ICTERUS NEONATORUM Symptoms.—Usually before the end of the first or second day of life, less frequently not until the third, fourth or fifth day, and only very exceptionally still later, the skin of the newborn takes on a yel lowish tint which usually appears first on the- face. The icteric tint spreads rapidly over the trunk and extremities. In many cases, espe cially in the beginning, the physiological hyperfemia of the skin conceals the yellow color, which then only becomes distinct on pressure of the examining finger. Besides the skin, the sclera as a rule, but not always, is distinctly yellow; here the icterus sometimes is completely concealed by ecchymoses or vascular injection. On "expressing" the blood from the mucosa of the mouth, the yellow color comes out promi nently in the anaemic area. The yellow color is usually specially distinct in ulcerative processes in the oral cavity (Bednar's etc.); the secretion of suppurative processes is also colored yellow.
The pulse role in the newborn is not influenced by icterus.
The icterus of older children is also usually unaccompanied by a slowing of the pulse rate. This must be attributed to the fact that the bile of children contains only small quantities of the biliary acids. Jakubowitsch in an analysis of the bile of children found glycocholic but no taurocholic acid.
The lirer and spleen show no changes. After the passage of the meconium, the feces take on the "yolk-yellow" or green color, charac teristic for the nursling. The urine is also pale during the course of the ieterus. The examination for bile-pigment, with the customary tests, is usually negative. Epstein, alone, claims to have often found bile pigment in icterus neonatorum by using Huppert's test; and, according to Cruse, bilirubin may be demonstrated in the extract after agitating the urine with chloroform. Halberstam was also able to demonstrate biliary acids, in fact glycocholie acid, in the urine of ieterie newborns.
The microscopic examination of the urine during the period of icterus shows clumps of a dark pigment: these were already known to Virchow. were termed "masses jaunes" by Parrot and Robin and were identified with bilirubin by Cruse; the low solvent power of the urine for bilirubin (the urine of the newborn contains usually only traces of the alkaline phosphates which could dissolve the bilirubin) is the reason for the failure of solution of the bile-pigment, which is then usually found forming clumps with epithelial cells for a nucleus.
Icterus neonatorum is usually very slight in degree; at times it is quite intense. The duration of the jaundice varies from two clays to three weeks; the intensity of the discoloration determines this. In the majority of children the icterus disappears or becomes indistinct. in from six to eight days. In case the icterus increases in intensity toward the end of the second or even the third week, we may well assume that we are not dealing with that variety of icterus termed icterus neonatorum, but rather with an icterus clue to some other and usually more serious disease. This disease, in most cases, is sepsis, in the clinical picture of which ieterus plays a prominent role. In case sepsis can be excluded and if toward the end of the first month of life the icterus becomes more pronounced, consideration must be directed toward the possible pres ence of an obstructive jaundice. The latter condition is, in general, rare in the newborn and may be due to various causes, one of which is a congenital obliteration of the bile-ducts, with which condition the feces are only slightly colored and the icterus increases in intensity from day to day until the skin takes on a yellowish green color.
In cases of obstructive or of septic icterus, one is usually able to demonstrate bile-pigment in solution in the urine; this ability to put bile-pigment in solution evidently depends upon changes in the metabo lism, which are brought about by the disease and which change the *com position of the urine. A positive finding with Gmelin's test or with any other test for bile-pigment, cannot be employed for the purpose of excluding icterus neonatorum, since in the latter disease the reaction is also, at times, positive.