Induration of the skin usually occurs soon after birth; occasionally it is congenital. It is more frequent in winter than in summer. Elsæsser has met with it chiefly in November and December. Palleta gives a table of 105 cases, of which 85 occurred between the first of October to the last of March; the remaining 20 between the first of April to the first of October. In a table of 177, collected by Billard, 106 occurred in the colder half of the year, from October 1st to March 31st. It prevails to the greatest extent in hospitals appropriated to the reception of children, and among the offspring of the impoverished classes of society, who inhabit unhealthy localities, and small, ill-ventilated, and filthy habitations. It has been observed by Caspar, Billard, Wolff, and others, that infants reared by the hand are more liable to the disease, under all circumstances, than those who are nourished at the breast. It has been met with most frequently, perhaps, in children prematurely born. Palleta (Archiv. Gen., t. v.-ix.) found that of 105 cases of the disease, 54 occurred in infants born before the close of the normal termination of gestation. Of 53 cases, Elsæsser found 43 of the infants were of premature birth. The number of boys attacked with induration of the skin, is, according to Denis and Valleix, greater than of girls. In 31 cases observed by Blanche, 20 were in males; in 53 cases, Elsæsser enumerates 29 boys and 24 girls.

Although the disease may attack infants apparently in perfect health, yet, in the great majority of instances, those who become the subjects of it are observed to be feeble or languid from birth; or to labor under more or less disorder of the alimentary canal previously to the occurrence of the cutaneous affection. We should hence be inclined to refer the disease to gastro-intestinal disease, and a generally languid and debilitated condition of the organism, the result of contaminated air, and improper or unwholesome diet; and probably, in some instances, an additional morbific cause, a cold and humid atmo sphere, may concur in its production. The connection of the disease with gastro-intestinal irritation had already been noticed by Denis, and it is further proved, by the fact of the frequency with which, in post-mortem examinations, inflammation of the mucous membrane of the digestive organs is detected.

The causes of the disease appear to differ but little from those which give rise to infantile erysipelas. To this disease it has a very close resemblance, and has prevailed in common with it in the same hospital. (Elsæsser.) It is often attended with a condition of the skin not very dissimilar from that which occurs in erysipelas; while the latter is frequently associated with considerable induration of the surface, for some distance beyond the inflamed margin.

The morbid condition of the surface is evidently dependent upon a simple infiltration of the cellular membrane with a serous fluid. This is proved by the condition of the subcutaneous tissue after death, and by the fact, that when, during the lifetime of the patient, incisions are made into the indurated parts, and pressure is applied, the serum is discharged, and the swelling, tension, and hardness entirely disap pear. It would appear, therefore, that the disease is, in fact, a genuine oedema; the extreme hardness of the skin resulting from the less loose

and yielding nature of its tissues in early infancy. The cedema has been referred, by Billard, to a languid circulation, the result of venous plethora, and the action of such external agents as have the effect of suspending the cutaneous transpiration, and thus favoring the accumulation of serosity in the subcutaneous cellular tissue.

When the oedema is general, and the venous congestion exists to a very great degree, all the organs abundantly supplied with cellular tissue have their functions more or less disturbed, in consequence of their infiltration by serum. The glottis becoming oedematous, while the lungs are overloaded with venous blood, the cry of the infant is rendered painful, acute, and smothered. The coldness of the surface is the result of the languid state of the capillary circulation, the deficient oxygenation of the blood in the lungs, and the general debility of the patient.

Cases have fallen under our notice in which the venous congestion, and consequent serous infiltration of the subcutaneous cellular tissue, were evidently the result of an imperfect distension of the lungs at birth, and the consequent production of the condition denominated by Jörg, atelectasis. The probability that this is a frequent cause of the disease was suggested by Dr. Maunsell: its certain occurrence in several cases, we have established by the result of our autopsies. Roger and Elsæsser notice the frequency with which partial consolidations of the lungs are met with; a condition which differs no doubt essentially from true inflammation of the lungs. In the latter the temperature rises even to 105°, while in that peculiar condition of the lungs which accompanies induration of the cellular tissue, it sinks as low as 71°, the pulse and respiration at the same time being slow, in place of accelerated. We believe that there is still another class of cases, by no means unfrequent, in which the serous effusion into the subeutaneous cellular tissue is the result of a subacute inflammation of the latter, consecutive, most frequently, to irritation of the alimentary canal.

