Book - Umbilicus (1916) 3
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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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Chapter III. Umbilical Infections in the New-Born
General considerations. Autopsy findings. Clinical history. Gangrene.
An epidemic of erysipelas of the abdominal wall in new-born infants. Trousseau, 1844. An epidemic of erysipelas and gangrene of the umbilicus. Meynet, 1857. An epidemic of gangrene of the umbilicus. Bergeron, 1866. Xon -puerperal erysipelas of the new-born infant. Yot, 1873. Runge on wound infection of the new-born.
Mild disturbances in healing of the wound of the umbilicus.
Gangrene of the umbilicus.
Diseases of the umbilical vessels.
Erysipelas in the first days of life. Septic pyemia and infection of the umbilicus of the new-born. Cohn, 1896. Umbilical sepsis in the new-born occurring in the nursery and child's hospital, New York, during
1896. S. W. Lambert. Tetanus in the new-born.
Treatment of the umbilical cord. Dickinson's method. Care of the umbilical stump — a bacteriologic study. Adair. Persistent vitality of the umbilical cord.
L'ntil the advent of asepsis, myriads of children succumbed to umbilical infection within a few days or a few weeks after birth. To give a thorough digest of the literature of the subject here would be out of the question, and I shall confine myself to a consideration of the more important articles bearing on the subject.
Meynet, in his monograph published in 1857, mentions the fact that Hippocrates drew attention to umbilical infections. He also refers to the writings of Ambroise Pare, of Mauriceau in 1712, of Hamilton in 1785, of Underwood in 1786, and of Billard.
Personally I have derived much information on the subject of umbilical infections from the articles of Trousseau (1844), Bednar (1850), Lorain (1855), Meynet (1857), Bergeron (1866), Pollak (1869), Yot (1873), Nicaise (1881), Meyer (1891), Runge (1893), Gremillon (1895), Lambert (1896), Cohn (1896), Dickinson (1899), Hinsdale (1899), Pinkerton (1900), Tarnier and Budin (1901), Wassermann (1901), Porak (1901), Maygrier (1901), Salge (1904), Porak and Durante (1905), and Cumston (1905).
Umbilical infections may be frank or masked. Unmistakable evidences of inflammation, such as redness, swelling, and discharge, may be present, or the umbilicus may show little or no evidence of disease, superficial healing occurring even when an infectious process is going on in the underlying tissues.
The umbilical infections have been designated as erysipelas, puerperal fever of the new-born, or gangrene, according to the different clinical manifestations ex 70
UMBILICAL INFECTIONS IN THE NEW-BORN. 71
hibited. They are all due to infection through the umbilicus, and are usually caused by the same organisms.
A careful study of the autopsy findings will not only give a clear idea of the general condition, but will also permit a correlation of the various symptoms with the avenues of infection concerned. Infection may occur before or at birth, but the symptoms usually first appear at some time between the third and the eighteenth day after birth.
Appearance of the Umbilicus. — -In some cases the umbilicus looks perfect!}' normal; in others there is a small opening from which pus is seen escaping; or the umbilicus is represented by a small ulcerated area. The tissue surrounding the umbilicus is sometimes soft, sometimes red and indurated, and occasionally, by gently stroking the abdominal wall from the symphysis upward, one can express a few drops of pus from the umbilicus. This pus may be watery, yellowish or greenish-yellow in color, the difference depending in large measure upon the pathogenic organism present and the duration of the infection.
When we cut into the abdominal wall, we may find the umbilical vein and the umbilical arteries perfectly normal, although the surrounding tissue is infiltrated.
The umbilical arteries and the umbilical vein as they appear at birth are seen in Fig. 60. These vessels rapidly atrophy and become impervious cords, as indicated in Fig. 61.
Much controversy has arisen as to the mode of extension of the infection from the umbilicus. Some authors claim that extension of the disease takes place through the umbilical vein; others that the arteries are responsible for the dissemination of the purulent process, and still others that the virus is carried by the umbilical lymphatics. A careful study of the autopsy findings in numerous epidemics clearly shows that in some epidemics the vein, in other epidemics the arteries, often showed marked changes; in not a few cases, however, the arteries, vein, and lymphatics were all implicated. Practically it matters little along which avenue the infection travels , the chief thing to remember is that, in the past, infection through the umbilicus at birth has been very frequent and has led to most disastrous results. The umbilical arteries may show no change, or one or both may contain partially or completely organized clots. When it is infected, the vessel often contains purulent material, and in some cases, as a result of the accumulation of pus, presents a fusiform swelling. The surrounding tissue in such cases often shpws a considerable amount of edema or even a purulent accumulation. When the umbilical vein is implicated, pus may be present in its umbilical portion; frequently, however, it contains here an organized thrombus, but in the neighborhood of the liver is filled with purulent material.
Implication of the Various Organs. — Liver. — When the umbilical vein is partially or completely filled with pus, it is only natural that the liver should be implicated. Sometimes the organ is a little enlarged. It may contain small abscesses, and an acute inflammation of the veins of the hepatic lobules may be noted. As a result of the extension of the infection a subphrenic abscess may develop.
Lungs. — In some epidemics the lungs have shown marked changes. Some
THE UMBILICUS AND ITS DISEASES.
times these took the form of a hemorrhagic pneumonia, multiple hemorrhagic foci being scattered throughout the lung. In other instances pulmonary infection manifested itself by blackish-green patches of gangrene, and in some cases scattered multiple abscesses as large as hazel-nuts were found in the lungs. As would naturally be expected, when these foci of consolidation had reached the surface of the lung, a pleurisy had developed.
Heart. — Only slight changes are the rule, but purulent endocardial exudates have been noted associated with a purulent pericarditis. In such cases the blood from the heart has been found to contain the organism responsible for the infection.
Kidneys. — Signs of a parenchymatous nephritis are sometimes demonstrable.
Fig. 60. — The Umbilical Vessels about the Time of Birth. The umbilical vein (a) conveys placental blood to the fetus. At a' it is joined by the portal vein, the combined trunk forming the ductus venosus. The arrows indicate the course of the blood to the heart. The blood passes from the fetus back to the placenta through the two umbilical arteries <b and V), only the left of which is clearly seen in the picture. It was chiefly through the umbilical vein and the umbilical arteries that fatal infections of the child were so prone to occur in former years. As will be noted in Fig. 61, these vessels become obliterated after birth.
Fig. 61. — The Umbilical Vessels in the Adult. As soon as the cord is tied the usefulness of the umbilical arteries and of the umbilical vein is over, and these vessels become gradually transformed into solid cords. a-a' represents the situation of the obliterated umbilical vein from umbilicus to portal vein. The ductus venosus has vanished. The location of the left umbilical artery is indicated by the dotted line b-b'. The artery is obliterated from the umbilicus to the point of origin of the superior vesical artery. The umbilical artery is the continuation of the anterior division of the internal iliac.
UMBILICAL INFECTIONS IN THE NEW-BORN. 73
Brain. — Occasionally a meningitis or multiple cerebral abscesses are present.
Peritoneal Cavity. — 'As a rule, there is little or no peritonitis unless there has been an extension of the infection directly through from the umbilicus to the peritoneum by continuity.
Terminal Infections. — Sometimes one of the first signs may be a circumscribed patch of erythema on the abdomen, buttock, cheek, eyelid, or the ear, or, in fact, on any part of the body. Swelling in the abdominal wall, between the umbilicus and symphysis, together with swelling of the testicle, with or without abscess formation, is not uncommon.
