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Melaena Neonatorum with Report
of a Case Cured by Transfusion.

By Samuel W. Lambert, M.D.,
New York

Medical Record 73(22):885-887, May 30, 1908.

 

Although the case which I have selected to report to the Practitioner's Society has received some notoriety in the daily press, it seems nevertheless worthy of a careful clinical study. The baby was born of healthy parents and was delivered after a ten-hour labor by an easy low forceps operation at 5 A.M. on March 4. The child was a girl, and appeared to be healthy, weighed eight pounds and twelve ounces, breathed and cried at once, and showed no signs of asphyxia. The blades of the forceps made slight marks over the right zygoma and behind the left ear; there was no abrasion of the skin. Five hours after birth the cord was re-tied because of slight oozing from the cut end. Twelve hours after birth a thickened, dark-colored spot was noticed on the right side of the tongue which was thought to be a nevus, but which has cleared up since and was undoubtedly a hematoma. Three hours later the baby's temperature was 102.2°, and it was put to the breast for the first time. After a quiet night the baby's morning temperature was 102°. She looked pale, and a slight amount of blood was noticed when the mouth was washed. She slept quietly all that morning, but became restless in the afternoon; her temperature at 4 P.M. was 103.4°. She grew markedly paler, cried continuously, and began to bleed slowly but steadily from the nose, and a hematoma appeared in the scalp behind the left ear. At 9 P.M. this subcutaneous bleeding had extended down the neck over the muscles, across the median line to the other ear across the coronal suture over the frontal bone, and forward under the left ear to the angle of the jaw. The bleeding from the nose was continuous and quite profuse. The temperature was 102.3°, a dark meconium stool gave a very positive reaction for blood, but the urine was of normal color. The baby was of waxen pallor. The diagnosis of melena was made, and treatment instituted upon the theory of its being an intestinal infection. One dose of thirty minims of castor oil and two grain doses of calcium lactate every two hours was given during the night. During March 6 the child did not seem to grow worse as rapidly. The scalp hematoma increased in size and tenseness, and the paleness of the skin increased, but the temperature gradually fell from the maximum of the attack at 2 A.M. (104.4°) till it reached 97.4° at 3 P.M., the nasal bleeding became less constant, and the baby nursed regularly. In the evening of March 6 and during March 7, there was some vomiting of watery fluid containing partially digested blood, especially after taking the calcium lactate, which was stopped. Adrenalin was tried in the nose at this time, but without effect. The feedings had to be by dropper, for the baby refused to nurse. The temperature range was 97.8° to 99.4°.

On the morning of March 8 the case seemed hopeless. During this day the baby's skin was waxen white and the mucous membranes without color; the nasal bleeding was continuous; the vomited matter contained food curds, dark blood, and at times bright clots; the stools were frequent and contained bright red blood; the subcutaneous hematoma on the scalp increased until the right eye was closed and ecchymotic spots appeared on the legs; the respiration was rapid and superficial; the pulse weak, counting 150 just before the operative procedure.

It was decided to attempt a direct transfusion of blood from the father of the infant by end-to-end anastomosis of the two blood-vessels after the manner devices by Dr. Carrel of the Rockefeller Institute. This was done through the skillful surgical manipulation of Dr. Carrel himself and Dr. Geo. E. Brewer. The right popliteal vein of the baby as sutured to the left radial artery of the child's father, without anesthetic to either patient, and enough blood was allowed to flow into the baby to change her skin from a pale transparent whiteness to a brilliant red color. No measure of the amount of blood was possible, but the evidences of a sufficient quantity were manifold. She began to cry lustily and to struggle against the bandages which held her strapped to an ironing-board. The wound in the leg up to this time had oozed a slight amount of pale watery blood, which did not clot well. It began to bleed freely and the blood promptly clotted. The nosebleed stopped instantly. The pulse became full and strong and slowed down, and the respirations were deep and full. As soon as the wound was sutured and dressed the baby was fed an ounce of milk, which she took ravenously and retained, and immediately went to sleep.

