Theories &

Haller and Munro attribute the detachment of the cord to be a kind of gangrene. Gardien considered it as due to the constriction of the dash-z epidermis; Chaussier, to an inflammatory process, and Billard to the traction of the abdominal muscles which separate the navel from the dried portion of the cord.

It is evident that here a complex process takes place preciselyembley similar to that which results from the torsion of arteries; a certain portion of the vessel shrivels, dies, and becomes separated from the living parts by means of a more or less evident inflammatory process, so as to be influenced by the slightest external traction.

This process of separation usually takes place without complication, Complicated and occasions a slight oozing, that is to say, an inconsiderable suppuration, by Supp which is observed on the small and thin cords, but is accompanied by cation in a more abundant suppuration, in some cases, if the cord is of a large size. It is sometimes complicated by serious hæmorrhagic or inflam- a lar matory symptoms. Underwood, Villeneuve, Richard (of Nancy) Sock. Burns, P. Dubois, Thoré and Mansley have seen hæmorrhage occur from the navel, and death to be the consequence of it. These instances may in are very rare, and merit the careful attention of practitioners. The Zu search following is a case related by M. Mansley. A male child born at full term, after a natural labour, well-conditioned and presenting all the symptoms of the most perfect health, was at first attacked, some days after his birth, by icterus neonatorum, for the treatment of which mild purgatives were administered. One morning the mother perceived

that the child's linen was spotted with blood; the cord had separated Case

Sponta

spontaneously, without violence, on the fifth day. Being immediately sent for, M. Mansley found the circumference of the navel in its normal condition, but the bottom of the hiatus was occupied by a putrescent substance resembling the debris of cellular tissue mixed with blood; the part having been carefully washed, it was ascertained latin. foliation that the drops of blood oozed from a small opening. This was several times touched with a stick of nitrate of silver; but in vain, the follow hæmorrhage was not diminished; the reapplication of the caustic, long-continued compression with the thumb, the actual cautery, the use by Fren of styptic powders, nothing could stop the hæmorrhage. Ligature, easte which was also thought of, became impossible in consequence of the in 48. depth of the hiatus. The child, died exhausted, at the end of fortyeight hours.

hous

Up to the present time, hæmorrhage has always occurred after the separation of the cord, at the end of seven, nine, eleven, and even Gu thirteen days after birth. The blood flows slowly in an intermittent 7 to 13. manner, and not per saltum, indicating the nature of an arterial jet.

It has been several times observed in children labouring under days with purpura, and it is a curious fact, that two infants, preserved from

Sing

Causes

Curpura the signs of a very evident purpura.

[Part III.

hæmorrhagic death by M. Jeunin and P. Dubois, afterwards died with In other circumstances the cause of the hæmorrhage has remained undiscovered, but it is probable 4 Sarbu, that we should be very near the truth in attributing it to a condition

Ry
Faustey

of scorbutic dissolution of the blood.

All means employed against this hæmorrhage are useless with the exception of the ligature of the cord en masse. Styptics internally and externally, alum, rosin, ice, cauterisations with potassa, nitrate of silver, or the red-hot iron, all are of no avail, and in my opinion, valuable time would be lost in the employment of these various substances. The ligature en masse, practised by M. P. Dubois, by MM. Jeunin and Bowditch is the only method which has up to the present succeeded.

The base of the bleeding navel must be transfixed with a pin, and beneath this pin a double thread is placed and tightened, so as to ay prevent the flow of blood. The obliteration of the vessel is thus occasioned and the separation of a portion of the skin attached to the cord. In one case the pin came away on the fourteenth day, and in a child operated on by Dubois it was removed on the seventh day, before the entire division of the parts.

Lon Lay bin 4

In other children the separation of the umbilical cord is the cause of inflammation of the abdominal walls, and of inflammation of the hypogastric arteries, as Oehm* and Hodgson have pointed out;t of inflammation of the umbilical vein, described by Duplay; and by Scholler. This phlebitis, which I have several times remarked, filled the vein with pus which extended into the liver; in these cases A symptoms of peritonitis and of erysipelas of the abdominal walls supervene, and the child rapidly dies.

