Melæna neonatorum is the distinct name given to a hemorrhage from the bowels which occurs a few hours or days after birth, and which is often so profuse as to cause death at once or in a short time. In most cases no anatomical lesions can be discovered after death, save an intense hyperæmia of the intestinal mucosa, so that the etiology of this affection is involved in obscurity. The various causes assigned in its production—ulceration of the stomach or duodenum (Bohn), embolism (Landau), fatty degeneration (Steiner), premature ligature of the umbilical cord (Kiwisch)—answer only for individual cases. Betz reported a case in a family subject to hæmophilia, and Trousseau once saw twins thus affected; but that heredity cannot account for all cases is shown by the fact that it occurs mostly in healthy children from healthy parentage. Klebs is inclined to attribute the affection to the action of micro-organisms, introduced perhaps as the result of puerperal infection, but this cause can be assumed in only a small minority of cases; at least, but a small percentage of cases coincide with puerperal disease on the part of the mother.
The affection is fortunately rare. Eichhorst states that Hecker observed it but once in 500 births, and Gemich but once in 1000 births. According to Rilliet, the hemorrhage is oftener (8/14) intestinal, rarer (4/14) gastric, and rarest (2/14) both. It is almost always abundant and quickly repeated, the blood being mostly pure, in clots or masses and fluid, though it is sometimes commingled with meconium. It usually ceases within twenty-four hours, though it may continue for three, five, or more days. Of 23 cases reported by this author, 12 recovered and 11 died.
MORBID ANATOMY.—Hemorrhage from the bowels, being only a symptom of very many different conditions, is marked by lesions characteristic of the condition in an individual case. These lesions are more appropriately described in connection with the various diseases. Not infrequently in these cases the intestine is distinguished by the absence of any lesion at all; but, from whatever cause, hemorrhage from the bowels, like hemorrhage from any other source, shows a more or less profound anæmia of all the internal organs, and in more chronic and protracted cases leads to fatty degeneration, more especially of the heart.
SYMPTOMATOLOGY.—Hemorrhage from the bowels is usually readily recognized by the discharge of blood, either pure or mixed with the natural contents of the alimentary canal. The actual seat of the hemorrhage may, however, only rarely be recognized by the rectal speculum. The colicky pains, borborygmi, or sensations of fluids in the abdomen which are occasionally experienced may not be relied upon in fixing the seat of the effusion. Should the hemorrhage occur in quantity, or, more especially, should the seat of the effusion be low in the intestinal canal, the blood which escapes is more or less pure. When the hemorrhage is higher, or when the stay of the blood in the bowel is longer, it becomes more or less incorporated with the contents of the bowels or altered by the intestinal juices to present a discharge of mushy or semi-fluid consistence, of dark-brown or black color. So-called tarry stools are thus largely composed of blood.
But serious, even fatal, hemorrhage sometimes occurs without the escape of any blood at all. Such are the so-called cases of concealed, occult, or internal hemorrhage, in which the nature of the malady is only suspected or recognized by the general symptoms attending the profuse loss of blood. Should the hemorrhage be gradual, anæmia slowly supervenes, with hydræmia and subcutaneous dropsy. Traube reports a fatal case of oedema of the glottis from such a cause. Sudden hemorrhage announces itself by pallor and prostration, dyspnoea, vertigo, and syncope. Amaurosis, tinnitus aurium, formication, emesis, and, if the disease be high up in the intestinal canal, hæmatemesis, are the common attendants of serious hemorrhage. In the worst cases of sudden effusion the patient may present the appearance of complete collapse, and the intestinal canal be found on autopsy distended with blood throughout a great part of its course, while no blood whatever has escaped from the rectum. In such cases, or with more gradual loss of blood, the patient experiences a sense of increasing weakness, the skin becomes cold and bedewed with a clammy sweat, the pulse grows feebler, the temperature falls, and death from exhaustion more or less speedily ensues.
DIAGNOSIS.—The presence of blood in any quantity in the stools is readily recognized by its coarser characteristics. Ridiculous errors have been made by mistaking the coloration produced by bismuth, iron, logwood, etc. administered internally, or by coloring matters introduced into the discharges for purposes of deception. The microscope, Zeichmann's test for blood-crystals, and in extremely doubtful or medico-legal cases the spectroscope, furnish easy means of detecting blood in whatever quantity or character.
It is the cause and seat, rather than the existence, of the hemorrhage that mostly cause embarrassment in differential diagnosis. Hemorrhage from the lungs, nose, or stomach is usually readily excluded by the absence of any evidence of disease of these organs, and the presence of the other symptoms of any general disease attended with enterorrhagia makes a diagnosis in most cases easy enough. Alterations in the contents of the bowel, the presence of foreign bodies, are recognized by the history of the case and by careful local examination, while a diagnosis of anomalies in the walls of the bowel is usually reached by exclusion. In no doubtful case should local inspection or digital examination of the anus and rectum be omitted.
TREATMENT.—As in all cases of hemorrhage, the first requisite is absolute rest. The patient should be at once put to bed and kept perfectly quiet. Many a case of hemorrhage in typhoid fever is produced by arising from bed to go to stool. The bed-pan is an absolute necessity in the management of a case of typhoid fever after the second week of the disease. Rest is the chief agent in prophylaxis as well as therapy.
The most effective styptic in enterorrhagia is cold. An ice-bladder should be laid upon or suspended immediately above the abdomen during the whole duration of the flow. The injection of ice-water into the bowel should be practised only in cases where the hemorrhage is believed to come from the colon. Otherwise, the peristalsis it awakens may only aggravate the danger. Should rest and cold fail to quickly check the hemorrhage, resort should be had at once to ergot. This remedy, in the form of ergotin, is most effective when introduced beneath the skin. In cases of less imminent danger the practitioner may be content to give the remedy by the mouth.
Small doses of the simple or camphorated tincture of opium frequently repeated speedily arrest contractions of the bowel, and at the same time feed the brain in threatening syncope. The astringents proper—tannic acid or its preparations, acetate of lead, alum, the perchloride of iron—are seldom necessary or advisable, but may be called for in obstinate or protracted cases.