NEONATOLOGY ON THE WEB

On Hemorrhage from the Umbilicus in New-born Infants, with an Analysis of Forty-six Cases by Francis Minot, M.D. Read before the Boston Society for Medical Improvement, April 26, 1852 Published in The American Journal of the Medical Sciences 24:310-320, October, 1852

It is only within a recent period that the attention of medical men has been called to a class of cases, usually considered of rare occurrence, but certainly worthy of more attention than has hitherto been bestowed upon them. The subject of hemorrhage from the umbilicus in new-born infants scarcely occupies half a page in any treatise on Children's Diseases with which I am acquainted, and in most of them is wholly unnoticed; yet the numerous instances that have lately been reported in the journals show that this disease, whose very existence, perhaps, was hitherto unknown to some experienced practitioners, is either not a rare one, or has increased to a great extent within the last few years. It is quite probable, however, htat our ignorance of the disease arises more from the deficiency of observations that from its rarity in former times; and as an illustration of this, I will allude to the description of a well-marked case, with a coloured plate illustrative of the post-mortem appearances, in Cheyne's Essays on the Diseases of Children, published in Edinburgh in 1801; the author also mentions other instances in which several children in the same family died of this affection. Capuron (Traité des Maladies des Enfants, jusqu'à la Puberté, Paris, 1820) describes the disease, but does not allude to its extreme fatality. On the other hand, it is not a little remarkable that men of such large experience as Churchill and West should barely allude to the subject. The latter, whose work on the Diseases of Infancy and Childhood, "contains the results of 640 observations, and 199 post-mortem examinations, chiefly made among 16,276 children" who came under his observaton, has never met with a single case. -- Second edition, p. 417.

Of late years several able articles on this subject have appeared from time to time in medical periodicals. I would especially notice one by Mr. Ray in the London Medical Gazette, for March, 1849, vol. xliii., and another by Dr. Manley in the same journal for May, 1850, vol. xlv., as containing admirable descriptions of the disease, but founded upon a small number of observations. The only instance of any attempt at statistical results from the comparison of a number of cases, so far as I know, is that by Dr. Bowditch, based upon twelve observations (American Journal of the Medical Sciences, 1850, p. 63). The recent occurrence in my own practice of a fatal case of this affection (being the second instance which I have met with), has induced me to make a collection of such cases as were within my reach, in the hope of contributing something towards clearing up the obscurity which surrounds this subject. Besides those cases which are reported in the journals, I am indebted to the kindness of friends, and to the courtesy of other gentlemen, with whom I am not personally acquainted, for a large share of the observations whose results will be given below. Whilst gathering these materials, I have carefully excluded all those cases in which the hemorrhage may be considered as accidental, or traumatic, such as where the cord was imperfectly tied, or had shrunk after being tied, or where the ligature was prematurely removed; and have retained only those in which the bleeding appeared to be wholly idiopathic. I am aware than an analysis of forty-six cases cannot furnish results which are to be relied upon with any great confidence; nevertheless, as I believe it to be more complete than any that has yet appeared, I offer it to the Society, in the hope, at least, that it may induce others to make careful observations of any similar cases they may happen to meet with, and thus to render more complete our knowledge of the nature and treatment of the disease.

For the sake of convenience, I shall arrange the results I have obtained under the following heads: General Description and Course of the Disease; its Symptoms; Pathological Anatomy; Nature; Causes; Diagnosis, Prognosis, and Treatment.

1. General Description. -- Umbilical hemorrhage is a disease whose first symptoms are observed a few days after birth, and generally after separation of the umbilical cord. A slight oozing of blood is perceived from the navel, which is at first easily arrested by compression or styptics, but returns in a few hours. A renewal of astringent or caustic applications is followed by only temporary relief, or by none at all. The bleeding continually recurs, and the child dies from exhaustion at the end of a period varying from a few hours to several days. If the hemorrhage be controlled by a ligature, and in other cases where no ligature has been applied, extravasations of blood appear upon various parts of the surface of the body, and the mucous membranes, and after separation of the ligature, the hemorrhage usually returns. Accompanying these symptoms, and occasionally preceding them, there is often well-marked jaundice, and infrequent, light-coloured dejections from the bowels, indicating derangement of the functions of the liver. The subjects of this disease are frequently robust-looking, and apparently healthy at birth, and born of healthy parents. They appear to suffer little or no pain. A majority of the patients are of the male sex, and there is a predisposition to the disease in certain families.