Infection of various joints — of the phalangeal joints, wrist, elbow, shoulder, hip, knee, ankle, and toes— has been noted in some epidemics. In such cases, when the process has been a very rapid one, a terminal joint has been found at autopsy to be the only one implicated, whereas when the disease had been of some duration, the pathologic process had extended toward the trunk. In some cases gangrene of the extremities had developed and the joints showed disorganization.
In the early days bacteriologic examinations, of course, were not made, and fortunately at the present time epidemics of umbilical infection are rare. The organisms most commonly found are Streptococcus, Staphylococcus aureus and albus, and Bacillus coli. Occasionally Bacillus pyocyaneus has been noted. Tetanus will be discussed elsewhere.
As a rule, the chMd appears well for several days after birth, but then commences to lose weight. At a period varying from three to eighteen days it grows restless and cries frequently. Its symptoms strongly suggest an intestinal upset, but an examination of the umbilical region will often clear up the diagnosis. On the other hand, the umbilicus may appear to be perfectly normal. As the infection advances the child will in some instances develop a fatal pneumonia or a cerebral abscess; or a blush on the buttock, abdomen, cheek, or elsewhere, or the swelling of an index-finger or of one of the smaller joints, may be the first indication of a general infection. In such cases one should always think of the umbilicus, and once more carefully examine it, since we know that in the vast majority of cases this is the avenue through which the infection occurs.
There is no definite set of symptoms; the clinical phenomena will depend in a large measure upon the organ or organs of the body that are secondarily infected. If the infection be of a mild grade, the child may gradually recover, but where "massive infection" exists, great depression soon develops and the patient speedily dies.
In the description of the autopsy findings and clinical picture of umbilical infections I have purposely omitted a description of gangrene of the umbilicus, preferring to consider it separately, although it is only another manifestation of an umbilical inflammation and is undoubtedly caused by the same organism or organisms. In the former cases the local manifestations of the disease are often overshadowed partly or completely by those of the general infection, whereas in cases of gangrene the local condition receives the greater part of the physician's attention.
74 THE UMBILICUS AND ITS DISEASES.
Several days after labor the skin in the umbilical region may be slightly raised and assume a yellowish tinge, while the tissue surrounding it shows some reddening and is indurated. This slough may come away, leaving a very superficial skin wound. In many cases, however, the area gradually increases in size and the central portion of the slough becomes black, while along its edges there appears a narrow, violet-colored line — the line of demarcation. Liquefaction takes place, and the slough gradually comes away in pieces .
If the septic absorption be abundant, the child soon shows signs of toxemia and death may rapidly follow. Bednar, in 1852, when this malady was relatively common, gave a most vivid description of the local conditions in the severe cases. He spoke of the grayish-black or gray appearance of the umbilical slough, and of the surrounding zone of inflammation, which was often as large as a dollar or even as the palm of a hand. In such cases the blood-vessels were filled with dark thrombi or with pus. The peritoneum in the vicinity was often of a dirty red color, markedly injected, and covered with a plastic, purulent exudate; and in some cases peritonitis developed. The general symptoms were naturally those of septic absorption, and in the severe cases the patients rapidly succumbed.
In rare instances the slough involves the entire thickness of the abdominal wall, and when it comes away, the intestines escape through the break. A most interesting case of this character was reported by Pollak. The patient (J. W.) was well developed, and, when eight days old, weighed 63^ pounds. When six weeks old he became very restless, and gangrene developed at the umbilicus. The tissue surrounding the umbilicus showed a grayish-brown appearance, was soft and foulsmelling, and surrounded by a zone of redness. The abdomen was markedly distended. By the end of two days the area of gangrene had become the size of a four-kreuzer piece. On the fifth day the gangrenous patch was as large as a thaler, and the child refused the breast and appeared to be dying. It revived, however, and two days later the abdomen opened at the umbilicus, a loop of bowel protruded, and a perforation occurred on the following day. The child died on the ninth day of the disease. By this time the slough had come away completely and there was a granulating surface.
After this brief discussion of the autopsy and clinical findings in cases of umbilical infection in the new-born, I shall briefly refer to some of the former epidemics, and describe somewhat fully some of their more interesting features, as from these one can obtain a graphic picture of the unfortunate conditions that formerly existed.
AN EPIDEMIC OF ERYSIPELAS OF THE ABDOMINAL WALL IN NEW-BORN INFANTS.
Trousseau, in 1844, reported a most disastrous epidemic that occurred in the months of September and October, 1843. As will be noted, the erysipelatous inflammation in most of the cases attacked the abdominal wall, and in nearly all instances there was an infection of the umbilicus or of the tissues immediately beneath it.
In the beginning of his article Trousseau quotes Paul Dubois as saying that he has never seen an infant recover from erysipelas during the first month of life. After discussing the subject of erysipelas in the nursing infant, he gives a short
UMBILICAL INFECTIONS IN THE NEW-BORN. 75
report of a family of 19, including the servants, in which, in the space of six weeks, 10 people were affected by what appeared to be a form of erysipelas. He then gives reports of several cases in detail.
Case 1 . — A boy, forty days old, developed signs of acute peritonitis associated with erysipelas. He died forty hours after the commencement of the trouble. There was some slight suppuration at the umbilicus.
Case 2 . — When the cord came away on the fifth day, there remained at the umbilicus a small area of suppuration with a surrounding zone of inflammation. The health of the child at that time, however, was perfectly good. Erysipelas developed on the twentieth day and the child died.
Case 3 . — A boy, eight days old, was affected with erysipelas. Applications of mercurial ointment were made, but death took place eight days after the onset of the disease. The umbilicus was the seat of an abundant suppuration and the erysipelas had spread to the lower extremities.
Case 4 . — A boy, three weeks old, was suffering from phlegmonous erysipelas and developed peritonitis. Death took place fifteen days after the onset of the disease. The mother had a grave puerperal sepsis. A great many of the women had died from puerperal sepsis in the hospital about the time of this patient's birth. There was an erysipelas of the scrotum and of the symphysis, but the umbilicus showed no evidence of reddening or of suppuration. At autopsy the cellular tissue of the abdominal wall was found infiltrated with pus; there was a seropurulent fluid in the peritoneum, and a false membrane on the convex surface of the liver.
Trousseau says that these observations are sufficient to show the extreme gravity of erysipelas, in the new-born.
AN EPIDEMIC OF ERYSIPELAS AND GANGRENE OF THE UMBILICUS.
In reporting this epidemic in 1857, Meynet points out that the disease was readily divisible into two groups. In the one an erysipelatous inflammation of the umbilicus was the dominant symptom; in the other, ulceration or gangrene of the umbilicus.
Zinc chlorid, in the form of Canquoin's paste (zinc chlorid with wheaten flour), yielded most unusual results in this epidemic.
Meynet, in the beginning of his article, draws attention to the remarks of Pare, who regarded this malady as being so grave that he warned the surgeon not to raise a hand for fear that he might be accused of causing the death of the infant. Following a lucid description of the literature on the subject, he gives an epitome of two epidemics. One began in April, 1856, and lasted throughout May and a part of June. Early in December of the same year a second epidemic occurred. It was one of great severity, and lasted until January of the following year. It was similar to the first epidemic in that it ceased abruptly as a result of the preventive measures which were employed.