There are, evidently, two distinct varieties of induration of the skin; that from serous infiltration of the cellular tissue, and another from induration or concretion of the adipose matter. The latter may exist with or without general infiltration of the subcutaneous cellular tissue. It is usually seated in the cheeks, nates, calves of the legs, or back, and occurs with or without derangement of the circulation or respiration, and is seldom attended with symptoms of a nervous character. (Billard, Rostan, Wolff, Valleix, Elsesser.)

When the adipose tissue is alone diseased, the affected parts are but little swollen, and have the firm feel, and yellowish-white appearance of wax, or concrete suet. In the latter stages of the disease they are said to be sonorous upon percussion, and are perfectly cold to the touch. In these cases, upon dissection, the subcutaneous adipose substance is found hardened and condensed like suet, with the skin contracted, and firmly adherent to it.

In this country, induration of the skin is an extremely rare disease. During an extensive practice of nearly half a century, for eighteen years of which we served as physician to one of the largest medical

charities, perhaps, in this country, we have met with but twelve cases of the disease. In the hospitals for children, in Europe, it is, however, of more common occurrence. In the Foundling Hospital of Paris, 645 cases occurred between the years 1808 and 1811; of which num-ber, 567 terminated fatally; and in 1826, there occurred in the same institution 240 cases, of which fifty died.

The disease is described by the generality of the writers on the subject, as being but little under the control of medical treatment, and as terminating fatally in the majority of cases. The condition of the skin, however, appears to be of less importance than that of the system generally; and death more seldom results, according to Billard, from the morbid state of the integuments, than from the serious diseases of the internal organs-the alimentary canal, the lungs and the brainwith which it is commonly associated.

When limited in extent, and occurring in infants possessed of some vigor of constitution, or even when general, but not of an aggravated character, and uncomplicated with severe visceral disease, it will often yield to very simple remedies.

To prevent the occurrence of induration of the skin, according to Gintrac, care must be taken to prevent the new-born infant from being chilled, by proper clothing and by a sufficient temperature in the apartment occupied by it during the cold and variable months. When indications are presented of the development of the disease, these precautions are still more important. The infant should be placed before, but not too near, a clear fire; its position being changed at short intervals. Its head should be kept somewhat elevated, and all compression of the trunk and limbs avoided. They should be unrestrained and enveloped in cotton wadding or flannel. Frictions of the surface should be practised with a soft, warm hand, and a kind of kneading of the parts that are engorged, hard, and cold practised.

Where the disease is fully developed, the proper treatment will depend pretty much upon the particular character of each case. Sometimes the extent of the general plethora or of the local accumulations of blood, may possibly demand the employment of leeches, cups, or even general bloodletting, with gentle purgatives. Friction of the surface with the hand, or with warm flannel, and the use of flannel garments next the skin, are still all-important remedies. Blisters have been strongly recommended by Richter, and according to the experience of Dr. Eberle, when early applied to the affected parts, they would appear to remove the sanguineous engorgement of the subcutaneous tissues, promote the absorption of the effused serum, and prevent its undue accumulation. We have, in several instances, seen good effects result from a well-timed blister. It should be kept on about three hours; immediately upon its removal, the part being covered with a large emollient poultice.

The exhibition of an emetic of ipecacuanha, for the purpose of relieving the air-passages from accumulations of mucus, and unloading the vessels of the lungs, has been recommended; we have no doubt that it will prove, in most cases, highly beneficial.

The vapor-bath has been considered by some practitioners one of

the most effectual remedies that can be employed in this disease. When it is dependent upon subacute inflammation of the subcutaneous tissues, or gastro-intestinal irritation, the bath will no doubt prove advantageous; but it is not a remedy adapted to the generality of cases. In many, dry heat, and friction of the surface, as directed by Baron, will have a far better effect. In some cases, the respiration, during the continuance of the patient in the bath, is painfully accelerated, and its use, according to Billard, has been occasionally followed by congestion and effusion in the lungs or brain.

Incisions through the skin, at the seat of the disease, have been suggested by Andry, Wolff, and others, as a means of relieving the overloaded state of the subcutaneous vessels, and of giving exit to the serum distending the areola of the subcutaneous cellular tissue. We are not aware that this procedure has been carried out to any great extent; nor are we acquainted with its results when it has been put in practice; we can, however, see no valid objection to its use.