2. Symptoms. -- These are reported in thirty-nine cases. A large proportion of the children (twenty-six out of thirty-two), were, to all appearance perfectly well at birth. Many are described as being "stout and healthy," "large, plump, and hearty," &c. Six were feeble at birth. In nine cases no symptom intervened between birth and the hemorrhage, which in one case did not commence until the eighteenth day after birth. In general, however, the fatal symptom was preceded by others, of which the most remarkable was jaundice, which was noticed in twenty-two cases. Besides these, a "saffron hue" was observed four hours after death, in the body of a patient who had constipation and clay-coloured stools during life, and in three others the skin is described as sallow, or light yellow. One of the latter had profuse hemorrhage on the evening of the day on which the cord separated, which was finally arrested, and the child lived. Six years afterwards she had an attack of jaundice from which she recovered. Only one patient with well-marked jaundice recovered. The jaundice was the first symptom noticed in ten cases. Along with jaundice there was in most cases constipation and clay-coloured stools, the former symptom being noticed six times, and the latter nine times.

The association with jaundice with the hemorrhagic diathess, is well shown in the following cases, which are reported by Dr. W. C. Anderson in the Boston Medical and Surgical Journal, vol. xli. p. 442 (for 1850). A mother who had lost a female child from umbilical hemorrhage, with jaundice and purpuric spots, had had another daughter previously, who at the age of four months, became icteric, and had purple spots without hemorrhage, and recovered. A woman who lost a chld on the eighth day from umbilical hemorrhage, with jaundice and purpura, had another who died on the fifth day with jaundice and purpuric spots, but without hemorrhage.

The time at which the hemorrhage commenced was exceedingly irregular, varying from a few hours to the eighteenth day after birth, the average of forty-one cases being the eighth day. In four cases, it began before the separation of the cord; in three, immediately after; in others, at periods varying from one to thirteen days; the average of nineteen cases being five and a half days. There is no apparent connection between the condition of the child, and the length of time which elapses before the commencement of bleeding. Thus in one child which was quite feeble, there was no bleeding until the thirteenth day after birth, and the fifth after the cord fell off. In another feeble child, the hemorrhage began on the second day, before the separation of the cord. A child, which was "plump and hearty" at its birth, began to bleed on the third day; a "stout and healthy" child on the sixteenth day, &c.

The character of the flow of blood is not generally described, although it is easy to infer that in most cases it was a continuous oozing, rather than a jet. Out of eleven cases in which these particulars were noted, the former state of things occurred eight times, the latter three times. The appearance of the blood during life is noticed eight times. In one instance only did it coagulate. In seven it did not coagulate, and in most of them it was thin and light coloured. In one instance it contained bile, as was evident from the yellow stain which it imparted to linen.

Ecchymoses were noticed in twelve cases. They generally existed in considerable numbers in various parts of the body, and also on the tongue, and inside of the mouth. In one case they preceded the bleeding, in one they followed it, and in four they appeared immediately after the arrest of the bleeding by the ligature, as if the blood, being checked in its onward current, had been forced to find a vent elsewhere.

Pain was noticed in four instances; in two, it appeared to be caused by extending the legs. The observations are necessarily very imperfect in this particular.

Cerebral symptoms occurred four times; in three the patients (one of whom recovered) appeared almost comatose. One child died with symptoms of compression of the brain.

Condition of the Bowels. -- Clay-coloured stools and constipation usually accompanied jaundice. The former occurred nine, and the latter six times. In three instances, the dejections were bloody; in two, they were green, and in one of these "regular."

Vomiting was recorded in one case only.

3. Morbid Anatomy. -- The results of thirteen autopsies show that there is no one lesion which is constantly found.

The umbilical vessels were examined in eight instances. In seven, all the vessels were pervious; but in one of these the vein and left artery were almost entirely obliterated, the right artery being pervious. In another, the vein was contracted, without being obliterated, and the arteries resembled white cords, the canals being very narrow. In once case the arteries were closed, but the vein was pervious. In one case, all these vessels were obliterated: this patient died on the tenth day.