Meynet says that after the epidemic and up to the month of March, when he left the service, they had not had another case in the Infirmary in Paris. During the first epidemic puerperal fever was not prevalent, but in the second the umbilical infection in children coexisted with puerperal fever in women.
Symptoms. — The progress and the termination of the disease were the same in both epidemics.
76 THE UMBILICUS AND ITS DISEASES.
Of 230 infants received at the Maternity during the month of April and to the end of June of 1856, 17 were born dead, leaving 213 living infants. Of this number, 53 were attacked — 14 in the month of April, 25 in the month of May, and 14 in the month of June. Thirty-six of the infants died.
In the second epidemic, which occurred in December and January, 175 children were delivered at the Maternity: 12 were born dead, 163 living. Of this number, 36 were attacked and 8 died. Meynet says nothing is more variable than the period of incubation in cases of this disease. In some, symptoms were noted a few hours after birth, in others about the fourth or fifth day. Only rarely did they appear after the eighth day. In these last cases the cord was black and horny, but had not separated from the umbilicus.
In both epidemics he describes the condition as nothing more than an exaggeration of an ordinary phlegmon, by which he means a moderate inflammation of the umbilicus accompanied by the dropping off of the cord. This inflammation was accompanied by ulceration at the base of the cord, and a more or less abundant suppuration, which retarded the dropping off of this appendage and the cicatrization of the umbilicus. Very soon this inflammatory condition became more intense, and the moderate inflammation was succeeded by an intense phlegmon. In the umbilical region could be noted a redness which became more and more marked; it disappeared upon pressure, and formed a circle around the umbilicus. At the same time there appeared numerous circumscribed swellings. The tissue around the cord became ulcerated, the margins were undermined, the ulceration extended deep downward, and the surface of the depression was covered with a false membrane, grayish white in color and soft, from which a bloody, purulent, thick, fetid discharge frequently exuded. The ulceration increased in size. The reddish zone also became larger and took on the color of wine-lees. The swelling became more and more voluminous and was hard. In a large number of cases the red areola was surrounded by a circle of small vesicles more or less confluent, dirty white, round, not umbilicated, and containing a seropurulent fluid. Sometimes there was a circle of erysipelatous redness, surrounded by numerous blebs containing a serosanguineous fluid. The blebs ruptured and exposed the skin, which readily became involved in the area of ulceration.
The general condition of the child was not affected at the beginning, but after a time the appetite diminished and was entirely lost. The child refused the breast or any nourishment and cried continuously. Its skin became dry and withered. The pulse was accelerated, and the general satisfactory condition of the infant was replaced by emaciation. The face was drawn from severe suffering, and the nasolabial folds became hollow; the tongue was dry and red at the tip; in some cases it showed a thick coating, and occasionally a coincident thrush. The abdomen was distended and an obstinate constipation, but more frequently a diarrhea, was present. The case progressed with alarming rapidity, and the little infant often died in from thirty-six to forty-eight hours. Sometimes the course of the disease was more gradual, but even then a fatal termination was frequent.
In other cases the clinical course was different. The cord was sometimes friable and soft; sometimes it was dry or ready to drop as the result of ulceration. The ulceration commenced at the margin of the cord, and proceeded from the center to the circumference. It occupied all the bottom of the cavity, and extended in different directions, sometimes destroying the attachment to the skin. It followed
UMBILICAL INFECTIONS IN THE NEW-BORN. 77
along the umbilical vessels for quite a distance, transforming their interior surface into a vast focus of suppuration. Sometimes, on the contrary, it would jump over the cutaneous external ring and invade the abdominal wall, spreading over a large area. In form it was also irregular; its margins were sometimes undermined. Most frequently, however, its surface was dull, of a grayish-violet color, and exhaled a gangrenous odor; or it was covered with a false membrane, which was thick, soft, and very adherent — the condition being analogous to what is known as "hospital gangrene." In such a case the reddish, circular area was less circumscribed, but livid in color. The swelling was less pronounced, the pustular eruption sometimes lacking. With an increase in the severity of the general symptoms the infant would pass first into a state of great agitation, but speedily into a condition of collapse and death would ensue.
Duration. — The duration of the disease was extremely variable. In certain cases the suffering lasted from thirty-six to forty-eight hours; in others it was prolonged to three or four days, but rarely longer.
Recovery. — Where recovery took place, it was slow. The inflammation diminished in intensity, the ulceration ceased to spread, the false membrane disappeared gradually, and granulation tissue took its place. The secretion gradually became of a healthier nature, and the redness and tumefaction disappeared little by little. At the same time the general symptoms improved, the skin recovered its moisture and lost its heat; and finally, after a more or less prolonged convalescence, the infant recovered.
Meynet says that it is easy to see that the disease presents two distinct forms : one is characterized by the erysipelatous inflammation and by swelling of the subcutaneous cellular tissue, with a pustular eruption and ulceration. The other, on the contrary, commences as an ulceration and presents the appearance of hospital gangrene. In several cases he observed an extensive ulceration which always occupied the center of the surface of the abdomen.
In all of Meynet's 18 autopsies the extent of putrefaction was carefully observed. Twenty-four hours after death the abdominal walls showed a greenish tint, the epidermis was raised as if undergoing maceration, the reddish color of the erysipelas was transformed into a blackish tint, and the abdomen was distended. Beneath the skin the cellular tissue around the umbilicus was thickened, indurated, more dense, and more friable. This induration was due to infiltration into the matrix of the tissue, sometimes with an amorphous plastic material, sometimes with serum.
Meynet says that he never found this process localized as a distinct focus, and he draws attention to the fact that his results coincide with those of Trousseau and Bouchet. The thickness and induration became more marked toward the margin of the' umbilical ring. At this point the peritoneum sometimes presented a circumscribed redness, evidently clue to vascular arborization, but in only two instances did Meynet find a well-developed general peritonitis.
In these two cases the peritoneum showed marked reddening and there was a false membrane, slightly adherent to the convex surface of the fiver and spleen, and between the intestinal convolutions. In the two cases of general peritonitis there was phlebitis of the umbilical vein. The lumen of this vessel between the umbilicus and its termination was filled with thick, whitish pus; the inner surface of the vein was bright red, and did not present any ulceration. The inflammation terminated abruptly at the ridge at the portal vein.
78 THE UMBILICUS AND ITS DISEASES.
In 10 cases there was a partial peritonitis, limited to the umbilical region. In three instances Meynet found inflammation of the umbilical arteries, with purulent material in their lumina. These arteries, which were formerly permeable from the umbilicus to the bladder, contained pus for a distance of from 1 to 2 cm.; in the remaining portion of their course they had been obliterated by fibrinous clots. In 6 cases he found only serous infiltration and seropurulent infiltration in the cellular tissue beneath the umbilicus.
In a resume (p. 24) he again says there were two distinct forms of the disease noted in these epidemics, the one corresponding to erysipelas of the new-born, and characterized by its tendency to invade large surfaces; the other by malignant ulceration with a tendency toward putrefaction and gangrene.
It may be of interest to refer to the notes on the individual cases in these two epidemics.
The observations are divided into two groups — those with erysipelatous inflammation and those showing a marked tendency to ulceration.
Case 1 . — The onset was marked on the third day after birth by an erysipelatous inflammation, followed by ulceration. Death occurred three days later. At autopsy there was a moderate degree of peritonitis; nothing in the umbilical vessels.