Since the ending of the transfusion there has been no hemorrhage, no vomiting, and no diarrhea. Convalescence from the operation was uninterrupted except for a slight infection of the wound. There was no evidence of hemolytic action at any time, and all the symptoms of melena ceased at once. The next morning the baby was found to be fourteen ounces below her birth weight. She has gained steadily since, and now, eight weeks after birth, she weighs ten pounds fifteen ounces. The hematoma was absorbed rapidly, except for a slight discoloration of the upper lid of the right eye, which still persists. The stools became of normal character two days after the operation. The wound is healed, and the child appears to be a normal child of its age to-day. The striking thing about the case is that the disease ceased suddenly, and the child has been cured from the moment of the transfusion of blood.

This case presents a complete résumé of the symptomatology of melena, and the condition was easily differentiated from the other various kinds of hemorrhage to which the newborn are liable. The essential points were the early nosebleed, the rapidly increasing pallor and anemia, the febrile action, and the restlessness followed by the characteristic bloody vomit and stools and the subcutaneous ecchymoses.

The disease is one of the oldest known to man, although it is of comparatively infrequent occurrence. The latest statistics (Shukowsky, 1907) place its frequency at 1 in 1000, or 29 in 30,000 living births.

Melena is a disease of the first two weeks of life, and usually begins in the first two days, the latest recorded case found began on the eighteenth day of life (Genrich, quoted by Shukowsky). It attacks the sexes equally, and well-developed children equally with the poorly-nourished.

Heredity seems to have no influence either as to the presence of true hemophilia or of hereditary syphilis. An interesting case which tends to disprove these influences is that of a pair of twins, one of whom died of melena, while the other was free of the disease. No influence has been proved from the effect of obstetrical operations or accidents, or from errors of anatomical development.

The results of pathological anatomy have failed to show any constant or fixed lesion. The various lesions in the cranium and those in the gastro-intestinal tract which have been described must be classified as chance lesions only. No rational explanation of the symptom syndrome of melena has ever been suggested as a result of fairly numerous autopsy examinations.

The prognosis has been extremely grave, and the mortality has varied in the experience of several observers from 50 to 80 per cent. Treatment also has been most unsatisfactory. A great variety of astringents -- various preparations of ergot, subcutaneous injections of salines and of artificial serum, cold irrigations, hypodermic use of 2 per cent. gelatin solutions in saline, antisyphilitic medication, and rectal and gastric lavage have all been tried with great lack of successful results. To the above one must add the equally unsuccessful use of cathartics and calcium salts in the case which is the text for this paper. The best results in the past have been secured from the use of gelatin and gastric and colonic lavage (Shukowsky). The cure of this case by transfusion leads to certain theoretical conclusions as to the etiology of melena which are interesting and which subsequent investigation may prove of great interest.

The theories of the etiology of no other disease have undergone more varied and more radical changes than those of melena. This disease has always attracted attention, and its etiology has been subject to the fashions and temporary fads of the prevalent medical theories of the moment. Its essential nature remains unknown at the present day. Lequeux published a thesis on this disease in the Paris series of 1906, and called attention to this lack of accurate knowledge by suggesting four periods of historical interest in the study of melena.

The first period up to 1825 is called that of confusion, and the explanations of the cases reported include such causes as plethora, asphyxia, passive hyperemia, and congestion of the mesenteric arteries.

The second period from 1825 to 1835 is known as that of clinical study. The causative factor is suggested as an ulceration of the alimentary canal, too early tying of the umbilical cord, and, equally supported by other authors, a too late tying of the same.

The third period is that of pathological anatomy, and extends from 1838 to 1875. The numerous lesions found in the newborn have all been held responsible for this symptom complex; Brain injuries from birth hemorrhage, ulcers of the intestines, including the embolic theory of such ulcer formation, patency of the ductus arteriosus, congenital heart lesions.

The fourth period of laboratory study, from 1875 to date, has not cleared up the obscurities of the disease, although all the power of investigation of bacteriology has been brought to bear upon it. At least ten different bacterial causes have been found in individual cases both in pure culture and in various combinations. The list includes streptococci and staphylococci, pneumococci, Bacillus pyocyaneus, B. lactis aërogenes, B. coli, and even the specific germs of typhoid and diphtheria. An interesting claim was made by Gaertner in 1893 for the discovery of a specific bacillus, but subsequent study proved his claims to be untenable. The bacteriological findings have been too variable to prove any specific infection. The relation of syphilis as a cause has been invoked to explain the symptoms of melena on a modern theory of "weakness of the walls of the blood vessels," and various authors have referred to special hemorrhages occurring in the course of the disease as a cause of the symptoms. Hamill's cases of hemorrhages into the suprarenal capsules, and the cases of cerebral hemorrhage of various authors, are examples of this faulty logic by which the symptoms are explained by interference with the adrenal glands in one case, and by nervous influences in the other.

