a nævus treated by vaccinal inoculation in which we have had to deplore a fatal result. As to the Vienna paste, it seldom gives rise to any primary or consecutive accident, and it is on this account that I here recommend its use.

[Extirpation of nævi is only practicable when they are of the cutaneous variety, or when they can be lifted up from the parts beneath, so that their whole extent can be ascertained. If the knife is used, two elliptical incisions should be made, so as to include the whole of the diseased growth, as well as a little of the surrounding sound tissues; the diseased part should not be cut into, for several cases are on record of children dying from the resulting, alarming, and uncontrolable hæmorrhage.

a do

South (Translation of Chelius; vol. ii, p. 283) prefers Brodie's method with the two needles, as thereby the whole base of the swelling is more completely included within the thread, and relates a case of its successful application in a child, twelve months old, who had taleangiectasies on the temple and ear. Fergusson has devised a knot of which there is a representation in Druit's Surgeon's Vade Mecum. A needle armed with a double thread is thrust transversely under the centre of the tumour. The centre of the thread, which has the needle in it, is th then divided. Next, one end of the thread is passed through the eye of a needle, which eye should be near its point, and having been brought one fourth round the circumference of the tumour is thrust transversely through its base. Then it" is to be disengaged from the eye of the needle, and the other end to be put into the eye, and to be carried back with it. Lastly, the adjoining ends of the Lastly, the adjoining ends of the two threads are to be tied tightly, so that each of the two threads shall include an 8-shaped portion of the tumour. The tumour may be punctured before the threads are finally tightened, but in every case the constriction should be made as tight as possible. After two or three days the ligatures should be tightened, or fresh ones should be applied. If the skin is not implicated, it may be dissected back in flaps before the ligatures are passed; or the process may be expedited, and pain be saved, by just cutting through the cutis vera, and sinking the ligatures in the cuts; so that the painful process of ulceration through the skin may be avoided. Cæsar Hawkins (Medical Gazette, N.S.; vol. iv, p. 940) states that the granulations after an operation often look large and prominent, as if the disease would return, but heal up readily. Curling (London Medical Gazette) relates a case of extensive nævus of the upper extremity in a child spontaneously cured by sloughing.

I have seen vaccination succeed in some cases, but in others it was unsuccessful, and it became necessary to destroy the nævus with Vienna paste. Dr. Gregory, from the frequent failure of vaccination, ceased to treat any in this manner. I have seen nitric acid succeed in a subcutaneous nævus of the finger which bled repeatedly at regular intervals.

Patterson (London and Edinburgh Monthly Journal; 1842; p. 552) cured a case of taleangiectasy of the size of a pigeon's egg, on the shoulder of an infant eleven months old, by passing needles, made red hot with a spirit lamp, in rapid succession, about twenty times, into the tumour in all directions. There was no hæmorrhage, and the child apparently suffered little pain.

The acid nitrate of mercury has been employed for the destruction of these morbid growths, and symptoms of poisoning have followed its use.

Tyrrell injected nævi with a strong solution of alum, first making a puncture with a lancet, and then inserting an Anel's syringe. I once saw this method applied in the case of large nævus over the sternum: extensive inflammation was the consequence, and the life of the child placed in some danger; the breathing

became exceedingly rapid, not from internal inflammation, but from the pain of the external inflammation, impeding the due dilatation of the thorax; the navis was perfectly cured.

The electric cautery may be used in the case of extraordinary positions of nævi, as on the lip, in the substance of the nostril or the ear.

In some cases the only remedy is tying the principal trunk of the arteries with which the swelling is connected. Mott, in a child three years old, obtained only an imperfect result from tying the carotid artery, and subsequently tied the carotid on the other side. Möller (Jaeger Handwörterbuch; vol. i, p. 497), a child four years old, tied both carotids with success. In a case of aneurism by anastomosis of the orbit causing prominence of the eye, Hayes Walton tied the carotid with decided success.-P.H.B.]

in

APHORISMS.

318. There are two kinds of nævi: pigmentary nævi and erectile nævi. They result from the changes produced by the accumulation of pigment, and the more or less considerable increase in the number and size of the capillaries of the skin, transformed into a spongy erectile mass.

319. The pigmentary nævi never disappear; the erectile nævi almost always remain.

320. If the erectile nævus increases too quickly, and threatens to burst, we should destroy it entirely or transform it into a tissue which is not susceptible of vascular degeneration.

321. Nævi become transformed into fibro-cellular tissue under the influence of vaccination, of the inoculation of the tartar emetic, of acupuncture, followed by caustic injections. They disappear for ever when they are energetically treated by a caustic such as the Vienna paste.

BOOK XVIII.

ON SCLEREMA, OR THE INDURATION OF THE SKIN OF INFANTS.

Sclerema is a disease characterized by induration of the skin and of the subcutaneous cellulo-adipose layer, with or without oedema of this tissue.

It is a peculiar disease, which is caused by a disturbance of the circulation of the skin and by the suspension of the capillary circulation. M. Roger has quite recently applied to it the term of algide dema, in consequence of the extreme lowering of the temperature which accompanies it; but this denomination appears to me incorrect-1stly, because there are non-dematous cases of sclerema; and 2ndly, because

M. Mignot has observed cases of considerable lowering of the temperature without sclerema.

It is truly impossible, after having read what authors have stated on the induration of the cellular tissue of infants, thus described under the term of ædema and sclerema, to form a precise idea of this disease. Some state that the skin is livid; others, on the contrary, affirm that it is of a yellowish white; there are some who say that the limbs are hard, as if frozen. Others reply that this is a mistake,

that the limbs are soft, and that they preserve on the surface the bel

impression from pressure of the fingers. Here, they tell us that it is a local disease; there, that it is a general disease; in fact, there is not a single point of the history of this disease which has not been thus the subject of controversy. After the study of the works of Andry, Auvity, Underwood, Gardien, Billard, Dugès, and M. Valleix, it dalare

results that it is impossible to find out what sclerema or the oedema of the cellular tissue of infants really is.

