After continuing for about twenty-four hours, the hsemorrhage, if the child survives, usually stops. In most cases blood ceases to be ejected from the mouth before the flow from the bowels is at an end. Sometimes, after a temporary intermission, the bleeding returns, and may continue, in diminished quantity, for several days longer. When the bleeding begins for the first time after the fall of the cord, haemorrhage may also occur from the umbilicus. Pale watery blood oozes from the navel, and the flow persists in spite of all efforts, to arrest it. In some cases the effusion of blood is confined to this region, but more commonly it is quickly followed by haemorrhage from the bowels, and, in some cases, from the ears, the gums, the vagina, and into the skin.
If the haemorrhage be profuse the child may not recover from the state of collapse into which he lies fallen. In the favourable cases he gradually improves, but remains weakly and pallid for some time after wards, with a tendency to intestinal catarrh.
In later infancy and childhood, gastro-intestinal haemorrhage, arising from the causes which have been mentioned, usually occurs in the form of melmna. The bleeding is, as a rule, more profuse when it is excited by causes acting through the system generally than when it occurs in conse quence of a purely local lesion. In hmmorrhagic purpura large quantities of blood may be passed per anum, bright red and clotted, or more or less altered and blackened. In this disease, as also in hmmophilia and in the malignant forms of the specific fevers, the tendency to haemorrhage is a. general one. The nose and gums bleed easily, the skin is spotted with petechiae, or larger heemorrhagic stains, and the urine is often discoloured.
When the bleeding occurs from local causes the effusion is scanty, as a rule, and is evacuated from the bowel, pure, or mixed with the ordinary fmcal clejections. In typhoid fever haemorrhage is the exception in young subjects. In this and the other forms of intestinal ulceration the bleed ing, when present, is seen in the form of small black clots at the bottom of the chamber-pan. In dysentery, and in cases of invagination of the bowel, the blood is brighter, and is passed pure, or mixed with mucus. It may amount, in the latter disease, to several ounces, but is rarely seen in so large a quantity. Usually only a few teaspoonfuls are passed at a time, and the discharge is only effected with excessive straining and pain. The irritation of worms is not often accompanied by bleeding, but in rare cases a bright red clot may be passed per anum. Catarrh of the lower part of the colon, especially if the bowel prolapse, may give rise to slight haemorrhage. The blood is usually in the form of light-coloured streaks, but sometimes small red lumps may be evacuated.
In polypus of the rectum the blood is also bright red, and may be in considerable quantity—a tablespoonful or more—pure, or mixed with mucus. If the growth be small and above the sphincter, the discharge of blood is accompanied by no pain ; but if it be large, and especially if it be caught within the sphincter, it may give rise to much straining and discomfort. In such cases there may be frequent desire to go to stool, without the appearance of a dejection ; much mucus is passed from the bowel, and the faecal masses may be grooved from the pressure of the growth during their passage. If the disease is allowed to go on long un checked, the child becomes pale and cachectic-looking from constant loss of blood.
Diagnosis.—The special form of haemorrhage of the newly-born (meleena neonatorum) is so rare a complaint that in every case where blood is ejected from the mouth or passed from the bowel in a very young infant, we should rather suspect the blood to be furnished from some extraneous source ; and if the child be at the breast, our first care should be to exam ine the nipple of the mother or nurse for fissures or signs of erosion. A true hemorrhage in a young baby is at once indicated by pallor of the face, sinking of the fontanelle, and depression of temperature. If, after bringing up a quantity of bright blood, the child seem contented and happy, without loss of colour or any sign of depression or distress, it is unlikely that his own body is the source of the bleeding. If, on the con trary, blanching of the face, coldness of the extremities, and signs of gen eral depression accompany or precede the passage of blood, there can be no doubt that the haemorrhage is no misleading phenomenon. Still, it is often far from easy to ascertain its source. If the bleeding occur at only a short interval after birth, and succeed to a prolonged and difficult la bour, or arise in a child in whom the respiratory function has been with difficulty established, we may suspect the phenomenon to be symptomatic of a congested state of the viscera, aided, probably, by a special hemor rhagic tendency in the child. If it occur some clays later, and have been preceded by signs of uneasiness after taking the breast, some difficulty of deglutition or frequent vomiting, the effusion of blood is possibly clue to a gastric or duodenal ulcer ; but a positive diagnosis of this lesion cannot be ventured upon. If hemorrhage occur solely from the navel, and be accompanied by an icteric tint of skin, the case is probably one of con genital deficiency of the bile-ducts. If previous infants in the same family have died after presenting similar symptoms, the probabilities are strong that this distressing malformation is present. This subject is considered elsewhere (see page 717).