To say that these granules are spores-organized things-endowed with a living principle, would be to stretch the imagination beyond all limits. That they are the result of destruction of blood globules is possible; still there is nothing in their shape, size, or elements to justify this as a positive conclusion. That they existed in the blood, independent of renal action, is certain, for they were plainly seen under the microscope intimately associated with both white and red globules. The blood used for experiment was taken from the longitudinal sinus of one of the deeply pigmented children. It is true that other blood was examined without the pigment granules being found, but it was taken from those who had become bleached to a pearl-like whiteness-who were seemingly bloodless-the granules having escaped through the kidneys.

Exclude the granules from the blood, and suppose the disease to be a true hæmaturia, we still need light as to the manner in which the globules or other blood elements are metamorphosed in the kidney. No foreign element or morbid product was found in the urine, nothing that could convert blood globules into black amorphous granules.

That the cases presented are those of "blood poison" may be true, but how induced? "Malarial poison" has not been in operation, nor do the cases resemble those of "malignant remittent fever."

In volume 13. part ii., p. 996, of the Edinburgh Journal, is an article on "Intermittent or Paroxysmal Hæmaturia," furnished by E. H. GREENHOW. He notices seven cases of this disease, and adds: "This disease, which has been observed only of late years, would seem to be of very rare occurrence, for ten or eleven cases, published by as many different observers, are all that I have been able to find in English medical records."

In addition to ordinary symptoms of intermittent fever, are those which mark the kidney trouble. "From half an hour to two hours after the chilliness or rigors the patient has never failed to pass the first dark-colored urine, which has always been highly albuminous, and has contained numerous crystals of oxalate of lime, with more or less of brownish or yellowish-red amorphous granular matter, and a few hyaline casts, but only occasionally some stray blood-corpuscles." His theory is, "that the disintegrated blood transudes through the walls of the blood vessels in the Malpighian bodies." He "regards the kidneys rather as the organs of elimination than as the seat of the disease." The article.

concludes thus: "I strongly incline to believe that the true pathology of the disease is to be sought in the condition of the blood itself, rather than in any local organic change."

Some of the children had died after the skin had changed from a dark to an extreme white color-after the curdy exudation had disappeared more or less from the mouth-after the urine had become more natural-after the green color of the dejections had changed-in a word, after the general change had justified a favorable prognosis, they have died. Is there not, then, some other blood change tending to a fatal result than in the admixture of amorphous black granules?

As puerperal fever existed in the obstetrical ward of the hos pital from time to time during the two years the infants were so strangely diseased, it may be interesting to inquire to what extent the mother exerted a destructive influence over her own offspring.

The mother of the first reported case had no very untoward symptom, although her convalescence was somewhat protracted. For a time she had scanty urine, and a deficient supply of milk.

The mother of the second child had a favorable and rapid convalescence. A mild attack of milk fever occurred early in the mother of the third child. The mother of the fourth child died of puerperal fever two days before the child was observed to be sick. No fever followed the fifth delivery. It may be stated here, without going any further into particulars, that not more than half the mothers had puerperal fever in an aggravated form, and of these about one-fourth died.

From all this it is apparent that the disease could not have been induced by contact with puerperal fever cases. Besides, some of those who had puerperal fever suckled their children after their fever had become decidedly manifest, without contamination.

Epidemics of puerperal fever and erysipelas have prevailed at the same time in the same neighborhood, and on this ground a belief has been entertained of their identity. These cases have existed independently in the same ward, and seemingly without the slightest relation the one to the other.

Three cases of erysipelas appeared in the ward during the period embraced in the above cases. In one several abscesses formed. In an adjoining bed lay a patient with crural phlebitis. An erysipelatous redness spread over most of the opposite leg. Another patient had a temporary blush on one of her legs.

Had the poison of erysipelas anything to do with the initiation

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of the infantile cases? If negative evidence is of any value in this connection, I should say not; for erysipelas has appeared in the ward many times without the presence of such disease as is here presented among the infants.

Infantile jaundice is common in hospitals as well as private practice, and as some of the cases with dusky skins and dark urine had also the outward sign of jaundice, the inference would have been easy, without further evidence, that the biliary apparatus was at fault. Again, stomatitis is a common attendant upon jaundice, and it was present more or less in all the above cases. The first case was treated as jaundice, and recovered. The same treatment failed subsequently.

The post-mortem conditions of the second case accord with the observations of Jörg, that atelectasis is present with an open foramen of the auricular septum. But the sixth case disproves the assertion of the same author, that an open foramen and atelectasis are invariably associated.

The fifth child was born prematurely. It was not cyanosed, but he ordinary red color of an immature foetus was so combined as to give it a bluish tint over the entire body. A brief relation of the state of the mother will naturally suggest the questions-Had the blood of the mother such an effect upon the placental circulation as to induce an early expulsion of the foetus ?-or did the emanations from her body enter the lungs of the child, and thus impress fatally its delicate tissues?