Case 2 . — The child was stricken on the seventh day after birth. At the beginning ulceration was noted. The disease lasted three days and was fatal. There was general peritonitis and phlebitis of the umbilical vein.
Case 3 . — The onset was noted six days after birth. There was an erysipelatous inflammation followed by ulceration. The actual cautery was used. The child died on the eighth day.
Case 4 . — Invasion on the fourth day; erysipelatous inflammation followed by ulceration. The actual cautery was employed. Death on the seventh day.
Case 5 . — The umbilicus was invaded on the third day. Ulceration took place. The actual cautery was used, but the child died three days after the beginning of the inflammation.
C a s e 6 . — Invasion on the second day. The erysipelatous form was noted at the beginning, and later ulceration. The actual cautery was used. Death took place on the third day of the disease. At autopsy a general peritonitis and inflammation of the umbilical vein were noted.
Case 7 . — Invasion on the fourth day. Erysipelas of the umbilicus followed by ulceration. The actual cautery was ineffectual. Later zinc chlorid paste was used. Convalescence by the fifteenth day.
Case 8 . — Invasion on the third day. Ulceration took place. Cauterization with zinc chlorid paste; the child was convalescent in seven days.
Case 9 . — Invasion on the fifth day, with ulcer formation. Zinc chlorid was employed; convalescence by the tenth day.
Case 10 . — Invasion on the second day. Erysipelatous form. The wound was cauterized with zinc paste and the child was convalescent by the ninth day of the disease.
UMBILICAL INFECTIONS IN THE NEW-BORN. 79
Group 2. — In "Which Ulceration was the Prominent Feature.
Case 1 . — Invasion on the third clay. Erysipelas followed by ulceration. The wound was cauterized with zinc paste. The child was convalescent by the eighth day of the disease.
C a s e 2 . — Invasion twelve hours after birth. Erysipelatous form. Wound cauterized 'with zinc paste. Healing by the ninth day of the disease.
Case 3 . — Invasion on the fourth day and an ulcer formed. The wound was cauterized with zinc paste, and by the ninth day the child was convalescent.
Case 4 . - — Invasion on the third day. Erysipelas followed by ulceration. Cauterization with zinc paste; the child was convalescent by the eighth day. The mother of this child had puerperal fever.
Case 5 . — Invasion on the fourth day. Erysipelas with coexisting ulceration. Cauterization with zinc paste; by the seventh day the child was convalescent. The mother had a severe, almost fatal, attack of puerperal sepsis.
Case 6 . ■ — ■ Invasion on the second day. Erysipelas was first noted. Convalescence had ensued by the seventh day after the use of zinc paste.
Case 7 . ■ — ■ Invasion on the seventh day. There was erysipelas in the beginning, and the cord was still adherent. There was ulceration of the outer part of the wound, and in this case the child had thrush. Zinc chlorid paste was employed, and healing had taken place by the tenth day after the commencement of the inflammation. The mother was suffering from a severe puerperal infection.
Case 8 . — Invasion on the second day. Erysipelas of the umbilicus was soon followed by ulceration. The wound was cauterized with zinc paste, but death occurred on the sixth day of the disease. The mother had a moderately severe attack of puerperal infection.
Case 9 . — Invasion on the third day. There was ulceration without apparent gravity at the beginning; the wound was cauterized with zinc paste on the third day, but death took place that evening.
Case 10. — On the third day there was ulceration of a grave character; at the base of the cord tumefaction and redness. The actual cautery was used, and four days later zinc paste was applied. Convalescence ensued on the seventh day.
Case 11. — L., born January 10th. The mother left the hospital in good condition on the eighth day, but the child on the third day after birth showed a reddish, erysipelatous tumefaction at the umbilicus. There was a pustular erysipelas, with ulceration at the base of the cord, but no general symptoms. The wound was cauterized with zinc paste. The child recovered and was sent to the country on the eighth day.
Case 12. — J. M., born January 12th. The mother had mastitis. The child was attacked on the third day with erysipelas and swelling at the umbilicus. The cord had ulcerated to some extent at its base. It was dry and adherent. The cord was cut, and the cautery applied to the surfaces. The child was well on the twenty-second of January.
Case 13.- — A. P., born January 6th. The mother left the hospital on the eighth day in good condition. The child was attacked on the fourth day with an erysipelatous condition at the umbilicus, with ulceration of a serious aspect. Immediate cauterization with zinc paste; recovery by the ninth day.
Case 14. — Charles V., born January 8th. Mother in good condition.
80 THE UMBILICUS AND ITS DISEASES.
The child was attacked on the second day after birth. There was erysipelas, with tumefaction in the umbilical region. On the third day ulceration of a severe nature was noticed in the base of the cord. The wound was cauterized with zinc paste. Convalescence ensued on the seventh day after the beginning of the disease.
Case 15. — -M.S., born January 15th, was attacked on the fourth day with marked ulceration of a severe character. There was a pseudomembrane with elevated margins, and the wound showed an erysipelatous character. It was cauterized on January 20th, and zinc paste applied. The child recovered and was taken to the country on January 27th.
Case 16. — D., born January 21st. He was a fine, healthy child, but on the second day after birth developed an erysipelatous inflammation of the umbilicus. The cord was soft. On January 24th the ulceration involved the skin margins in the umbilical region. The wound was cauterized with zinc paste, and he was convalescent by January 28th.
Meynet said that he could multiply these examples, but that those given were sufficient to show the gravity of the disease. He dwelt upon the efficacy of cauterization with the chlorid of zinc paste.
AN EPIDEMIC OF GANGRENE OF THE UMBILICUS.
Bergeron discusses an epidemic which occurred in the Hospital Necker in 1865. Before taking up the description of his cases he discusses the writings of Hippocrates, Ambroise Pare, Mauriceau, Hamilton, Underwood, Billard, Trousseau, and Meynet. In speaking of his own cases Bergeron regrets the incompleteness of the pathology. In 11 cases he had 9 autopsies which yielded the following results. The portion of the gangrenous skin was black, moist, and situated at a lower level than that of the surrounding normal skin. It was separated from the normal skin by an irregular, slightly reddish zone. Sections through the affected part showed in the center a dry layer, which was easily detachable from the underlying tissue and was held in place by several filaments at its periphery. It was 2 mm. in thickness, and its margins seemed to conceal an underlying part of normal skin. The gangrene was always superficial, and penetrated only through the skin. The vessels surrounding the slough were obliterated, but in no case was phlebitis found in the umbilical veins ox inflammation of the umbilical arteries. One important point was that the peritoneum was always healthy except in one case (Case 3), in which it was injected. These observations differ from those reported by Lorain. In the epidemic in 1865 Bergeron did not observe the second form of the disease noted in the one reported by Meynet.
Symptoms. — Gangrene of the umbilicus in the beginning usually presents a benign aspect, the only sign being a little redness at the umbilicus and at the inguinal folds. Sometimes there are fretfulness, a mild diarrhea, and a slight cough. The infant refuses the breast, and death soon follows, as a rule peacefully, without convulsions, but with marked pallor of the skin everywhere.