Lequeux concludes that the melena is a symptom syndrome due to several causes, that certain predisposing conditions, of which syphilis is one, will cause certain infections to bring about the development of the disease. The same idea is expressed by Holt that melena is due to "changes in the blood or to changes in the blood-vessels, or to both, whereby the vessels are no longer able to hold their blood."

Abt, writing in 1903, reaches the same conclusion, as follows: "Future research in the etiology of this disease should be directed along the line of histological examination of the minute blood-vessels contemplating also conditions governing the clotting of the blood."

The modern theories of the chemistry of the blood, of its clotting, of its cellular structure, have been appealed to by Lequeux to explain these phenomena of hemorrhage, but a sufficient number of observations and experiments are lacking in his work to make these views of more than theoretical value. He formulates the sequence of events which probably occur prior to these hemorrhages, thus: "An increase in the bulk of circulating blood; a change and weakness in the blood-vessels; a diminished power of coagulation in the blood, which becomes fluid, and has no tendency to limit its extravasation; difficulty with vasomotor function, resulting in a passive dilatation of the vessels, and a final rupture caused by changes in the vessel wall restricting its elasticity." In these recent opinions special stress is laid upon the condition of the blood-vessels.

The tendency to apply the newest theories of pathology and physiology to explain the unknown has been referred to as characteristic of the older discussions; it is found as well in the latest literature of melena. The older theories of embolism, of circulation, congestions, and of asphyxia, have been discarded, and explanations by disturbance of cerebral centers, by changes in internal secretion, especially of the suprarenal glands, or by some undiscovered lesion of hereditary syphilis, have been offered both with and without an added bacterial infection. The latest accepted theories of melaena neonatorum point not to ulceration or to gross lesions, but to the capillary blood-vessels as the seat of bleeding, and the clinical picture of these cases is undoubtedly very like that of an infection as the etiological factor. But the course and remarkable cure of the case reported here would seem to disprove both the infectious theory of its origin and the blood-vessel explanation of the diapedesis of red cells and disturbed osmosis resulting in the capillary hemorrhages.

To review the facts of the case: Hemorrhages and fever began simultaneously, normal temperature was reached forty hours after the onset of fever, but the hemorrhages became progressively worse, for three days after all fever had disappeared. At time of operation the baby was in a dying state, and had palpably only a few hours to live -- immediately afterward the baby was in perfect health. There was no period of convalescence.

Such a sudden change in condition could not be due to a structural regeneration in the capillary vessels, nor to a sudden overcoming of an infection; clinical experience will permit of no such inference. Neither the crisis of a pneumonia nor the relief of a spasmodic croup can be compared with the observed fact in this case, either from the point of view of reversal of pathological condition, or of lapse of time necessary to bring it about.

The only possible explanation of so rapid a change must be found in a chemical condition of the blood. And the final conclusion as to the nature of this disease is that melaena neonatorum is a congenital malformation of the blood of unknown chemical nature. The solution of the problem of its etiology is to be found in a chemical study of the processes of osmosis in the capillary vessels, of the chemistry of blood coagulation, and along kindred lines which are for the most part new and untouched.

A complete bibliography of this disease can be found at the end of Dr. Lequeuex's thesis. The following articles have been especially consulted in the preparation of this article.

 

Bibliography

Abt: Journal Am. Med. Ass., Vol. XL., 1903.

Gaertner: Arch. f. Gyn., Bd. XIV., 1893.

Holt: Diseases of Infancy and Childhood, 1897.

Kilham: Arch. of Pediat., 1899.

Lequeux: Thèse de Paris, 1906.

Nicholson: Am. Jour. Med. Sci., 1903.

Shukowsky: Arch. f. Kinderheilk, 1907.

Wilson: Arch. of Pediat., 1905.

 


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