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Yellowness of skin, which is common among infauts, especially those of feeble action, disappears without medication, and without direct evidence of hepatic derangement.
From observation in the diseases of infants, I have sometimes been induced to believe that previous to the full establishment of the hepatic function, or when the kidneys fail to disengage effete material from the circulation, the skin performs a substitute office.
In 43 cases Billard found no disease of the lungs; in 34 they were variously affected. Forty presented the foramen ovale closed. No shortening of the intestinal tube in any case was found after careful measurement.
In 50 out of 70 cases there was intestinal inflammation, yet he thinks the non-inflammatory cases are sufficiently numerous to exclude the former as a cause of the cellular induration.
The views of Billard are mainly that induration of the cellular tissue in young infants is nothing else than simple cedema, analo. gous to the oedema of adults, and this he ascribes to a suspension of cutaneous transpiration, “and an obstruction in the course of the blood, resulting from its quantity in the circulatory apparatus.”
Condie quotes largely from Elsaesser, and coincides with him in the statement that "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.”
The obstetrical ward of the Cincinnati Hospital had not contained a case of erysipelas for many months, and not a feature of this disease was present in our case, nor was the ædema of Billard. My inference is that this disease was of that form which consists of “induration or concretion of the adipose matter," and not that " from serous infiltration of the cellular tissue."
In the consideration of the case a brief outline of the mother's condition may be given.
Her labor was natural. Four days subsequent to delivery (October 12), both lochia and dejections became offensive. An eruption in red elevated patches appeared on the forehead. On 16th, 17th, 18th, had a chill, temperature following varying from 102° to 105° ; pulse at times full as well as frequent; tongue from
' day to day became more and more loaded with thick brown fur.
19th. Has been vomiting; pain in right hip; abdomen greatly swollen, but without pain or tenderness on pressure. Symptoms gradually, nay rapidly increased, until 21st, when they terminated in death. From the beginning to the close of the disease the sur. face was bathed in perspiration.
The autopsy furnished no satisfactory evidence of the cause of death. The peritoneum was somewhat injected, but not decidedly inflamed. Both thoracic and abdominal organs were healthy. In a word, there was no trace of active disease in any of the viscera or tissues. Was this a case of pure blood poison? If so, were the morbid products transmitted to the foetus with the above results?
Treatment. The treatment in all the cases was commenced by clearing the bowels of their curdy and green contents. The stomatitis suggested the use of chlorate of potassa, and the feebleness the gentle use of stimulants. Quinine, iron, carbolic acid, etc., were given without confidence being established in the efficacy of either.
Probable cause.—No bospital could be better constructed for light and ventilation than the Cincinnati Hospital. Built in the pavilion style, each pavilion being, in one sense, independent of the rest, secures for it an immunity from those diseases which extend their influence to surrounding patients in hospitals compactly built. The question is, in which ward is there most cleanliness and painstaking ?-the perfection of each leaving the question unanswered. Still, emanations of an unexpected and pernicious character will sometimes occur, to be felt rather than seen.
From the favorable hygienic condition of the hospital it has seemed impossible for any disease to be generated within its walls. There can be no cause assigned, however, for the production of the strange disease among infants, except that of local origin. What is the poison, and whence comes it? The female surgical ward has been located under the obstetrical. The mortuary has been so near as to send its odors, at times, where they were not desired. Suspicion has rested on these localities. The remedy is being applied, and we await hopefully the result.
After the above was written, the following cases occurred, and, notwithstanding they present no new features in the main, their termination, with one exception, is gratifying; they are, therefore, subjoined.
M. R. gave birth to a healthy female infant May 23d, 1875. One week subsequently the mouth became aphthous. The next day the entire body was dingy; nursed well; urine and stools were natural. 31st. Discoloration of skin deepened; urine dark, leaving black deposit on napkins. These symptoms, with slight variations, continued until June 5th, when a decided improvement was perceptible.
14th. Discharged cured.
The next child (male) was born May 25th, with every indication of good health. June 2d. Aphthæ with the usual prominent symptoms appeared, and continued until the 5th, when the urine became natural, and the skin white. On the 7th it died. Nothing
. abnormal was observed except a blackened condition of the apices in the kidneys.
Infant A. (male) was born May 29th, to all appearance healthy. Two days following, the mouth became aphthous. June 2d. The skin was yellow and the eyes greenish, the color of the former gradually changing until the 7th, when it became very dark. Then the color began to fade, and in forty hours it had disappeared. On the 9th there was a large amount of black deposit in the urine. From this time a general improvement was manifest, and now, June 16th, it is seemingly well.