The local manifestations present certain special points of interest. The lesion usually appears at the umbilicus before the separation of the cord. There is moderate redness, or more frequently an erysipelatous erythema, which invades usually at the onset the region which is later occupied by the gangrene. By the following day the cellular tissue has become indurated. Later, as a consequence of the mor
UMBILICAL INFECTIONS IN THE NEW-BORN. 81
tification of the skin, there appears in the inguinal fold or in a fold of the skin surrounding the cord a yellowish plaque which has a tendency to extend. It is more or less bright in the center, and moist at the margins. The yellowish color sometimes changes to black in the center, and the black usually extends to the margin of the lesion in the last minutes of life. The skin surrounding this part is of a light violet color for a distance of 1 mm. The violet border follows all the contours of the slough, which is more or less irregular.
In the more favorable cases this violet strip disintegrates. The slough softens, separates at the margins, and comes away in small pieces, but is never detached in a single piece. It leaves behind it a more or less deep ulceration, covered over with granulation tissue, which is sometimes very pale. The depth of the ulcer varies. In certain cases it extends through the entire thickness of the abdominal wall, so that it would appear that the intestine must come out. This, however, does not occur. As a matter of fact, the necrosis is only skin deep. In more severe cases, which are very rapidly fatal, sloughing takes place not only at the umbilicus but also in the inguinal fold. Finally, occasionally sloughs occur over the malleoli, the scapulae, from the ears or from any region where the skin is exposed to continued rubbing or to humidity.
In one of Bergeron's cases there was gangrene of the eyelids which occurred very early. He says that the abdomen was never distended, and, if there was swelling, its point of departure was chiefly in the abdominal wall, not in the cavity of the abdomen itself. The final symptoms were always those of profound weakness. Seeing the children in the last day of the disease, one would have been led to think that they had been ill for a long time.
Diagnosis. — It 'is hardly possible to confound gangrene of the umbilicus with any other affection. The prognosis is always very grave.
Etiology. — Bergeron says that gangrene of the umbilicus was epidemic, and he thinks it possible that the virus of gangrene belongs to the same family as that producing erysipelas, puerperal fever, and analogous conditions. In the beginning of the year 1865 there were in the Hospital Necker 8 cases of puerperal fever with 3 deaths. Several days after, 5 children showed multiple abscesses, and 3 deaths followed. Of the 5 infants, 4 had been with their mothers before the puerperal fever appeared. For the greater part of 1865 the sanitary state of the lying-in ward was excellent; only 4 children had erysipelas of the cord. In the later months of this year, however, 11 were attacked and only 2 recovered.
Case 1 . — Simple Erysipelas of the Umbilicus; Recovery. — The girl was born May 26, 1865. On June 5th the mother noticed a small area of redness around the umbilicus, and the physician found a small round ulcer from which there was a slight suppuration. There was a reddish thickening which extended for several centimeters around the umbilicus. The umbilicus had cicatrized by about the fifteenth of July.
Case 2. — Gangrenous Erysipelas of the Umbilicus. — Gangrene of the skin at various points. Death after fifteen days' illness. The child was born October 23, 1865. The mother nursed the child, but did not have much milk. On November 3d a little redness was noted at the level of the umbilicus. The child was brought to the physician on November 5th. The cord had come away four days before, and at the point of detachment was seen an elevation and some swelling. In the umbilical depression was a sort of yellowish, adherent 7
82 THE UMBILICUS AND ITS DISEASES.
membrane, which in reality was a slough of the superficial portions. The skin was loosened and rolled up at the margins. By the seventh the plaque at the umbilicus had increased in size, and the redness occupied a circle about 2 cm. in diameter. The slough was yellowish, 6 by 3 mm., and arranged transversely. The small patch in the left inguinal region had a yellowish point about the size of a pin-head. The right inguinal region commenced to show a slight erythema. On the ninth the umbilicus was in the same condition, but in the left inguinal region was a yellowish discoloration, about 4 mm. in diameter, and in the right inguinal region a small superficial ulcer without a slough. By the tenth the umbilical lesion had increased, and the epidermis was implicated over an area 3 cm. in diameter. The yellowish slough was 1 cm. in its transverse diameter and 0.5 cm. from above downward. The slough in the left inguinal region had increased, and the area of ulceration of the right inguinal region had a yellow discoloration. By the eleventh the gangrenous ulcer in the right inguinal region had increased in size, and at the lower angle of the scapula on the left side could be noted a redness, in the center of which was a small black point. There was likewise redness behind the right ear. The general condition of the child was not so good, although it continued to nurse. The umbilical slough had not increased, but in its center showed a little black point. By November 15 the child was much weaker. The area of induration at the umbilicus had increased. The slough in the inguinal region had become intensified in color, and the one at the scapula showed a similar change. The small plaques on the ears were brownish and had a gangrenous odor. The child died the same evening. The autopsy showed that the abdominal viscera were normal.
Case 3. — Spontaneous Multiple Gangrenous Erysipelas, Involving the Eyelids. — Female child, born on October 31. Two days later the lids of the left eye were seen to be inflamed and presented a marked yellowish color. On November 5 the conj unctival margins of the eyelids were covered with a false membrane, whitish gray in color. On the eighth, a gangrenous patch was noted at the umbilicus, and a livid redness at the level of the folds of the buttocks. The child died on November 10. At autopsy it was found that the sloughs were superficial. The one at the umbilicus was insignificant.
Case 4. — Gangrenous Erysipelas of the Umbilicus, Multiple Gangrene.- — Female infant, born November 13, 1865. It must be mentioned that a child suffering from a similar affection had slept in the next bed in the same room and had died three days previously. On November 20 the mother brought the child to the physician. The cord had dropped off the day before. The surrounding skin was red. Palpation showed that there was induration, imperfectly outlined and occupying an area around the umbilicus. The epidermis had disappeared from over an area 1 cm. in diameter, and presented whitish or grayish patches, evidently sloughs. The right inguinal region presented a similar aspect. By November 22 the gangrenous plaques had become brownish and commenced to give off an odor of gangrene. The child died on November 22. At autopsy it was found that the slough hardly extended to the bottom of the skin. The umbilical veins were normal. The umbilical arteries had been transformed into hard cords and were surrounded by yellowish, plastic lymph. The peritoneum was not injected.
Case 5 . — Male infant, born October 27, 1865. On the next day a moderate
UMBILICAL INFECTIONS IN THE NEW-BORN. 83
degree of redness was noticed around the umbilicus. By the evening, the redness had increased and had a radius of 2.5 cm. By October 29 the redness had not increased, but the underlying cellular tissue was slightly indurated. In the umbilical fold was noted a yellowish plaque, 3 mm. broad and 5 mm. long. This was moist, and its margins were irregular. By October 30 the redness around the umbilicus had increased. In the inner fold in the groin a reddish plaque the size of a franc was noticed, in the center of which was a yellowish point about the size of a pin-head. The child improved, but was taken away by the mother before it was perfectly well.
Case 6. — Gangrene; Erysipelas of the Umbilicus and of the Inguinal Regions. — ■ Male infant, born November 24, 1865. On November 30, the mother brought the child for examination. The cord was just about ready to drop off. On lifting it with the scissors the examiner found that the tissues were grayish and formed a small elevation where a slough with a gangrenous appearance had formed. There was a slight redness of the skin at the fold of the groin on the right side. The child was well nourished. The umbilicus presented a raised blackish point, and around it was an ulceration and a yellowish depression. At the internal malleolus on the left there was seen a plaque having a yellowish center and reddish margins. The nurse said that this had had the appearance of a boil, and that she had opened it with a needle. The child died on the fifteenth of December. The umbilical ulcer was black and the skin around it greenish.
