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Book XVIII.]

ON SCLEREMA.

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of the patient's fingers. The pulse is always very feeble and usually hard to slow. It is on the contrary very much accelerated in certain compli- tate inb cations, as pneumonia for example.

PROGRESS AND COMPLICATIONS.

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The most frequent complication observed in children with sclerema betrays itself externally by a peculiar colour of the skin, due to the passage into the blood of the colouring matter of the bile; I refer to jaundice. This phenomenon is met with in a great number of patients, and especially in those who present the variety of induration without oedema, or at least with not very decided oedema. It is in relation with a slight hypertrophy, accompanied with congestion Entert

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Pulmonary congestion and confluent lobular pneumonia are very litis an common complications. They have been previously referred to.

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In the course of the sclerema of infants, irritation of the bowels clien and entero-colitis are also sometimes observed; but we must not fall into error; these complications are much more rare than is stated by M. Denis, who is probably mistaken in his appreciation of the anatomical characters of inflammation of the intestine and who has l'encens undoubtedly accepted slight congestions for unequivocal traces of inflammation. What would lead to this belief is, that he wrote at a time

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see what he observed.

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This disease commences by disturbances, the nature of which it is difficult to appreciate and which are evidenced by the cries of the children. Twelve or twenty-four hours afterwards, the limbs become hard, then the face, afterwards the trunk; the child refuses to suck, it is restless, and incessantly utters the acute and feeble cry to which u we have referred. The oedema commences to show itself on the 7143 second day, and it increases in a very variable manner, according to the subjects, so that there are, as we have already stated, cases of induration of the skin without oedema, or with slight oedema, or lastly, with a very considerable oedema. This phenomena should be xlooked upon as the result of the disease of the skin. Commmes

The disease generally lasts from two to six days, and always terminates by death when the induration is of any extent. Resolution occasionally takes place, on the contrary, when the disease is less intense, but a long time elapses before it is accomplished; it requires from fifteen days to a month to effect it.

DIAGNOSIS.

An attempt has been made to distinguish true sclerema, that is to say, induration of the skin, a special disease, with or without

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oedema, from the adipose induration which sometimes comes on at the last day or in the last hours of departing life, of course not wishing to include cadaveric adipose induration.

But there exists a very great difference between a phenomenon which develops itself without precursory symptoms, which is the cause Laof others, such as cedema, icterus, pneumonia, &c., and another phenoto ce menon which is observed at the termination of a great number of diseases of young children at the moment of their death. It is not possible to confound these two states; one is primary and of itself constitutes a disease which may last some time; the other is secondary and forms one of the precursory symptoms of death.

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CONCLUSIONS.

To resume, then, sclerema is a disease of the skin in which an obstacle is presented to the cutaneous circulation in the red and white capillaries of Bichat.

Eshenk Thence a disposition to oedema results as in diseases of the large

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vessels. The induration of the skin, the consequence of the disturbance of the capillary circulation, constitutes the first phenomenon of the disease; serous infiltration constitutes the second.

This disease is either partial or general.

It is very serious when it is general, and it may be cured when it is partial.

It is often accompanied by icterus or pneumonia.

It is a disease of infants, but it is sometimes met with in children and in adults under the form of partial induration.

TREATMENT.

The therapeutic means recommended for the sclerema of infants are not numerous. Bleeding has been employed rather to combat a symptom, than from the rational views which should preside over its employment. Its use has been recommended because the skin is often the seat of active congestion, the same being also the case in most of the viscera. However, there is not in this disease any febrile reaction properly so called. The pulse is slow and feeble, and the skin is always chilly.

It is infinitely preferable in my opinion, to allow oneself to be guided by the indications which the nature of the disease affords. Moreover, it is evident and this is a fact admitted by all authors, that the capillary circulation is lowered and that it is to its disturbance that the congestion of the organs must be referred.

It is consequently more rational to endeavour to reanimate the circulating functions by internal and cutaneous stimulants than to set to work to make abstractions of blood. In fact, it is found to be much

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Book XVIII.]

ON SCLEREMA.

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better to order irritant frictions on the skin by means of linen cloths either dry or moistened with irritant liniments. It is moreover necessary to place the children in a properly heated ward. This means is sometimes sufficient, observes M. Valleix, to cure these patients. Bags of hot sand, or of hot bran, should be placed round ́ the children. They should be also put into simple baths, or in warm bran baths, or those of mint, melissa, canella water, &c., and especially vapour baths, which have been very often employed by M. Baron with some success.

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Internally, cordial and aromatic draughts should be given, the basis ordinl of which should be principally formed, either of wine or of the stimulant liquids extracted by distillation from the plants of the natural order Labiata.

It is in this manner that we may hope to cure this serious disease, if it has not by its extent already compromised life from its very invasion.

[This disease, although of such frequent occurrence abroad, is apparently uncommon in this country. Dr. Willshire states that he has now only seen three cases of this rare affection, two of them fatal ones, and West speaks of its extreme rarity.

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Dr. Elsaesser (Archiv. Gén.; N. S.; i, 531) has lately made some observations on this disease, founded upon fifty-three cases (twenty-nine males and twenty-four females) which he has met with in the hospital during the years 1828-51. Of this number, ten only were full-timed, and of the forty-three others, ten were twins. During the same period there were born in the hospital 4,468 children ed at full time, and 267 premature.