Infant L. (male), healthy, was born May 30th, 1875. June 3d. Mouth aphthous; sclerotics greenish-yellow. 7th. Skin has a decidedly brownish tinge. 12th. Urine dark, with black deposit; semi-comatose. 13th. The chest and extremities covered with a red rash. Temperature 1011° 14th. Condition of child greatly improved. 17th. Appears well. This is the only case in which the temperature was above 99o.
The mother of this child had puerperal fever, while the other three mothers were free from post-partum trouble.
Tincture of iron was administered in these cases from the beginning to the close of morbid phenomena.
I now leave my cases, with all their singularity, to the consideration of those wbo are given to plausible speculation as well as a wise application of facts.
The above four cases were speedily followed by three others, two of which have been fatal. The remedy, to which much credit was given in the cure of the former cases, effected no favorable change in these.
Infant C. (male), born June 8th, 1875. 11th. Sclerotics slightly tinged; buccal membrane reddened; saliva frothy between the lips. 15th. Mouth white, with curdy exudation ; lips livid. 19th. A. M., general surface dingy; P. M., is now dark brown; urine
dark with black deposit. 21st. Died. No autopsy. The mother had a favorable convalescence.
Infant R. (male), born June 11th, 1875, was healthy until June 16th, when the eyes became tinged and the mouth frothy and curdy. The entire surface is discolored. 19th. Urine dark with black granular deposit. The first discharge of granules was in a mass weighing 61 grains, besides a considerable portion adhered to the papkin. 21st. Died.
Autopsy by Dr. Dandridge.—Lungs and heart normal ; left ventricle contains a soft clot; liver large but normal in appearance; spleen natural; umbilical vein contained a coagulum ; kidneys considerably enlarged, substance unusually dark; the line of demarcation between cortical and tubular portions not apparent. Pelves and calices completely filled with a slate-colored mass, which in situ is moist, but on exposure soon becomes dry and readily powdered. When moist it has the consistency of semiorganized fibrin. The pyramids are filled with the same granular substance.
The bladder is greatly distended with coffee-colored urine. Be. sides it contained a black substance of clayey consistence, moulded to the shape of the bladder, and when removed entire measured over an inch in diameter.
In all the cases the order of symptoms was as follows: Scle. rotics tinged greenish-yellow; frothy saliva between the lips; more or less aphthæ; discoloration of skin; coffee-colored urine, with black granular deposit; inability or unwillingness to nurse, varying as to time in different cases.
For purposes of investigation the mother's blood was taken from a vein in the arm. It was not subjected to any chemical tests, but nothing unnatural could be detected by the microscope, nor was there anything abnormal in the blood of the child obtained by scarifications from the arm. A thin layer of skin taken from the heel presented the following appearances, the examination being made by Dr. Carson. “One-half of the connective tissue of the section in view is of a purple, deepening into a blackish sbade, and distinctly separated from the other half, which is of a pale buff color. There is no granular deposit in either half of the section.”
CHEMICAL LABORATORY OF Miami MEDICAL COLLEGE,
CINCINNATI, O., July 22, 1875. PROF. M. B. WRIGHT, M.D.
Dear Sir: The specimens of pigmentary deposit sent me have been submitted to careful chemical analysis, with the following results so far as the work has been carried out. Owing to the hurried demand for a report for publication along with your paper on Pigmentation Cases," my work has been necessarily more hurried than the interesting nature of the subject demands. Further researches are in progress, tbe results of which will be made known in due time.
The specimens received were from four different cases: the first, a dried deposit from urine passed at one time; quantity 64 grains. The second and third specimens were taken from the kidneys of separate cases, and the fourth from a large deposit nearly filling the bladder of another patient.
The different specimens were found to possess as nearly the same chemical properties as so many different samples of normal blood or urine. The ultimate analysis given below is the average of two analyses, the first from the mixed matter of the first, second, and third cases, and the other from the fourth case.
The deposit in its moist state, and after preservation in alcohol, has very much the appearance and consistence of liver. In its dried state it is quite black and exceedingly hard, and very difficult to fracture or pulverize.
It is slightly granular in its moist state, but structureless when dried.
It will be observed that the gravity of the moist substance agrees with that of normal blood.
It differs in its chemical relations and composition from any substance with which I am acquainted, bearing, however, some resemblance to melanin, the black pigment of the eye; on this account I propose for it the provisional name of melanoidin.
100 parts of the moist mass dried at 212° F. give 34.5 parts of dry pigment.
100 parts dry pigment contain