or four weeks this kind of pompholix will usually have run its

career.

As a more general disease, pompholix seldom terminates so speedily. Successive crops of bulle will appear, and thus prolong the complaint for many weeks, or it may be indefinitely. In some cases we may judge of the probable extent and severity of an attack, from the duration of the previous premonitory symptoms, which may comprise a period of several months. After the disease is on the wane, an uniform dryness of the affected surface is usually observed; and on closer inspection, a number of oval or round patches, smooth and pale red, which have succeeded to the bulla; in the intervals between them, the cuticle is semi-detached or rough, like the thin scales of eczema, and oftentimes of a brownish

hue. This change of colour is most marked where the skin is soft, as the inner aspect of the thighs or the dorsal surface of the feet. Any former irritation has now, in a great degree, subsided, but sometimes a burning sensation is experienced in the part towards evening; and as the skin recovers itself, it is apt to present a number of small but painful furunculi, each surrounded with a hard and red margin. Even when almost universal, the palmar aspect of the hands and the soles of the feet will be often free from bullæ, although they share in the general renewal of the cuticle, which afterwards takes place.

Pompholix may terminate fatally, but such instances are rare. The most severe case that has come to my knowledge was communicated to me by a professional friend, from whose notes I extract the following:-"The patient had always enjoyed excellent health to the time of puberty, but soon after this period she began to be feverish and languid. Removed for change of air, an eruption was observed one morning, it had become developed in the course of the night, on her chin; and of its true nature there could be no doubt. In the course of three weeks the disease had extended over the whole body, from the head to the toes, and specimens of the eruption might be seen in every stage. The bullæ ranged in diameter from sixpence to a crown piece; some had discharged their serum, and in others the cuticle had been torn off with the dressings. The meatus of the ears, the inside of the nostrils, the conjunctiva, whether of the eyes or lids, were covered, as well as the mucous membrane of the mouth the upper and under surface of the tongue, the back of the pharynx and soft palate, all were thickly studded with bullæ. I am quite convinced that the

Pompholix diutinus.

whole mucous track throughout the alimentary canal was similarly affected. She suffered great pain in her limbs and joints, and this quite independently of the sores arising from the state of the cuticle. It is now five years since the disease commenced, and during the last twelvemonths the eruption has declined. The skin is at this time (December, 1865) free, except that some ecthymatous pustules occasionally appear. Owing to adhesions having formed between eyelid and the globe, total loss of sight has resulted in one eye; and as the other is nearly in a similar condition, the patient is only able to distinguish light from darkness."

In pompholix diutinus of children, the first sign is usually an eruption of several minute red spots on the surface, generally on the abdomen and thighs, and afterwards on any part of the body. In the course of a day or two, each becomes the seat of a small vesicle, not larger than a pin's head, and contains a clear fluid. It is surrounded with a narrow red margin, and unless care be taken in the search, is very likely to be overlooked. The vesicles enlarge rapidly, and to such a degree as to attain, many of them, the diameter of a hazel nut in the space of twenty-four hours or less. It not unfrequently happens, that long ere the vesicle has reached this size it bursts, but the red patch on which it was evolved still spreads, and generally in a circular direction; in this manner it may attain one and a half inches or more in diameter. Further changes now ensue. The bleb may either shrivel or dry up in two or three days, and leave no trace, except a slightly rough and red spot, which at first sight might be mistaken for psoriasis; or it assumes a dark and somewhat wrinkled condition, adherent and surrounded by a red margin, and like, in character, to

ecthyma, save in the thinness of its crust; or, the border will show a narrow and raised rim, the remains of the bleb. These different conditions may very frequently be observed on various parts of the body. The general health is unaffected, and often remarkably good. The local irritation is slight, and only experienced at night.

In another class of cases, the disease is in like manner denoted by blebs which rapidly form in the course of a single night, and are neither preceded nor accompanied by any reddened state of the skin. The bleb may resemble an ordinary blister in appearance, and contain a clear serum; or may acquire great variety of colour, and partake of a dark or purple hue. The tendency of the blebs in this variety of pompholix is to pass into a purulent or semi-purulent state; and in either case the crusts which succeed in three or four days are characterised by thickness and irregularity. They are mostly of a yellow or brownish colour, and the vesicles from which they originate are without any inflamed base. In some places are seen considerable patches, consisting of blebs which have been united together. The later characters vary with the condition of the bleb. Thus, if of a purplish tinge, a white but superficial cicatrix commonly supplies its former place; otherwise, a red stain alone is seen, which finally disappears. Sometimes a red and thickened state of the integument occupies the site of the original bleb.

A curious form of pompholix diutinus is sometimes seen on the palm of the hand, and involves the fingers even to their extremities. The blebs are of small size, ranging downwards from that of a pea, and appear imbedded in the skin; along the fingers they are very minute. A

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