The disease was especially prevalent during 1849-50, when puerperal fever drith

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also prevailed; and it is oftenest met with in November and December, no case
having been seen in May. In ten cases it began to manifest itself within the
first twelve hours after birth; but usually it was not met with until the third
and from that to the fifth day. The diminution of weight that occurred was to
remarkable, as was also the diminution of temperature, both generally and in
the indurated parts. Whenever any improvement occurred, this rose again.
Of the fifty-three cases all but four proved fatal, either from the sclerema itself
or some incidental disease. Icterus was the most frequent complication, then
pemphigus and erysipelas.

On incising the parts after death, a turbid fluid, resembling that of anasarca, often flows out. The adipose tissue consists of solid, fatty granules, which are easily detached, being already separated by the effused fluid. This tissue, of a deep yellow, is usually from half a line to three lines thick, and sometimes below it a gelatinous one is found. The indurated tissue is traversed by numerous veins gorged with black blood; but no lesion of the large vessels, or obliteration of capillaries, as noted by Bouchut, have been met with. The induration rarely extended below the chorion. The muscles were pale, as if infiltrated, and in those of the buttock, small apoplectic deposits have been found. The veins and sinuses of the brain were mostly filled with dark diffluent blood, and effusion was found in the ventricles or at the base. In a tenth of the cases, lobular pneumonia was present, and in a third, portions of the lungs were impermeable to air. Intestinal lesions and hyperæmia of the abdominal viscera were common, and in eight cases, peritonitis was present.

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Whatever hygienic care may be lavished on the children of hospitals, these diseases are far more frequent and fatal among them than in private practice. Among the most prominent causes, vitiation of the air must be noticed, another being the influence of chill. Cold impedes the functions of the skin, leading probably to a determination to the kidneys, which are found hyperæmic, albuminuria being often present. A principal predisposing circumstance is the innate debility or incomplete development of the organism, premature children constiChalda tuting four-fifths of the subjects. On the other hand, vigorous children are sometimes attacked; and in premature twins one shall have the disease and the constitute other be exempt from it. The treatment has chiefly consisted in the employment of hot, aromatic baths, and the administration of stimuli, such as musk. Dr. Elsässer has not met with the chronic form of the affection.-P.H.B.]

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APHORISMS.

322. Sclerema results from an obstacle to the circulation in the cutaneous capillaries.

323. Sclerema is a disease peculiar to infants, it is very rarely observed in children or in adults.

324. Sclerema exists with or without oedema of the cellular tissue. 325. Sclerema is either general or partial.

326. Chilliness and induration of the skin, accompanied by considerable lowering of the temperature, announce sclerema.

327. In an infant, acute, isolated, feeble, and frequent cries, repeated every minute, indicate the existence of sclerema.

328. Towards the termination, sclerema is almost always complicated with pneumonia.

329. The sclerema of infants is usually fatal.

330. Partial sclerema is sometimes cured; general sclerema never. 331. Sclerema becomes less and less serious after the fifteenth day from birth.

BOOK XIX.

ON DISEASES OF THE NECK.

1st. ON CERVICAL TUMOURS.

Young children are sometimes troubled with tumours of the neck, the origin of which is very obscure, and on the nature of which physicians and surgeons are far from being of the same opinion. There are two varieties of them-some are acute, others chronic, some are congenital, others acquired or accidental.

All chronic tumours of the neck in young children make slow progress, and are constituted of erectile tumours or of unilocular and multilocular cysts.

All accidental tumours of the neck generally originate in acute or chronic enlargement of the superficial or deep cervical glands. Their history is sufficiently well known, and is allied to that of inflammatory adenitis or to that of scrofulous diseases.

Congenital tumours of the neck are more rare and less known; they are composed of the erectile tumours which have been previously described under the name of narus, or by cysts to which we shall briefly refer.

2ND. ON CYSTS OF THE NECK.

Cysts of the neck are observed in the newly-born or some months after birth, but, then, their origin belongs to the later term of intrauterine existence. They are congenital cysts developed with more or less rapidity. Cæsar Hawkins has observed three examples of them, the first in a child three months old, another in a child of eight months, and the third in a subject one year old. Dr. Evans has seen a case at its commencement in a newly-born infant, and I have observed another in an infant twenty-one days old. There are also other instances of this disease dispersed in various writings, and collected by Berndt, Arnolt, &c., but I have been unable to collect the details, and I abstain from mentioning them.

In one of the cases related by Hawkins, three months old, the respiration was very much obstructed by the presence of the tumour, which was of very large size; it had numerous attacks of suffocation, and frequently awoke, especially to take breath.

This tumour was elastic, soft, compressible like a nævus.

The child died suffocated, and at the autopsy a tumour was found at the right side of the neck, being nearly as large as two oranges, separated by a deep fissure formed by the digastric muscle. This tumour was formed by the agglomeration of several hundreds of small cysts, of very variable size, as large as peas or as nuts, and even attaining the size of a walnut. These cysts closely united together, and semitransparent, were filled with colourless transparent serosity, either reddish or black like venous blood. They extended below the jaw, surrounding the vessels and nerves of the neck, which they compressed, and then descended along the vertebral column, behind the pharynx and oesophagus to the sixth cervical vertebra.

Here is another case which came under the observation of Dr. Evans :

Case. Hydrocele of the neck in a newly-born child; cure. In March, 1845, I assisted a lady who was delivered of a very healthy male child. Some days afterwards I observed a relaxed and wrinkled fold of skin below the horizontal ramus of the lower jaw, at the right side of the neck, to the extent of a square inch. At the end of two or three months, a sensation of fluctuation was observed at this spot; a small round and soft tumour soon formed, without any change in

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