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57
Clinically there appeared to be two types—the mild, in
which the vesicles, though multiple, definitely tended lo heal
after reaching a certain size and terminating in the recovery of
the patient. The severe type was either *one in which the
vesicles grew to large bullæ, which, or rupturing, denuded
large areas of surface; or an exfoliative condition in which the
course seemed too rapid to allow time for the formation of
vesicles. The infection seemed to spread beneath the skin,
leading to exfoliation of extensive areas. Nothing in the severe
type appeared to bd of any avail in' preventing a fatal
termination.
In the course of the year, pemphigus appeared in the
practice of 17 midwives, though only once in the course of 10
of them and twice in another four. One case occurred in the
practice of three separate doctors. One midwife had a tota
of 14 cases, one 10 and a third 8. A frequent occurrence was
the association of two cases in the practice of a midwife, one
case appearing and followed after an interval of a few days by
another case. The frequence of this occurrence, seemed to
preclude its having been due to mere chance and suggests that
the second baby was already infected before the appearance of
the eruption in the first. This would suggest that the first child
was infectious before the onset (of the eruption, with the possibility
of a period of incubation in the second case. This would
bring the disease into line with the systemic infections.
The facts known with regard to pemphigus are—in its
spread a definite association with the prartice on one person;
its frequent association with a dirty umbilicus or some other
injury; and also with cases of impetigo. Organisms found in
the vesicles are not necessarily the causative agents, being in
some cases possibly secondary invaders. Although there
the association with a person, the means of communication of
the disease are unknown, The fact that ordinary means, which
are effective in preventing the spread of other infections, are ineffective
in this suggests the possibility of infection by carrier
The facts can be explained on the assumption that pemphigus
is a systemic infection occurring in infants by droplet or air
born infection. Its association with impetigo would be that
the organism causing this is, either always or frequently one
capable of causing infection. Its association with a dirty
umbilicus would be either that this lesion forms the source of
supply of infecting organisms, or at other limes the unhealthy
umbilicus leads to a local lack of tissue resistance. The
eruption then starts at this place or at some other with
weakened resistance—for instance, through mechanical injury