With regard to the other foetal openings, the statistics are not sufficiently numerous to be of any value. The ductus arteriosus was found closed in two cases, and nearly closed in two others. The ductus venosus was open in one case, and closed in one. In one observation it is noticed that the foramen ovale was open.

The liver was examined in seven cases. It is described as

Full, firm, dark-green, in	1 case
Of natural size, colour, and consistence, in	1 case
Of normal size, olive-brown colour, the free edge ecchymosed, in	1 case
Yellow, flaccid, soft, adhering to and staining a cloth like feces, in	1 case
Large, reddish brown, in	1 case
Of normal size, soft, full of bile, in	1 case
Slightly congested and denser than usual, in	1 case
Not described, in	1 case

The gall-bladder was noticed in seven cases. In one, it was empty and contracted; in one, it contained a small amount of bile; in two, it was distended; in one, it was "not distended;" in one, it contained a light amber fluid. In all these cases there was icterus except the last, in which nothing was said of it, though the dejections were reported to be "white ike milk, the patient having never passed anything like meconium or bile." This patient died on the twentieth day, having begun to bleed eight days after the separation of the cord. In one, it was small, collapsed, containing only a little mucus (the ducts, in this case, were wanting); in one, it contained a quantity of bile, which could not escape, owing to the ductus communis being plugged.

The condition of the gall-ducts was reported seven times. In four cases, they were all pervious; in one, they were "wholly absent;" in one, the ductus communis terminated in a cul-de-sac; in one, the same duct was completely closed by a plug of inspissated bile.

The abdominal viscera were tinged yellow in four cases, from the presence of bile in the tissues. Ecchymoses, in various organs as well as the skin, were noticed in two cases.

The state of the blood is described, in three instances, as being pale, thin, liquid, or containing slight coagula. In one case, there was pus mixed with blood in the umbilical arteries.

4. Nature of the Disease. -- The facts which I have collected lead me to think that idiopathic hemorrhage from the umbilicus in young infants is only one of the various manifestations of the hemorrhagic diathesis which, in other cases, is exhibited in bleeding from the gums, mouth, stomach, intestines, &c., and in the appearance of purpuric spots beneath the skin in various parts of the body. In proof of this, we see the occurrence of these phenomena with umbilical hemorrhage. Thus, nothing is more common in the latter disease than a purpuric eruption. In three cases, there were bloody dejections, and in one, bleeding from the gums. Another argument is the thin and watery condition of the blood, and its great deficiency in fibrin, whereby mechanical means become almost wholly inefficacious to arrest its flow.

Although occupied at present with a single local manifestation of this affectoin, its dependence on a constitutional cachexy should never be lost site of, especially in connection with the subject of treatment; for, unless means be adopted for correcting the constitutional difficulty, local applications offer but a slender chance of saving the patient.

5. Causes. -- The causes which have been assigned to umbilical hemorrhage comprise hereditary predisposition, the influence of sex, derangement of the functions of the liver, and an imperfect closure of the umbilical vessels.

In what way the condition of the parents was concerned in the production of the hemorrhage it is not easy to ascertain. Of the health of the fathers little or nothing is said. Of twelve mothers, eleven were healthy, one was feeble. It is evident that the disease may be the result of some inherited peculiarity, because, in several instances, two or more children in the same family have been affected in the same way. At the same time, as Dr. Manley remarks, these cases differ from the ordinary rule in the history of bleeders, for in none of them is the direct transmission of the hemorrhagic constitution clearly proved. He alludes, however, to one case (not included in my collection), in which a woman, who had been liable to copious epistaxis, and whose mother and sister were also subject to hemorrhage from various parts, lost a male infant, on the third day after birth, in consequence of hemorrhage from the navel and gums. The same law obtains in this as in other transmitted diseases, namely, that while some of the children succumb to the malady, others escape it altogether; thus, in four instances, the mothers each lost two children from umbilical hemorrhage, and each had two living and healthy; one woman lost three, and three others were healthy; another lost two, and had three living. Other similar cases are also alluded to by the reporters of some of these observations. Nothing has been observed in the condition of the mother which could account for the disease transmitted to her offspring, nor does her health appear to differ during successive pregnancies which have resulted in healthy children and in those born with the hemorrhagic tendency. How far the imagination of the mother can have any effect on the production of this or any other disease in her child, can only be ascertained by numerous and accurate observations. A case bearing on this subject will be noticed hereafter.