The mother was transferred from the surgical to the obstetrical ward, February 8, 1874, and delivered the same day. The right mamma was large, and had a dark, ecchymosed appearance. The inferior portion was devoid of epidermis, from which issued an offensive discharge. The entire swelling was boggy, without any distinct point of fluctuation. Constitutional symptoms supervened, requiring stimulants, tonics, and supporting diet, with whiskey and carbolic acid as a local stimulant and disinfectant.. Large sloughs were thrown off from time to time, to the destruction of the mamma down to the pectoral muscle. The odor from this diseased tissue was so offensive and sickening as to necessitate the removal of the patient to a separate room. There was doubtless a bad condition of system in the mother previous to delivery, and this may have somewhat enfeebled the child in utero. Allusion has already been made to a fluctuating tumor on the right parietal bone of one of the infants. It was not a serous.

swelling (caput succedaneum), which indicates the most dependent part of the foetal head during labor, but a true cephalæmatomia. It was filled with blood-like material, of semifluid consistence, situated between the pericranium and inner table of bone. To the extent of the tumor the outer table was absent, and its boundary was defined by a hard ridge. Authors have attributed this ridge to an osseous exudation, to coagulation of blood, to fibrinous deposit, to deception of touch. In this case, however, dissection proved it to be an edged circle of bone, occasioned by the absence or destruction of the outer table of bone within the circle.

As no case similar to the following has ever occurred in the hospital during the thirty years of my observation there, and as it was associated with the preceding cases, I am induced to give it a place in this paper.

On the 8th of October, 1874, Agnes A. was delivered of a seven months' foetus weighing three pounds. It was feeble, even more feeble than is ordinarily observed in a foetus of this premature age. It was fed from necessity, and could 'swallow only a few drops of liquid at a time. As the red tinge of skin belonging naturally to a short-term infant began to fade, a slight yellowness took its place. Pain or uneasiness was manifested by a whine rather than distinct cry. The joints were stiffened and seemingly painful on forcible motion. The lower pressed strongly against the upper jaw, and considerable effort was required to give mobility to the joints. The skin conveyed the idea of tightness, and could not be wrinkled even by strong pinching. The muscles felt hard, and the limbs were more like dry sticks than pliable texture. The lids were applied closely to the eyeballs, and the lips were stretched tight over the gums. Both were destitute of voluntary motion. The scalp and cranial bones were like a solid immovable structure. There was too much fixed rigidity for spasmodic action. At one time a few drops of blood escaped from the vagina. Death occurred eleven days after birth.

Post-mortem Appearances.-The umbilical cord had desiccated to firmness, but was still adherent. The umbilical vessels were free from obstruction or inflammation down to their entrance into the liver. All the thoracic and abdominal organs were in a healthy state. The subcutaneous cellular tissue was rather dry than moist. Was this a case of "sclerema," "skin bound," "adema cellularis," or was it "trismus nascentium ?"

As there were no convulsive movements, no bending of the

head backwards, no opisthotonos, no violent contractions of the fingers or toes, no bending of the foot upon the leg, my diagnosis has been "sclerema."

Different opinions have been expressed by writers more or less familiar with this curious malady of infancy. An early belief was that the liquor amnii played an active part in the condensation of the integuments, and, again, it was attributed to impressions on the mind of the mother while viewing marble statues.

Among the more recently assigned causes may be mentioned cold, impure air, hepatic derangement, gastro-intestinal disease, shortening of the intestinal tract, imperfect closure of the foramen ovale, obstruction in the pulmonary circulation. Most, if not all, of these causes were inoperative here.

Condie remarks that "there is always more or less disorder of the alimentary canal" in induration of the cellular tissue. Then the case before us must be deemed an exception.

Billard has given us an extended argument against the many theories advanced upon the subject of causes. He admits that out

of 173 cases treated in a medical infirmary, 74 occurred during the winter; but, as disproving the exclusive influence of cold, he cites the remaining cases which were treated during the summer months.

The same author admits that a yellow tinge of skin is often associated with the disease, but claims that it is not an essential element. During the three or four earlier days in our case, there was a yellow mixed with the red tinge of skin. This, however, was not jaundice, if the term is restricted to the absorption and commingling of bile with the circulation.

The prevailing physiological doctrine is, that the coloring matter of the bile is formed in the substance of the liver, and that its reabsorption results in the bile color of the skin. Is this an exclusive physiological fact? If so, how are we to explain that other fact, that the skin may be deeply yellow or dark brown, while all other tissues retain their normal color? and this, too, without any obstruction in the liver ducts. Several of the infants whose diseases I have reported to the Association, and others, have presented variously discolored surfaces, without any change in other tissues or organs, save the kidneys. Is it not fair to infer that the skin, either by transpiration or secretion, or some peculiar function, is capable of extracting coloring material from the blood, independent of the liver or the real absorption of bile?