Dr. Bowditch (American Journal of Medical Sciences; No. 37, N. S.) relates two examples of this fatal occurence, observed in infants of the same mother, herself a healthy young woman. The first child was a female, and the cord fell off on the third day, without being followed by any unusual appearances until the fourteenth, when oozing of blood commenced. After styptics, compression, and other means had been tried in vain, needles were passed through the skin, to which ligatures were applied, as in hare lip, so as to enclose a circle of integument. This seemed at first quite successful, and the child to be doing well; but on the eighteenth day, bleeding returned; on the nineteenth, it had several bloody stools, which, as well as the umbilical bleeding, continued on the twentieth day, when it died.

After having had two other children, who manifested no tendency to haemorrhage, the fourth, a male, exhibited this on the tenth day, the cord having fallen off on the fifth. Some ecchymosed spots soon after appeared on the body; and the hæmorrhage in spite of all means, amongst which the actual cautery was employed, continued until death on the fourteenth day. In this case there was some jaundice during life, and a very diseased state of the liver found after death.

*De morbis chirurgicis natorum infantum; Leipsick, 1772. Traité des maladies des artères et des veines; Paris, 1819; t. i, p. 8. ‡ Journal l'Expérience, 1838, § Gazette Médicale, 1840.

Dr. Bowditch supplies a short analytical reference to twelve cases which occurred in Boston; and from the imperfect particulars given, we glean that the average age at which the hæmorrhage came on, was seven days and three quarters; the earliest

being the third, and the latest the eighteenth; seven days being, too, the longest is mos period that life continued after the hemorrhage begs the most cases the bleeding of Frede

was temporarily stopped by treatment, and in many there were bloody dejections. Jaundice was a very common accompaniment (as noticed by Dr. Campbell, Northern Journal of Med., 1844), and the usual termination of life was by prostration. Cust Dr. Radford (in the Edin. Med. and Surg. Journal, 1832) makes two divisions of this hæmorrhage: one in which it results from bad tying, or disease of the funis, such as an ossified or varicose state of the vessels; and the other, in which it is due to an incomplete closure of the vessels. The only recourse here, is cutting down and tying the vessels. Some authors have advised internal remedies in umbilical

followed

hæmorrhage, on account of the fluidity of the blood observed in these cases; and did by

Dr. Bowditch tried grain doses of sulphate of soda (Brit. and For. Med. Rev., ix, p. 247), but without avail. He refers to the possibility of other cases dependings, upon the hæmorrhagic tendency, analagous to that seen in adults, and which is

sometimes hereditary; and this is, probably, the rational explanation of his own, and phy

the great majority of other recorded cases, and explains the great difficulty of cure.

In the Medical Times and Gazette (March 25th, 1854), a case is described of infantile ka icterus, followed by fatal hæmorrhage from the umbilicus, six days after the separation of the remains of the funis; various styptics were applied, and an attempt was made Cho to place a ligature on the bleeding vessels, but the textures were so frail that the ligatures did not succeed. On post mortem examination, the umbilical vein was found to be pervious throughout its entire course the left umbilical artery was also pervious-so that the previous opinion, that the blood was arterial as well as venous, was probably correct.-P.H.B.]

After the separation of the cord, the abdomen presents an infundibuliform depression, surrounded by a more or less decided ridge, formed by the skin, which is still a little reddened and inflamed. A

крамя

slight purulent oozing soils the linen, and the cicatrix is not perfect atly

and entire until after the tenth or twelfth day. The navel becomes daily more formed. The umbilical vessels contract, drawing the cicatrix, inwards, so as to depress it, whilst externally the plumpness of the children appears to deepen it still further. This cicatrix should be bandaged; for when the child cries, the effort might rupture it, protrude 72 the intestine, and give rise to umbilical hernia, as is very frequently observed.

EXFOLIATION OF THE EPIDERMIS.

In the first few days following birth, a process of epidermic desquamation constantly takes place from the skin, which has received the name of exfoliation of the epidermis, and which has been very well studied by Chaussier, Capuron, Orfila, and Billard.

dila Should

2

Children prematurely born do not present this phenomenon directly after birth; in them the exfoliation of the epidermis is not observed until they have acquired a certain age.