Out of fifteen cases in which the nature of the labour was notied, it was natural in fourteen and difficult in one. This last case occurred at the Lying-in Hospital in Boston, under the care of Dr. William Read. It was a case of twins. The first child presented the shoulder. Spontaneous evolution took place, the breech presented, and the child was stillborn. The second child was quickly and easily expelled, but was feeble. It began to bleed on the second day, and died on the third.

Sex. -- The predisposition of infants of the male sex to this disease is remarkable, and is particularly alluded to by Mr. Ray. The comparison of a large number of observations have shown the disproportion to be less than he thought it. Unfortunately, in a number of the cases, the sex was not noticed; but out of thirty-two cases in which it is alluded to, twenty-two (or 68 3/4 per cent) were males, and ten females. Whether this difference be anything more than accidental, can only be ascertained by more ample statistics.

The remarkable proportion of cases in which jaundice was noticed (twenty-two out of thirty-nine, or fifty-six per cent), shows it to be something more than a mere coincidence. Whether, to use the words of Dr. Cheyne, the bleeding proceeds "from the unhealthy change produced in the blood by the reception of the bile into the mass of fluids," becomes a question of interest, especially when considered in connection with a class of cases in which icterus in adults was accompanied by a remarkable tendency to obstinate and even fatal bleeding from slight wounds, such as scarifications or leech-bites. Several such cases are quoted in Dr. Manley's paper, and others have been reported to this Society by Dr. J. B. S. Jackson, all of which tend to show that the presence of bile, or of some of its elements in the blood, appears to diminish the coagulating power of this fluid. The jaundice itself was satisfactorily explained in three instances by the absence or obstruction of the bile-ducts; but in four cases the ducts were pervious. It is plain, however, that derangement of the biliary function does not play an indispensable part in the production of the disease, since in three cases it was noticed that there was no yellowness of the skin, and in five the autopsy showed the liver to be, in all appearance, healthy. Moreover, a remarkable case is reported by Dr. Campbell, in which the icterus commenced on the day after birth, and the child died at the age of six months. The liver was so large as to fill the greater part of the abdomen, and neither a gall-bladder nor bile-ducts could be discovered. Yet, in this case, there was no hemorrhage. The association of these two phenomena, and, at the same time, their independence of each other, are shown in the following cases, communicated to me by Dr. A. Hooker, of East Cambridge, who says: "I attended a woman, to all appearance healthy, and who has good labours. She has lost four children from umbilical hemorrhage. She has since had a child which presented a slightly jaundiced look, but no hemorrhage took place, and it did well." The other case is as follows: "A mother had two children, who are now alive and well; but one of them had jaundice at the age of four or five. She has since had two others, both of whom died of umbilical hemorrhage, preceded by jaundice."

The state of the umbilical vessels has been supposed to be quite sufficient to account for the hemorrhage in many cases. I am far from thinking that a pervious state of these vessels, a few days after birth, ought to be considered as a pathological condition, and, in this opinion, I am supported by Mr. Ray, who says he has frequently found them pervious in children of a month or six weeks, who died without bleeding; hence, this condition alone cannot be enough to account for the hemorrhage of those children who did bleed. Dr. Manley, however, believes that, in some of the cases, "this natural process was defective, and not sufficiently advanced." He quotes the results of observations of Billard and Bernt on this subject, who agree that the process of obliteration commences as soon as the second or third day after birth; but, unfotunately, nothing is said as to the time when it terminates. If the hemorrhage were owing to the open state of these vessels, why should it not be arrested permanently by the ligature, as in any other bleeding vessel, instead of returning after the ligature came away, which it did in almost every instance? An example of the persistence of an umbilical artery in an adult, which proved very embarrassing during an operation for hernia, may be found in the Brit. and For. Med.-Chirurg. Review, for April, 1852, p. 553.