Case 7. — Spontaneous Gangrene. — A male child, born November 27, 1865, a*t a time when cholera existed in the hospital. On December 2, the child was brought for examination. The cord had not come away completely, but around its base, and attached to the skin, was a blackish point and a noticeable elevation. The blackish area was surrounded by a yellowish circle; there was a diffuse redness, and the skin was indurated. There were no general symptoms, and the child was well nourished. By December 4, the tumor of the umbilicus appeared as a roundish nodule, the size of a franc piece. It had a reddish circumference and was yellowish in other portions. In its center was a small black slough, ready to separate. By December 11, the ulcer had practically healed. The child, however, died on December 12. At autopsy it was found that the ulcer at the umbilicus was insignificant, and that it had never extended beyond the skin. The peritoneum was intact, but adherent over a large area. There was no trace of peritonitis. The child had died of pneumonia.
Case 8. — Multiple. Gangrene. — A female child, two months old, entered the hospital on November 27. About a month before, the mother had noticed a small reddish ulcer in the right inguinal fold. The umbilical cicatrix, which had never completely healed, was also the site of a small ulcer. Two or three days before her entrance the skin in the lower part of the abdomen had become reddened and there was some induration,' as in erysipelas of the umbilicus of the new-born. On her admission, at the umbilicus was a deep fold. At the bottom it was grayish yellow. There was some slight discoloration at other points. The right inguinal fold presented a patch of the same color, about 1 cm. in diameter. The child died on December 1. The umbilical slough had reached a considerable depth. At the bottom, on a level with the umbilical vein, was a small mass of purulent material. The vein itself was perfectly healthy, free, without clots.
84 THE UMBILICUS AND ITS DISEASES.
There was no trace of peritonitis. The iliac vein and arteries were free. The slough in the inguinal region was deeper than that of the umbilicus. The peritoneum was normal.
Case 9 . — Female child, born January 7, 1866. About the fifth day a slight redness was noted at the umbilicus, which extended for a distance of 2 cm. On admission to the hospital it was found that the left eye was the seat of a limpid secretion and contained several yellowish fiocculi. The eyelids were a little swollen, but not red. At the umbilicus there was reddening and a little induration. The cord had probably come away only a few days before. At the site of the umbilical cicatrix, in a fold of the skin, was an ulcer, yellowish at the bottom, and about the size of a hemp-seed. In the left inguinal fold was an ulcer, 1 cm. in diameter, and yellowish at it's bottom. On January 19 it was noted that the umbilical ulcer had increased, and pus was escaping from it. By January 28, the ulcer at the umbilicus had cicatrized, but the one in the inguinal region had made considerable progress. Its margins were marked by a fine black line, and the center was occupied by a dry yellowish plaque. This gangrenous ulcer was limited by the inguinal fold. The anterior surface of the left inguinal fold was red, indurated, and denuded of its epidermis for a distance of 2 cm. In the center was a yellowish crust. The child died on January 31. At autopsy it was found that the sloughs were superficial, and that they had implicated the skin only. The underlying cellular tissue was infiltrated. The peritoneum contained an abundance of fluid with a reddish tinge. There was no false membrane. The intestines were healthy.
Case 10. — A female child, born January 19, 1866. On January 28 a redness was noted at the umbilicus. Poultices were applied, but by the next day the redness had increased. On January 30 an ulcer was noticed at the umbilicus. By February 4 the redness had diminished to the size of a five-franc piece. By the next day the crust had disappeared and there was an area of ulceration 0.5 cm. deep. The general condition was good. By March 1 the child was completely well.
NON-PUERPERAL ERYSIPELAS OF THE NEW-BORN INFANT.
Yot, in his thesis published in 1873, dealt with erysipelas of the new-born and described a number of cases. In a few instances the lesions started at the umbilicus.
Case 6 . — The child was brought into the hospital when it was nine days old with an erysipelas in the subumbilical region. The skin was of a reddish tint, and there was tumefaction of the parts. The inflammation extended to the symphysis and also to the inner parts of the thighs. On the right side it extended to the vertebral column, but on the left it had not gone beyond the fold of the inguinal region. The umbilical cicatrix presented at its center a small surface of ulceration which may have been the point of departure of the erysipelas. From the tenth to the seventeenth day the process ran the usual course. On the seventeenth day an abscess opened in the coccygeal region. By the twenty-eighth day the child was well.
Case 9 . — The child was brought into the hospital when it was five days old. An erysipelatous inflammation covered the entire umbilical region, the lower portion of the abdominal wall, the lumbar region, the scrotum, the penis, the right side of the thigh, and the right leg, except in front. The parts were livid, and the temperature was 38.8° C. The child died on the same day.
UMBILICAL INFECTIONS IN THE NEW-BORN. 85
Case 11. — -A female infant was brought to the hospital when it was twelve days old. The umbilical cicatrix was imperfect and showed a bloody discharge. There was an erysipelatous inflammation over the entire region below the umbilicus to the thighs and legs, and a large part of the anterior portion of the thorax anteriorly. The temperature was 37.8° C; the pulse, 184. The child died the same evening. The umbilical vein was found to be normal. There was no trace of peritonitis. The thymus was enormous, and on incision there escaped a purulent liquid.
Case 13. — A boy, born December 6, 1867, entered the hospital on December 16, 1869, showing erysipelas around the umbilicus and in the suprapubic region. The scrotum, penis, and the inner portions of the thighs and legs were implicated and there was edema of the lower and lateral part of the abdomen. At the umbilicus was an area of sloughing, 20 cm. in diameter, which was blackish in color. Pulse, 144; temperature, 36.6° C. The child died on December 19. A general peritonitis was present. Under the gangrenous area the abdominal wall was adherent to the large intestine, which had likewise become gangrenous.
Case 14. — The infant was ten days old when it was brought to the hospital. She had thrush. There was an erythema and a purulent discharge from the umbilicus. The tissues around the umbilicus were covered with exfoliated epithelium. There were redness and tumefaction below the umbilicus, and to the right and on the anterior surface of the thigh on the right side. The labia majora were tumefied and reddish in color. The erysipelas had apparently started from the umbilicus. The child died on the next day, the temperature being 30.5° C. At autopsy small vegetations were found on the mitral valve. The umbilical vein and arteries were filled with pus, and there were signs of a general peritonitis. The kidneys contained coagulated blood-globules and pus. The calices contained a blackish material resembling coffee-grounds, and the papillae were of a brownish color.
Yot then goes on to consider the nature of — (a) puerperal, (b) traumatic erysipelas. He discusses the symptoms and the complications. He concludes that there are two kinds of erysipelas in the new-born — one puerperal, epidemic, infectious, and fatal in its course, and terminating as puerperal infection in women who have recently been confined; the other he designates as an "inflammation." He says the fatality in this group is nothing in comparison to that in puerperal erysipelas.
RUNGE ON WOUND INFECTIONS OF THE NEW-BORN.
Runge, in his Wound Infections of the New-born" (1893), has given us the best monograph on the subject that we possess. On account of their importance I have given Runge's findings and his interpretations somewhat fully, even at the risk of some repetition, as I am particularly anxious that the reader should be cognizant of his views, although these at times fail to coincide with those of others who have had much experience in the handling of these cases.
The umbilical wound is most frequently the point of entry of infective material. This was proved in 30 out of 36 autopsies. The pathologic lochia contain a pathogenic organism and can lead to very severe wound infection. The carrying of infective material to a wound in the new-born is almost entirely through contact, and infection through the air is, to say the least, doubtful. In the new-born the organisms most frequently found are streptococci and staphylococci (Runge, p. 58).
