The probability of sepsis increases when the hemorrhage is not single or from only one organ, but multiple. This leads us to the symp tom-complex which has taken a place in the literature under the title of Buhl's disease or acute fatty degeneration of the newborn. The cases coming under this title occurred in children horn at term, asphyc tic for some unknown reason, and often dying without any attempt at respiration. The children which were resuscitated breathed badly, re mained cyanotic, hfemorrhages appeared in the skin and mucous mem branes, bloody vomit, bloody fluid evacuations and umbilical haemor rhages occurred and the infants rapidly died. In case they lived on for a few days longer, severe anremia, icterus and sometimes also anasarca occurred and then death in collapse.
At necropsy, beside countless haemorrhages in the organs, there was found fatty degeneration of the cells of the pulmonary alveoli, of the muscles, the heart, liver and the epithelium of the uriniferous tubules.
The disease is said to occur sporadically and to closely resemble the disease of animals known as "spring-halt," in its manifestations and pathological anatomy. However, Bollinger proved that this latter dis ease as it occurs in foals is rarely an umbilical sepsis. It is highly prob able that the symptom-complex described by Buhl is nothing else than sepsis, which it so closely resembles.
The clinical picture which Winckel described as icteric cyanosis or cyanosis icterica perniciosa cum lurmoglobinuria (also known as epi demic htemoglobinuria), resembles sepsis in many aspects. \Vinckel first observed this disease occurring as an epidemic in the maternity at Dresden, and since then only a few cases, also sporadic, have been reported.
These eases occurred in vigorous full-term children during the first. days of life, in whom the principal manifestation was a yellow, icterie,. and then deep blue discoloration of the entire cutaneous surface and of all the mucous membranes, just as with the severest cyanosis; and further a brownish color of the urine. The urine contained hremoglobin,. blood corpuscle casts, renal epithelium, bacteria, urate of ammonia, and small quantities of albumin. The children had little or no fever, rapid respiration and died, sometimes in convulsions. The blood was mark edly thickened, contained numerous granules and a slight increase in the number of leueocytes.
At necropsy besides the icterus, countless hmmorrhages were found,, especially in the mucous and serous membranes; also fatty degenera tion of the organs and, especially characteristic, masses of granular hfemoglobin in the kidneys and spleen. In all eases, with one excep tion, the umbilical vessels were found to be healthy.
In a similar epidemic reported by Kamen, in which, however,, hmmoglobinuria was absent, a bacillus was found in the organs and blood, which Kamen considered identical with the bacillus soli com munis. Kamen found the same bacillus in well-water; according to his opinion the children were infected through cleansing the mouth. After the well had been closed up the epidemic ceased. As Epstein has already assumed, Winekers disease is also nothing more or less than sepsis.
The classifying of these cases under a separate head is hardly justi fied, as no proof has been furnished of the presence of a htemoglobinu•ia. and moreover the presence of red blood corpuscle casts argues against a. hremoglobinuria; the finding of brown granules in the urine and kid-. neys is of no import since no chemical examination was made to deter mine whether or not they were composed of blood-pigment.
Symptoms.-1. Fever. This is not a constant manifestation. A rise. in temperature, at times very high, occurs at the onset in the majority of cases. The further course is then either afebrile or else attended by a very irregular fever. Chills never occur. Toward the end of the disease. a markedly subnormal temperature is the rule.
2. Sensation is benumbed in many cases; the children are at times comatose and at times show great unrest, jactitation, tremors and pro longed, severe, unvarying cries which are the expression of a state of excitation; this state sometimes alternates with profound apathy in which the reflexes are diminished and may be totally absent. Convul sions are rare. Upward rotation of the bulbi with open eyes, as in sleep and flaccidity of the muscles occur; but more often spastic conditions of the muscles of the extremities, trunk, neck and head; with trismus, rigidity of the neck and extreme flexion of the hand and finger-joints, which is more frequent the younger the child. Paral yses do not belong to the usual picture of sepsis and depend on compli cations with meningitis or encephalitis.
3. The skin, presents varying signs. Children in the first weeks of life usually show a marked icterus, which may, especially with umbili cal sepsis, attain the degree of a bronzing (Porak and Durante). Older infants have often a livid, ashen-gray color which easily becomes bluish (cyanosis) on the distal parts of the body and on the mucous membranes. There is often oedema of the feet, over the tibia' and in the pubic region. In some instances sclercedema and more rarely sclerema occur toward the end of the disease, especially in premature children, during the first months. The haemorrhages are characteristic and very important diagnostically; they spread over the trunk and extremities, sometimes as small petechite and sometimes as more or less extensive effusions. Furuncles and extensive skin abscesses—as a rule not embolic but occurring through infection from frequent findings and also often form the entrance point for the infection. Bed sores occur not uncommonly over the parietal bones, the sacrum, the heel, the internal malleoli and more rarely the elbow; the sores soften and lead to deep ulcerations which sometimes extend to the periosteum and cause necro sis of the bones. Erysipelas is not rarely added to the above, especially in cases of umbilical sepsis. The various septic erythemata are charac teristic; they occur at times as small rose spots, at times as a diffuse redness, seldom similar to erythema multiforme and only exceptionally as an urticaria; their tendency is to spread over the trunk and extrem ities. At times blebs, with purulent or serous, rarely bloody, contents, are formed.