Gution

This process, which sometimes commences at the first or second See the

134

SPECIAL PATHOLOGY OF INFANCY.

[Part III. day of existence, is generally in full activity on the third or fifth day. The epidermis becomes dry, cracks, and loosens; it then falls off in a felur days scales of greater or less size. In some cases the exfoliation is scarcely perceptible. It lasts from ten to twelve days, and may be prolonged Then to thirty, forty days, and even two months. It is slower and more butun decided in children whom a premature chronic affection has rapidly brought into a state of marasmus. Emmences In proportion as the epidermic layers become detached, a fresh Inter. epidermis forms in an imperceptible manner. The skin is red, very

Aut time it

44,

irritable, and very readily inflames. Billard has seen a child in which the epidermis of the scrotum was entirely removed, and in which also the urine, irritating the dermis, determined the appearance of a very intense erysipelas. The epidermis is rapidly reproduced in places exposed to the contact of the air, but it appears more slowly in the covered parts, in the axillæ, the neck, in the groin, and in the folds of the skin. Its protecting influence is supplied by lycopodium and all other absorbant powders, which dry up the moisture of these parts, and preserve the skin against external irritants.

ON DISEASES OF THE HEAD AND OF THE NERVOUS SYSTEM.

in

In some children the head and the upper part of the neck are deficient at the same time as the brain and medulla oblongata. In these cases the pregnancy is rarely simple, it is always a twin one at least, and it is one of the foetuses which has obstructed the development ww , of the other.

The acephali, moreover, present vices of conformation in the organs of respiration and circulation, which are either wanting or are modified to a greater or less considerable extent. They cannot live independent of the mother, and they die as soon as this communication is interrupted by the ligature of the umbilical cord.

CHAPTER II.

ON ANENCEPHALUS.

Anencephalus consists in the absence of a part of the brain, with or without absence of the cranial cavity.

The most usual form of this vice of conformation is characterized, according to Billard, by the absence of the cranium and of the brain. “The upper part of the cranium is open, the frontal bones are wanting or are mutilated, the parietal bones scarcely leave traces of their existence. A shapeless cerebral mass, covered by red and bleeding membranes, is situate on the base of the cranium, which is usually hara placed much nearer the shoulders than in the natural state; the considerable projection of the arches of the orbits and of the eyes, the defers crushed appearance of the face, which then presents some analogy in form with the head of certain unclean animals, to which the vulgar are pleased to compare these children; such is the assemblage of the usual features of anencephalia, in which, in the greater number of cases, the medulla oblongata, and sometimes the cerebellum, and portions of the optic thalami, and the corpora striata only are observed. In others there is integrity of the bones of the cranium, which are only deformed, but internally there is atrophy of the brain, or the absence of the internal lobes, or a simple pouch filled with liquid, having the corpora striata, the optic thalami, and the cerebellum for its base. Nearly all the anencephali, although appearing prematurely, are otherwise plump and well formed. They usually live one or several days, and thus prove that the spinal cord and the medulla oblongata are sufficient to support life during foetal evolution, and some time, also, after birth.

Any Im

[In case of acephalus, the skull is either altogether wanting, or is reduced to a Ount & merely rudimentary condition. It is liable, also, to various degrees of defect, in acrania being without any vault, and in encephalocele and anencephalus presenting e various but less degrees of the same anomaly. Defects of other parts of it are noticed when the cranial or facial bones are fissured; when certain portions, of Cranium the brain are wanting, or symmetrical parts of it are fused together, as happens in cyclopia, &c. Examples are also met with in which the development of the skull is arrested in a less degree; apertures closed by membranes being found in its bones, or large membranous interspaces between those that form the cranial vault; the fontanelles are large, or unusual ones exist; or certain sutures continue permanently unclosed. The cases of this class mostly owe their origin to a prematurely large size of the brain-to hypertrophy or hydrocephalus.

The number of bones composing the skull is occasionally incomplete; particular

Кики