86 THE UMBILICUS AND ITS DISEASES.
On page 65 he says that the portion of the cord remaining on the child beyond the point of ligature dies and becomes, as it were, a foreign body. A reactive inflammation occurs in the skin of the umbilicus. Death of the. cord is usually by mummification; high temperature and dryness increase mummification. Moisture and exclusion of air hinder the extraction of the water and lead to a moist gangrene. Simultaneously with the mummification there begins an active inflammation at the umbilicus. A few hours after birth the capillary network is found markedly distended and filled. Then the redness spreads over the entire skin umbilicus. This swells, and the distal portion of the umbilical remains takes on a yellowish-white color. Microscopic examination shows emigrating white blood-corpuscles in abundant numbers. They soften the dead tissue, which is gradually loosened and falls off, leaving a granulating surface. The dropping off of the cord takes place, on an average, on the fifth day. In premature and in weak children it usually drops off later, because in such cases the energy of the inflammation is less marked. The amnion first loosens, then usually the arteries, and finally the vein. The granulation surface of the umbilical wound after the cord drops off is frequently at a deeper level than the abdominal wall, because the intraperitoneal portion of the umbilical vessels has contracted. In those cases, however, in which the skin has been carried out for a long distance over the cord, the wound lies above the level of the abdomen and appears as a definite umbilical stump. By retraction of the umbilical vessels there is gradually formed an upper and a lower umbilical fold, i. e., a duplication of the skin covers the deep-lying umbilical wound, and further retraction of the umbilical vessels goes on simultaneously. From the day that the cord drops off the redness and swelling begin to recede, and the healing process ends from the twelfth to the fifteenth day. The umbilical scar is usually covered over with folds of skin. As a result of adhesions of the endothelial surfaces the intra-abdominal portion of the umbilical vein closes and now forms the ligamentum teres. The degree of obliteration of the vein varies greatly. Baumgarten (quoted by Runge) says that the closure is never complete. A thrombosis of the vein is by most authors considered as pathologic.
Runge says that in the arteries the closure is due to the growing together of the arterial walls, especially of the intima. Small thrombotic plugs sometimes exist where the arteries bend in the bladder region.
Mild Disturbances in Healing of the Wound of the Umbilicus. — Runge says (p. 71) that the determination of the line between the healthy and diseased umbilical wound is difficult. The degree of reactive inflammation of the umbilicus depends on various conditions. With the dropping off of very succulent umbilical cords the reaction is more marked than in the case of those that are somewhat dry. In strong children the inflammatory reaction comes on earlier and is more intense; more cells are produced than in the weaker ones, and in the case of the latter the cord drops off later.
Runge quotes Widerhofer, who says that if the umbilical wound begins to be moist, it secretes "mucus" and pus. If the umbilicus takes on the character of a mucous membrane there is produced a condition termed by the authors "blennorrhea of the umbilicus." In these conditions it becomes difficult to determine whether or not the wound is infected. When the umbilical wound increases in area and is covered with a whitish and necrotic layer, and when, in addition, it discharges an abundance of pus or purulent material, there can be no doubt that an
UMBILICAL INFECTIONS IN THE NEW-BORN. 87
extensive local reaction exists and we have an "ulcer of the umbilicus." Ulcer of the umbilicus hardly ever exists if the process remains localized.
In all his autopsies on infants who had umbilical ulcer, Runge found either disease of the vessels of the umbilicus or a peritonitis to account for the death. If neither of these was present, he was able to find some other cause of death independent of the ulcer.
On page 81 he takes up the subject of omphalitis and says that it is characterized not so much by marked inflammation of the umbilicus as by an infiltration of the abdominal wall around it.
Symptoms. — In cases of well-marked omphalitis the umbilical region is markedly reddened and the umbilicus projects conically outward. The area is rarely cicatrized, but usually appears as a wound or a discolored ulcer. The redness and the inflammation extend beyond the raised portion and form a circle around it. The skin is tense and glistening; the folds have disappeared. On palpation a hard infiltration of the abdominal wall can be felt, and examination gives rise to a great deal of pain. The extent of the infiltration varies. It may be limited to the immediate vicinity of the umbilicus, or the greater portion of the abdominal wall may be implicated. It may extend deep down and take in the entire thickness of the abdominal wall as far as the peritoneum.
In every case of marked omphalitis the general condition of the child is affected. It is restless, does not take its nourishment, and has fever. There is pain with every movement of the body. The legs are stiff and drawn up on the lower abdomen. The breathing is costal in type. The markedly engorged and dilated veins of the stomach region sometimes appear as thick, bluish strings seen through the skin. The duration of the disease depends on its intensity. It may last several days or many weeks.
Healing is the rule where the phlegmon is small. The exudate is absorbed, the umbilical wound cicatrizes, or there may be several small abscesses which break outward and discharge a few drops of pus. Healing then takes place in a few days. If inflammation is associated with the phlegmon, it extends far out in the abdominal wall and healing is much less likely to occur. The most favorable outcome is obtained when there is rapid abscess formation before the infant has been prostrated by the fever. If the inflammation extends markedly inward, death from peritonitis is likely to follow. If an involvement of the umbilical vessels is found at autopsy, a general sepsis has existed. Another unfavorable termination is in gangrene. This is more apt to occur in weak children.
From the foregoing it is seen that all cases of wide-spread omphalitis are to be considered as dangerous to life. The younger the child, the more unfavorable the prognosis. Breast-fed children have a better chance than bottle children. Children suffering from some congenital cachexia — syphilis, scrofula — and children of tuberculous parents are predisposed to this disease.
Gangrene of the Umbilicus. — Runge, on page 84, says that gangrene may be the consequence of a pathologic umbilical wound, an ulcer, or of an omphalitis; or it may develop in cases of severe general infection. Gangrene as a localized infection of the umbilicus does not appear to be very frequent. Many authors, particularly Wiclerhofer, say that it develops from a severe omphalitis. Ill-nourished children and those born prematurely show a tendency toward the development of local gangrene. Severe diseases of the umbilicus, such as gangrene, which were of frequent
88 THE UMBILICUS AND ITS DISEASES.
occurrence formerly, especially in foundling hospitals, have recently diminished greatly. Fiirth, in the Vienna Foundling Hospital, before antiseptic days saw 191 infants suffering from gangrene of the umbilicus, and 169 of this number died.
Symptoms. — The wall of an inflammatory umbilical wound becomes discolored, breaks down, and shows more or less loss of substance; or there develops, especially as a result of an omphalitis, a blister with cloudy contents. This ruptures and a defect is produced. An area of moist gangrene then appears and extends rapidly, sometimes superficially, sometimes penetrating deeply. The cases in which the process goes inward are much more dangerous. The gangrenous area is surrounded by bright reddening of the skin and reactive inflammation. Gradually the gangrenous portion becomes loosened. It emits a fetid odor. Usually the fever is not high, but rapid collapse is unfortunately the rule. Where the child's constitution is good and the morbid process is not wide-spread, healing takes place at this stage, the reactive inflammation producing pus, which throws off the dead portion, a defect of greater or lesser extent being left, which heals by granulation. If the child's strength has been overtaxed, it dies before the loosening of the gangrenous area can occur. The average duration of the disease in fatal cases, according to Fiirth, was 5.64 days. In several cases death took place on the second day. "When the child recovered, the duration of the disease at the minimum was twelve, at the maximum thirty-seven days. Again, the gangrenous process may spread, and in certain cases reported two-thirds of the abdominal wall was implicated. Where the gangrene involves the whole thickness of the abdominal wall, intestinal loops may become adherent and perforate, with a resulting peritonitis or a fecal fistula. Gangrene may lead to general sepsis, in which either the peritoneum is directly involved or the septic material gains entrance through the umbilical vessels to the general system.
