In later infancy and childhood we should inquire about epistaxis, and examine the throat and gums for ulceration and signs of recent bleeding. If the apparent hmmatemesis be due to epistaxis, blood will be often seen trickling down the back of the pharynx. If the case be one of hemor rhagic purpura, we notice the petechim on the skin, and can detect the general disposition to ready effusion of blood. In cases of haemophilia the same tendency is probably a well-recognised peculiarity in the family, and information as to its existence is usually forthcoming. In the malig nant forms of the specific fevers the accompanying symptoms are usu ally sufficiently characteristic of the nature of the illness ; and, more over, the existence of an epidemic in the neighbourhood is probably well known.
In cases where the haemorrhage is due to a local cause, the source of the bleeding may be discovered from the symptoms by which the passage of blood has been attended. Small black clots lying at the bottom of a thin, dark-coloured water or pea-soup-like fluid, usually indicate ulceration of the bowel. Small red clots or streaks are commonly dependent upon catarrh of the lower part of the colon, with tenesmus. Red blood in larger quantity, pure, or mixed with mucus, and passed with great straining and pain, may be possibly due to an invagination of the bowel, or may be the consequence of a polypus of the rectum. In cases of intussusception other characteristic symptoms are present. If the blood be due to a polypoid growth, this may be often seen at the end of defcation caught in the grip of the sphincter, and looking like a bright red ball. If the finger is in troduced into the rectum, the polypus can be distinctly felt attached to the posterior wall of the bowel by a slender stalk.
Prognosis.—When hemorrhage occurs in the new-born infant, the danger is always great; but the probabilities of a favourable issue depend partly upon the degree of strength of the child himself, and partly upon the opinion we have formed as to the source of the bleeding. A well nourished infant of robust constitution can often bear an extraordinary loss of blood without sinking under the hemorrhage. A weakly infant succumbs quickly. If we have reason to suspect an ulcer of the stomach
or duodenum, the prognosis is exceedingly unfavourable. Also, if con vulsions occur, if the bleeding continue beyond the first twenty-four hours, and if it return after apparent cessation, we have reason to fear the worst. Of Lederer's eight cases, five died. Of twenty-three cases collected by Rilliet and Barthez, eleven ended in death. Dr. Croom estimates that, taking all forms of the disease together, the mortality is about sixty per cent. In older children the danger of intestinal hemorrhage depends upon the cause to which it is owing, and the severity of the condition of which it is the consequence. Rectal are readily removed ; indeed, some times they separate spontaneously and are discharged with a stooL Treatment. —In cases of melmna neonatorum, the child must be fed with his mother's milk given with a spoon, or failing this, with ass's or goat's milk, diluted with an equal quantity of barley-water, with whey and cream, or with white wine whey. Pancreatised milk, prepared according to the directions given in the chapter on Infantile Atrophy, is also very suitable. Whatever may be the food, it should be given cold and in small quantities at a time. The infant must be kept perfectly quiet. An ice bag should be applied to his belly, and his feet must be kept warm. He may take internally a grain of gallic acid, or a couple of grains of the ex tract of krameria, every two or three hours; or one or two drops of oil of turpentine may be given every hour. In addition, four or five ounces of the infusion of krameria may be thrown up the bowel. The strength of the child must be supported by white wine whey, or by a few drops of brandy given at short intervals.
In older children haemorrhage must be treated according to the condi tion which has given rise to it. Polypus of the rectum is removed by seizing the growth with a forceps and passing a silk ligature tightly round the pedicle. But in early life the slender stalk often snaps when stretched, and the mere action of drawing the polypus below the sphincter often detaches'it from the mucous membrane. Its separation is followed by no bleeding, and ceases from that time.