In cases attended with derangement of the alimentary canal, small doses of calomel in combination with ipecacuanha, three or four times a day, with the occasional interposition of a dose of castor oil and turpentine as recommended in infantile erysipelas, should be administered. If, however, the symptoms indicate that the gastro-intestinal mucous membrane is the seat of acute or subacute inflammation, a few leeches. should be applied to the epigastrium, or wherever the tenderness is most decided, and followed by large emollient cataplasms.

Where there exists very great debility, wine whey, or even ammonia in combination with the aqua camphorata; friction of the surface with camphorated spirits, or the oil of amber, followed by the application of a flannel envelope, will be the most appropriate treatment.

18. Nævus.

Children are often born with permanent spots or marks upon the skin, varying in extent, and very materially in their nature and importance. The whole of these have been generally included under the vague denomination of nævi materni.

A very common form of nævus is that of a mole or slightly elevated tumor, differing in size in different cases; generally of a dark color, and often covered thickly with fine, short, silky hair, of the same color as the mole. These nævi may occur upon any part of the body, and when seated upon the face or neck, or upon the shoulder or breast in the female, produce very considerable deformity. They often increase slowly in size, and acquire a darker color, until towards puberty; after which period they commonly remain stationary for the remainder of life, and are unattended with pain or inconvenience. They are generally attributed to some alteration in the structure of the rete mucosum; their true nature does not appear, however, to be as yet well understood. It is not customary to interfere with them; they could certainly be dissected out without much difficulty, but the deformity resulting from this procedure would probably be almost as great as that it was intended to remove.

Another very common form of nævus is a dark-red circumscribed stain, which generally appears upon one side of the face, and is sometimes of considerable extent. It is perfectly superficial, and has been supposed to result from a simple dilatation of the subcuticular capillary vessels at the part affected. It would appear to us to depend rather upon a local abnormal condition of the rete mucosum. Like the former, this form of nævus sometimes increases in extent until about the period of puberty, and then undergoes no further change throughout the remainder of life; being attended with no other inconvenience than its unsightliness. We have known it, however, to disappear entirely during childhood. It has been proposed by Fränkel to diminish the deformity by tattooing the part affected with a white pigment.

The nevus appears frequently in the form of a slight dilatation of the capillaries; in some cases superficial, and in others extending deeply into the mucous membrane of the lips. In some instances the dilated capillaries appear as tortuous, wide-spread lines, proceeding from a small round spot, like the legs of the spider from its body. In others, they form small, defined, granular tumors, of a bright red color. In other cases, again, the nævus is composed of a congeries of venous capillaries, and is of a deep-blue, or bluish-red color. These sometimes disappear before puberty; at others, they continue stationary, neither enlarging nor diminishing during life. They are never troublesome, constitute but a very inconsiderable deformity, and, as a general rule, should not be interfered with.

The most important of the nævi is that which appears in the form of a deep red-colored, slightly elevated spot; it often rapidly augments in size, with a well-defined margin, and a granular surface; is obliterated by pressure, but rapidly rises again when this is removed. It is formed of an erectile, vascular tissue, and if accidentally wounded, often gives rise to copious, prolonged, and dangerous hemorrhage. When seated near to an arterial trunk of any size, it pulsates powerfully beneath the finger, and is attended by a thrilling purr, synchronous with the action of the heart. (Aneurism by Anastomosis.)

Various plans have been proposed for the removal of the vascular

nævus.

1st. The application of cold and pressure. (Abernethy.) This will frequently succeed when the nævus is small, and not disposed to increase rapidly in size, and when it is seated over a bone. In those of larger size, of rapid growth, and seated over soft parts, it is altogether inefficient.

2d. Vaccination over the surface of the tumor. (Hodgson.) This will frequently succeed. It is always, however, productive of a considerable scar, and if ulceration or sloughing occur, as is sometimes the case, the scar is often large, and forms a very decided deformity in parts exposed to view.

3d. Pustulation with tartar emetic upon the surface of the nævus. (J. B. Brown-Cumming.) The same objections are applicable to this as to the preceding plan.

4th. Caustic. (Wardrop.) This will also repeatedly succeed when