6. Diagnosis. -- The diagnosis of umbilical hernia is easy, and is only liable to be confounded with accidental bleeding, such as occurs from an imperfectly tied cord, or one which contracts very much after being tied. In no case that I have met with did the bleeding take place from the end of the cord. It proceeds by exudation from the sides of the cord (where that has not fallen off), from the margins of the umbilicus, from granulations at the bottom of the cicatrix, or directly from the umbilical vessels. The frequent coexistence of jaundice with this affection should always be borne in mind, and whenever a new-born infant becomes very yellow, especially if there have been other cases of umbilical hemorrhage in the family, every precaution should be taken to prevent bleeding. Ecchymoses may also sometimes serve as marks of the disease before the appearance of the fatal symptoms. I believe they seldom fail to be followed by it; but they are not of frequent occurrence. [1]

7. Prognosis. -- Out of forty-six cases, thirty-nine, or more than eighty-four per cent., were fatal at periods varying from six hours to six weeks after the commencement of hemorrhage, the average of twenty-seven cases being six days. Six of these children died on the day after bleeding began; five on the second day after; three on the fourth day. From this we see that umbilical hemorrhage is an extremely fatal affection. Even in those children who are apparently robust, and seem to offer the best chance for recovery, the prognosis must be very guarded, while, in feeble infants, it is almost inevitably fatal. We must not, however, forget that many cases which recovered are perhaps not reported. The descriptions given of the favourable cases prove that they were genuine examples of the disease; hence, although the chance of recovery is excessively small, the prognosis is not absolutely fatal in every case. Jaundice appears to be a very grave symptom, since only a single case recovered in which it had been observed.

8. Treatment. -- The treatment consisted in various astringent, styptic, and caustic applications to the navel, and the internal exhibition of substances supposed to act specifically on the liver and on the blood. Among the former class were lunar caustic, acetate of lead, tannic acid, alum, matico, the actual cautery, &c.; also plaster of Paris, pressure, and the ligature. The latter included mercurials, taraxacum, sulphate of soda, cathartics, &c.

The treatment employed in those cases in which the hemorrhage was permanently arrested was principally the following:--

Compression in	3 cases
Ligature in	3 cases
Collodion in	1 case
Plaster of Paris in	1 case
Scrapings of sole leather in	1 case
Nitrate of silver in	1 case

But in three of these cases the patients died, eventually, from exhaustion, or diseases evidently caused by the feeble condition of the child.

It is recommended by some writers to cut down upon the bleeding vessel and tie it. This must be a very difficult, if not impracticable operation, even in the small number of cases in which the bleeding comes from a single vessel. I think the ligature en masse is easier, safer, and more effectual. The ligature, however, will succeed in a very small number of cases, unless the diathesis upon which the malady depends be corrected. The same may be said of styptic and caustic applications, which in four cases actually appeared to increase the hemorrhage.

The internal use of astringents and tonics appears to me to have been too much neglected in the treatment of these cases. I find but a single instance of their employment among thirty-three cases whose treatment is reported. We employ such remedies in purpura hemorrhagica, in scurvy, and other hemorrhagic diseases of adults; why should they be omitted in a disease so similar in its character in infants? The instance referred to was communicated to me by Dr. S. S. Whipple. The child, a male, was to all appearance perfectly sound, and weighed between nine and ten pounds. It was born on the 10th of May last, of robust parents, and after a perfectly natural labour. Thirty hours after birth, Dr. W. was called to it, and found blood issuing from around the umbilicus, rather by exudation than from any disturbance to the integrity of the parts. It was not disposed to coagulate, and was compared to cranberry juice in consistency and colour. It was immediately checked by a solution of the sulphate of copper. At the end of twenty-four hours, the hemorrhage returned, more profuse, with extreme prostration. The action of the heart was imperceptible; and the respiration was accompanied by a feeble moaning. The bleeding was again arrested by styptic applications, and tincture of the muriate of iron, with brandy, was given in as large doses as the patient could bear. He soon revived, with a healthy appearance, and commenced taking the breast. The discharges from the bowels and bladder were natural, and he continued to improve in strength and appearance for four days, during which time the cord was detached without hemorrhage. On the 9th day (second from the separation of the cord), the bleeding commenced again, and he died on the 10th. In this connection, I will also mention an interesting case lately reported to the Society by Dr. W. E. Coale; there was no bleeding from the navel, and, therefore, the case is not included in my tables; it is evidently identical in its nature with the others: A female child began to vomit blood the day after its birth. The next day she also passed considerable quantities by stool, so that the two towels were saturated with it. One drop of the aromatic sulphuric acid was given this day at 11 A.M., and continued every two hours. On the third day, the hemorrhage had diminished; on the fourth, it was still less, but the child was pale and very feeble. A quarter of a grain of sulphate of iron was now substituted for the acid. On the fifth day, the symptoms improving, the medicine was ordered every four hours; and the intervals being gradually lengthened, it was left off on the seventh day. The child recovered perfectly. So far as two cases teach anything, these afford some encouragement, and the use of the mineral acids, or other astringents and tonics should always be tried.