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4

However, if I may decide from my own observation, preference is Billa to be given to the work of Billard; I have there found the most clear,. the most correct, and the most intelligent description of this disease.

There are two varieties of sclerema; the one characterized by theo an induration of the skin and of the adipose tissue, this is simple sclerema;

the other characterized by induration accompanied by edema of the

subcutaneous cellular tissue, this is what I term odematous sclerema.

The skin, contracted, hard, and cold, appears no longer to exercise its functions, and to refuse passage to the blood in its capillaries, whence an obstacle to the general circulation results, which determines anasarca to a greater or less extent.

The serous infiltration of sclerema is, then, of the same nature as that of ordinary anasarca. The cause of the effusion of the liquid out of the vessels is the result of an obstacle offered to the circulation of the blood in the tissues. The oedema is thus purely symptomatic of the sclerema; it resembles that which sometimes succeeds diseases

زم پینا

of the heart, the obliteration of the principal vessels of a limb, and disras that of erysipelas of infants; it is evidently the result of the disturbance of the capillary circulation and of the functions of the skin. In the description of sclerema, oedema of the integuments should not be put in the first rank, as this is, in fact, only one of the more secondary symptoms, and one which is not constant. sometimes wanting, just as it is observed to be wanting in certaine La diseases of the heart and of the organs of circulation.

It is even

The affection of the skin, whatever its nature may be, is here the principal disease; whether it is the result of the disturbance of the capillary circulation or of the perspiratory functions of the skin, little

concerns

us at present; it is this which is the cause of all the!

symptoms, it is this which constitutes sclerema, and to it we should principally direct our attention. We shall afterwards assign in the symptoms the place which the oedema should occupy.

Now that we have precisely defined what we would understand by this term, sclerema of infants, we shall describe the causes, anatomical changes, symptoms, progress, and treatment of this disease.

CAUSES.

Sclerema is especially met with amongst the children of the poor, aus and amongst foundlings. It is seldom observed in the children of the middle and upper classes of society.

thesus It appears that its development is very much favoured by the

action of cold. Most authors agree in mentioning this influence, and state that cold interrupts the insensible transpiration, lowers the circuLlation, and condenses the mucous and serous fluids in the tissues. This may be so; but here is a table from Billard, which demonstrates that the disease develops itself at all periods of the year; however, we may have cold weather in every season.

In 1826, out of one hundred and seventy-seven children with sclerema, observed at the infirmary of the Enfants Trouvés, the number is thus divided for each month:

As will be observed, there are about twice the number more children attacked in cold and damp seasons; but we also find examples of this disease in the hottest months of the year.

Sclerema is a disease which should be considered as peculiar to the newly-born; however, it is also met with in children of more advanced age and even in adults; it then presents itself under a different form and with a much less degree of intensity. The induration is purely local; it is difficult to discover its causes. I have observed three examples of it, one at the Hôtel Dieu, under the care of M. Caillard, the other while dresser there, and the last was for a long time under the observation of the pupils, in the practice of M. Trousseau, at the Necker Hospital: it was the case of a young girl who had the skin of the whole of the left side of the face, neck, and chest hardened, firm as wax, white and cold like marble. The health was otherwise very good. Every one might have seen at the

Hôtel Dieu, in the practice of M. Récamier, a fourth example of the same nature, with the details of which I am unacquainted, and which was to be found at this hospital when M. Trousseau attended the practice there. Lastly, MM. Thirial, Forget, Gintrac, and Ravel, have observed other examples of it, which they have published under the terms of stegnosis, chorionoïtis, sclerodermia, &c.

These few words suffice to illustrate the comparison which may be established between certain partial indurations of the skin in adults and the induration of the newly-born. The nature of the disease appears to me to be identical. We leave to other observers the

care of verifying and of defending this hypothesis.

ANATOMICAL ALTERATIONS.

The induration of the cellular tissue of infants is local or general. It is sometimes confined to the inferior limbs, superior limbs, or face; it is often extended over the whole surface of the body.

The skin is reddish, or on the contrary without colour, of a yellowish white, according to circumstances with which we are unacquainted. It sometimes presents a very decided yellow jaundice-like tint; it does not appear to be changed in its structure; its thickness is the same as in the ordinary state, only it is very compact, very hard, and with

difficulty preserves the impression of pressure of the fingers; it gives

to the touch the sensation that a portion of wax or the skin of a

white.

a les dead subject would do. We may here observe that this alteration is a di not a cadaveric effect, for it is observed on living subjects, not only Coupl

towards the close, but also in the course of the disease.

The layer of cellular tissue immediately beneath the skin is also hard indurated and forms distinct and somewhat hard adipose granulations, similar to the granulations of the adipose tissue of infants who have died from every other disease. Beneath this layer of cellular tissue is found another, the meashes of which retain a more or less con-ula: siderable quantity of semi-transparent serosity, which partly oozes out at the time of section. A similar liquid is enclosed in the cellular tissue of the interstices of the muscles.

there is

M. Chevreul, in the analysis which he has made of this liquid, has discovered that it contains a plastic matter, spontaneously coagulable on contact with air; and M. Breschet, who directed these experiments, at one time thought he had established a connection between this alteration and the disease we are now considering. Billard, fo naturally astonished by this extraordinary proposition, repeated the experiment; he placed in a capsule the serosity of the cellular tissue of a child with sclerema, and he observed it become jelly-like Serin at the end of some minutes. This result required a contra-proof; an experiment was made on the serosity of a child attacked with.