from the gastro-intestinal tract usually on within the first four days of life, most often on the first and second day, rarely later. In Silbermann's collected report. of 42 cases, the Lemorrhage commenced on the first day in eleven cases and on the second clay in sixteen cases. Evidence of the bleeding is most. often seen in the stools; sometimes the meconium is streaked NVIth blood or covered with clots, or lye find a blood-red halo around the stool on the diaper. The bloody evacuation is usually trifling at first, but often increases in amount so that the stool is made up entirely of large clots or else is liquid, dark red or almost black in color and contains small solid particles. In some cases (according to Silbermann, 23 per cent.) the intestinal bleeding is accompanied by limmatemesis, in the minority (16 per cent.) hamatemesis forms the only symptom. In these latter cases the child vomits a dark red or brown fluid in which there are many small clots. In case the child has already ingested milk, black or brown lumps are vomited, together with the disco'_ored milk, shortly after the feeding. Sometimes, however, there are only small streaks of blood demonstrable in the vomitus.
ILumatemesis and bloody stools may cease after a single occurrence; then, if no underlying disease be present, the child \vill show no signs of disease. In other cases, however, the bloody vomit and stools recur and then the inevitable consequences of severe loss of blood become evident; the temperature falls, the distal parts of the body become cooled off, the face takes on a waxen pallor, the pulse becomes hardly perceptible, the heart sounds weak and the respiration st)erficial; there is sup pression of urine and refusal to take nourishment. Rarely there are convulsions. In case the bleeding stops, the infant may recover even in severe cases, otherwise it succumbs as a result of the loss of blood, or, recovering from this, dies from the underlying disease.
It is self-evident that the symptoms are appreciably different when Ive are dealing with a constitutional disease which has given rise to symptomatic mehuna. Sometimes the bleeding lasts for only a few hours and sometimes for several days.
Causes of melxna, like other in the newborn, was attributed to a "hemophilia." This view, however, is either not. tenable at all, or else it holds good for only the rarest of cases. In the first place Illumophilia usually does not occur during the first months of life; secondly, in children that have recovered from mehena, the "haemophilia" also disappears; further, htemophilia is a disease which generally affects males: and, lastly, it is an hereditary disease transmitted through the mother. All these are rea
sans which, with a careful history, permit as a rule of the exclusion of hemophilia. It was thought necessary to assume hfemophilia when several cases occured in the same family (not hereditary). As a matter of fact it is rather striking that there are families in which several chil dren have had me4ena and died of it during the first days of life. J. Fischer reviewed the cases already reported and added his own observa tions occurring in the first two children of a family; he considered haemo philia as the etiological factor in these cases. Proof of heredity, how ever, was not: adduced; a third child in the same family had no mehena, likewise no hemophilia. We must, therefore consider the assumption of a hemophilia in these cases as entirely unwarranted and admit rather that the cause of melfena in such cases is not clear; since no autopsy report is given and no bacteriological examination was made, no well supported opinion concerning the origin of the meldena can be given.
In other cases the hannorrhage from the rectum or the Inematemesis forms only a part of the symptom-complex of sepsis. Septicaemia often leads to hemorrhages; this has already been shown in the chapter on sepsis. Multiple belong typically to the clinical picture of sepsis of the infant; however, sepsis not infrequently occurs under the guise of a Inemorrhage from a single organ and then sometimes under the clinical manifestations of melfena„ Klebs, Ritter and Epstein have shown the role that sepsis plays in the causation of haemorrhages in the infant and the investigations of the last years have confirmed the opinion that the so-called "hasmorrhagic diathesis of the newborn," which leads to bleeding in various organs, is, in the vast majority if not in all cases, nothing other than septicaemia. The investigations of Gartner, Neumann, Babes, Finkelstein and others have established this. More recently endeavor has been made to attribute mehena neonatoruni to infection with certain specific organisms. Gartner described a "mehena bacillus" which he found in two cases of melEena. Despite the lapse of ten years since his communication, no confirmation of his findings is at hand. It is certainly not to be doubted that certain species of bacteria are particularly prone to produce hemorrhages with the infections which they cause; but the specificity of neither the "melfena bacillus" nor the so-called "bacillus of hxmorrhagic infection in the human" (Babes) has as yet been established. Moreover, we know that infection with the most diverse kinds of bacteria can lead to multiple or single haemorrhages.