Hemorrhage may occur in the young subject both from the stomach and bowels. In gastric haemorrhage the blood may be vomited directly from the stomach, or may pass down the alimentary tube and be voided dark, and more or less altered in appearance, with the stools. The presence of blood in the evacuations is, therefore, no proof that the source of bleeding is in the bowels. Nor, indeed, does blood ejected from the mouth always come from the stomach. Even blood which is brought up by evident retching, and intimately mixed with curdled milk, may not, and often does not, owe its origin to the gastric mucous membrane. Infants at the breast not uufrequently vomit blood which is drawn with the milk from the breast of the mother. Cracked nipples are often very irritable, and bleed easily. In such cases, the act of sucking may determine a hmor rhage from the fissure, and a large quantity of blood may be swallowed by the child. At the end of the meal this is often vomited with part of the milk which has been taken, and is a cause of great alarm to the parents.
In older children who suffer from epistaxis, the blood which flows down int6 the throat from the posterior nares is almost invariably swallowed. If this be large in quantity it is sometimes vomited, and appears then to have been thrown out by the stomach. So, also, ulceration of the back of the throat and of the gums, such as is seen occasionally in scrofulous and badly-nourished children, may be a cause of bleeding. If at the same time the child be suffering from disordered stomach, and vomiting be frequent, the efforts of retching may determine a flow of blood from the ulcerated surface. The blood mixes with the contents of the stomach as these pass through the mouth, and gives the appearance of haemorrhage from the deranged gastric membrane. I have known such a case to occur and be a cause of great perplexity.
Causation—Real gastrointestinal hmmorrhage may be due to many different conditions. There is a special form of haemorrhage which is
occasionally seen in new-born infants as a consequence of causes which have not even yet been fully made out. Melcena neonatorum occurs usually within a few hours of birth. It is said to be more common in girls than in boys, although this is not the experience of all observers, and sturdy, well-nourished children are as amenable to it as the feeble and the frail. The occurrence is fortunately very rare. Sometimes it has been known to follow a tedious labour, in which the child's head had suffered great compression. In other cases the respiratory function after birth had been established with difficulty. Often, however, the bleeding can be attributed to no such reason. Sometimes it appears to be the direct result of ulceration of the stomach and duodenum. Such a lesion has been occasionally discovered iu the new-born babe, and has been ascribed to follicular gastritis by Billard; to an embolism of the umbilical vein near the liver, and extending for some distance into its branches, by Landau ; and by Steiner, to a fatty degeneration of the blood-vessels. An example of such a gastric ulcer was shown by Dr. Goodhart in 1881, at the London Pathological Society. A new-born infant had died from hmatemesis thirty hours after its birth. The child's appearance was healthy. On examination of the body, after turning out the blood-clot with which the stomach was distended, a small, ovafulcer, one-eighth of an inch in length, was seen at the cardiac end of the stomach and close to the greater curvature. This sore was clean-cut, sharp-edged, and firm in texture. In its floor was a dark speck, which proved, on close inspection, to be an open vessel. It is, however, uncommon to find any distinct breach of surface. In the large majority of cases the haemorrhage appears to be capillary, and nothing but a congested state of the vessels of the stomach is discovered on examination or the body.