As to local treatment, we have seen that the ligature and pressure were each successful in three cases, and that caustic and styptic applications generally failed. The most that can be hoped from local application is a temporary arrest of the bleeding until the condition of the blood can be improved. The ligature appears to me the most likely to effect this, and the sooner it is employed the better, since every drop of blood is of importance in such young subjects. I believe the best mode of employing it is to transfix the umbilicus by two needles at right angles, and wind the thread tightly underneath them.

It is important to sustain the strength of the patient by nourishing diet and stimulants; the apartment should be cool, the clothing light, and every effort made to prevent the child from crying.

I am indebted to Dr. M. S. Perry for a valuable suggestion concerning the prophylactic treatment to be employed by women who have already given birth to children with the hemorrhagic diathesis when again pregnant. Observing that women accustomed to take alkalies in considerable quantities during pregnancy, for dyspeptic or other symptoms, were peculiarly liable to hemorrhage after parturition, he has been in the habit of interdicting such remedies, and of substituting for them the mineral acids with very satisfactory results. Dr. Perry suggests that the use of mineral acids during pregnancy by women whose children have been affected with umbilical hemorrhage might be followed by favourable results. The experiment is worth trying.

The following extract from the letter of Dr. Whipple (before referred to) is worthy of attention: "I will mention a singular coincidence in the case, which must be taken for what it is worth: Some time in the latter months of pregnancy a female friend told the mother to be sure and caution her attendants about the navel, as a friend of hers had had much trouble from carelessness of a like kind. She said she had felt great solicitude from that time; the description of the bleeding child gave her feelings something of a shock, and she was frequently hear to speak of the circumstance to the nurse before her confinement." In our ignorance of the precise extent of the influence of the imagination of a woman upon the physical organization of her offspring, it is surely worth while, on all accounts, to urge upon the mother the expediency of avoiding those useless anticipations of evil in which pregnant females are prone to indulge.

It has been suggested that tying the cord before its pulsations have ceased may be a cause of hemorrhage in new-born infants. No light is thrown upon this question by the statistics I have collected, except that it one fatal case the cord was not tied until it had ceased to beat. Mr. Ray says that he has observed the cord pulsing even after the placenta was thrown off, and that in other cases it has seemed as if the child did not begin to breath and cry vigorously until the cord was tied.

For convenience of reference, the most important of the foregoing results are subjoined:--

Mothers healthy in	11 out of 12 cases, or 91 2/3 per cent.
Labours natural in	14 out of 15 cases, or 93 1/3 per cent.
Children born healthy in	26 out of 32 cases, or 81 per cent.
Male children in	22 out of 32 cases, or 68 3/4 per cent.
Jaundice in	22 out of 39 cases, or 56 3/5 per cent.
Ecchymoses in	12 out of 39 cases, or 30 per cent.
Umbilical vessels pervious in	7 out of 8 cases, or 87 1/2 per cent.
Gall-ducts pervious in	4 out of 7 cases, or 57 per cent.
Liver apparently healthy in	7 out of 8 cases, or 87 1/2 per cent.
Fatal cases in	39 out of 46 cases, or 84 per cent.
Day on which hemorrhage commenced, average of 41 cases	8th day
Average duration of 27 fatal cases, after commencement of hemorrhage	6 days

Footnotes

[1] Since the above was in type, a fatal case has been reported to me, in which the first symptom noticed was an extravasation on one eyelid. The child was large and vigorous.