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True Sclerema

body, induration, according, infants, temperature, fat, skin, life and fluid

TRUE SCLEREMA.

True sclerema (induration of the cutaneous cellular tissue) is confined to new-born infants. This lesion is not to be confounded with the sclero derma which attacks older children and adults. It occurs only, according to Parrot, in feeble infants and those wasted by bad feeding and unwhole some conditions generally. According to Underwood it appears as a fea ture of the last stage of atrophy from digestive derangements.

Morbid Avatomy.—The lesion consists in a curiously condensed state of the skin. This tissue is thinned as if from compression of the several layers. The rete Malpighii and corium have sensibly lost thickness, and the coils of the former layer can hardly be detected, so intimately are they amalgamated into a compact mass. In the adipose layer the fat-lobules are atrophied; their globules are wasted; and the connective-tissue bands • are more numerous and thicker than in the normal state. According to Underwood, the induration of the cellular tissue may reach the sheaths of the muscles and even affect their fibres. There is never any subcutaneous oedema in the true disease. The blood-vessels, especially those of the pap illae, are so narrowed that their lumen is obliterated. These pathological changes form a very distinct condition—different on the one hand from oedema of the new-born, and on the other from scleroderma of older chil dren and adults. They are the consequence, according to Parrot, of de siccation of the tegumentary tissues owing to the draining away of fluid by the copious watery discharges from the bowels. There must, however, be some other cause for the pathological change, for in this country it is com mon enough to find young infants reduced by bad feeding and profuse watery diarrhoea to a state of extreme emaciation ; but sclerema is a lesion so rare that when discovered it is regarded as a clinical curiosity.

A form of sclerema called adipose sclerema is sometimes met with. This is different pathologically from the preceding. It is due to a solidifi cation during life of the subcutaneous fat. According to Dr. Langer the melting point of infant's fat is 113° Fahr., or a higher point than the temperature of the body ; while adult fat becomes perfectly fluid at a tem perature of Fahr. Hence, in the healthy child during life, a large proportion of its fat is not quite fluid but merely soft. If, from any reason, such as collapse, or the rapid withdrawal of heat which sometimes occurs in young infants as a consequence of depressing illness, the temperature of the body falls to 89.6°, this degree of cooling, according to Dr. Langer, is sufficient completely to solidify all the fat in the panniculus adiposus.

Symptoms.—The more special symptoms of sclerema are preceded by great impairment of nutrition and rapid wasting. The induration begins

to be noticed at the end of the first week of life, or on the ninth or tenth day, or in some cases in the course of the second month. According to some writers it is especially in infants born fairly healthy and robust, and whose nutrition has become rapidly impaired that the cutaneous symptom is most likely to occur.

The induration generally begins in the lower limbs and spreads thence to the loins, the back, the chest, and eventually to the whole body, face included. In some cases the face is said to be attacked early, and the in duration to spread from this part to the body. The affected skin, com pletely losing its natural softness and suppleness, becomes hard and un yielding, and pressure with the finger meets a resistance like that of horn or hardened leather. The folds and lines of the skin disappear, and partly from rigidity, partly from its close connection with the underlying tissues, it can no longer be pinched up between the finger and thumb.

When the whole body is thus affected the induration prevents any bending of the joints, so that the limbs are stretched stiffly out, and it is even said that the body may be supported in a horizontal position in the air by a hand placed under the loins. The rigidity of the face, especially of the lips and cheeks, makes sucking impossible, although the induration of this part is usually less advanced than that of other regions of the body. But for this, and for the little feeble respiratory movement of the abdomen and chest, the infant might be thought to be dead. Indeed, the tightly compressed lips, the closed eyes, the mask-like face, the immobility of the frame, and the peculiar coldness of the surface, resemble death more nearly than life.

The lowness of the temperature is one of the striking features of this condition. The diminution of heat of the skin gives a marked sensation of coldness to the hand, and even in the rectum the temperature may fall far below the normal level. The body is not only cold, but seems incapa ble of being warmed ; and even the occurrence of pneumonia has no ap preciable effect in raising the temperature. The pulse and respiration fall in frequency. The former may be as low as sixty in the minute, the latter fourteen. The respiratory movements are hampered and feeble, and the cry is weak and almost inaudible.

The course of the disease is very rapid. The induration proceeds apace. By the third day, according to Underwood, the skin has become intimately adherent to the tissues beneath. By the fourth the induration has become general over the body. The child usually dies on the seventh day or soon afterwards.