Much more frequently there is a second kind of gangrene affecting the umbilicus, which appears to be the result of general sepsis. According to Widerhofer, there is a gangrene which follows cholera infantum. In these cases a localized necrosis occurs, and gangrene is also found in other portions of the body, this condition being produced by emboli. This gangrene is characterized by its rapid development and the complete absence of reactive inflammation.
Often in the course of a few hours the gangrenous area reaches the size of a dollar. It is remarkable that this gangrene occurs not only in the first days of life, but also in well-nourished children several months old. Widerhofer observed secondary gangrene of the umbilicus in children suffering from cholera, in the foundling hospital in Vienna, 63 times within four years. In each case death occurred very quickly. The prognosis in cases of gangrene of the umbilicus, accompanied by cholera and sepsis, is absolutely fatal. Even in those of localized gangrene the outcome is doubtful and depends upon the resistance of the child. The absence of inflammatory reddening is proof positive of a fatal outcome.
Diseases of the Umbilical Vessels. Runge says (p. 88) that where infection of the umbilical vessels exists, the disease first starts in the perivascular connective tissue, which becomes infiltrated with a serous fluid and shows evidences of edema. Often the process extends to the adventitia, and the vessel itself is involved. The inflammatory infiltration of the
UMBILICAL INFECTIONS IN THE NEW-BORN. 89
vessel-wall causes a paresis of the muscularis and a dilatation of the vessels, or gives rise to a thrombus which soon breaks clown. Runge regards the thrombus and its disintegration as a secondary manifestation. He draws special attention to the fact that the arteritis and phlebitis invariably start with an inflammation in the outer coats of the vessels.
He then quotes various authors who had made experiments, with results agreeing with those obtained from his own autopsies. In 55 cases from the obstetric clinic of the Charite Hospital in Berlin, in which autopsies were made on children dying of diseases of the umbilicus, Runge found arteritis in 54 cases — 22 times in combination with pneumonia, 16 times with other evident septic complications. Only once could he determine a phlebitis, and in this instance it was associated with a very intense arteritis. As a result of these observations Runge concludes that of all the fatal diseases of the umbilicus, arteritis is the most frequent and most important. He says that this view as to the great fatality in infants from arteritis as compared with phlebitis has been corroborated by the more recent observations of Epstein, Monti, Birch-Hirschfeld, and of Lomer.
[Careful study of the various epidemics leads one to conclude that in some epidemics the arteries are more frequently involved, in others, the veins. — T. S. C:]
On opening the abdomen and throwing outward the right abdominal wall Runge found that the diseased arteries were to be seen as thick, tense, usually slightly brownish-tinged cprds, with marked thickening and development of the vessels of the adventitia, and that there were also an edema and infiltration of the surrounding connective tissue. In several cases the arteries were implicated for their entire length from the umbilicus to the bladder.
Runge says that frequently remnants of the umbilical cord, after dropping off, leave the umbilical wound covered with crusts and changed into an irregular ulcer with bays running off from it. In other cases, on the contrary, the wound shows a perfectly normal appearance; in fact, it may have completely healed and yet an intense arteritis may still exist. If the remnant of the umbilical cord is still intact, it is usually completely mummified. In other cases the cord gives out a very foul odor. After the softening of the crust from the wound, one occasionally can see the gaping umbilical arteries and note that they are filled with pus or friable material. If an incision is made through the umbilical wound, it is sometimes possible to see with the naked eye that the infiltration at its base extends directly into the diseased perivascular connective tissue; and when the vessels are incised transversely, there is an escape of yellowish-green pus from them, or they contain a friable, cheesy material mixed with blood. The surrounding connective tissue often presents a glistening appearance.
An incision in the long axis of the arteries, that is, from the umbilicus toward the bladder, indicates the degree of extension of the pus, which usually is associated with an infiltration of the surrounding connective tissue. Occasionally, at the far end of the accumulation of pus in one of the arteries, a reddish-colored thrombus is found attached to the vessel-wall. The intima of the artery is cloudy; it has lost its brilliancy, and there may be numerous unevennesses, due to loss of substance in the vessel-wall. The dilatation of the arteries bears no relation to the intensity of the inflammation in the perivascular tissue. On the contrary, the inflammation
90 THE UMBILICUS AND ITS DISEASES.
of the connective tissue may be enormous, and yet the lumen of the vessel may be hardly large enough to admit the passage of a probe.
Sometimes the dilatation of the vessels is marked throughout their entire course ; or again, at certain points, sac-like dilatations occur in which an abundance of pus and caseous masses are found. In no case of phlegmonous infiltration, however, was he able to follow the vessel as far as the bladder. The extraperitoneal connective tissue and iliac arteries were always free.
Pneumonia is the most frequent complication. Runge says that in 55 cases of arteritis it was present 22 times. This occurred in two forms, either as a lobar pneumonia, often complicated with a fibrinous, serofibrinous, or purulent pleurisy; or there were numerous pea-sized and bean-sized foci scattered throughout the lung. Where these reached the surface, there was an accompanying circumscribed pleurisy.
Runge found hyperplasia of the spleen with marked softening of the tissue, cloudy swelling of the liver, parenchymatous nephritis, serofibrinous or seropurulent peritonitis, joint affections, periostitis, and finally phlegmonous inflammation of the subcutaneous connective tissue, with or without pus formation.
Erysipelas, when observed as a complication, usually extends from the umbilical wound outward; nevertheless, Runge says, it may be primary in the face or in other portions of the body.
Very frequently the bodies show a slight degree of jaundice, especially when the death occurs between the fourth and sixth days, although no direct connection between the arteritis and the jaundice can be traced. In such a case one is dealing with the so-called physiologic icterus of the new-born. When, as happens more rarely, there is an intense icterus, the complication is to be attributed to a parenchymatous hepatitis. Runge says that very frequently the lungs show partial atelectasis.
Bacteriologic investigations in cases of umbilical arteritis have been rare. Runge drew attention to those of Baginsky, Meyer, and Babes. The most frequent cause of the infection was found to be a streptococcus. In a case described by Baginsky Streptococcus pyogenes was found in the internal organs and there was a pyemia as a result of inflammation of the umbilical arteries.
Runge gives a table of 55 cases in which an autopsy was performed and an anatomic diagnosis of umbilical arteritis was made (p. 95). These 55 cases of umbilical arteritis were taken from a group of 340 autopsies. This means that 16.1 per cent, of the children who came to autopsy in the gynecologic clinic of the Charite Hospital in Berlin, from 1879 to 1882, showed inflammation of the umbilical arteries. From his table it is seen that in 9 cases arteritis only was found. This was undoubtedly the cause of the death. In 16 cases there were complications (syphilis, etc.) which apparently bore no relation to the arteritis.
In this group were 8 cases in which the complication, for example, hemorrhage of the brain, had been definitely the cause of death, and the arteritis in 5 cases was not marked. In 30 cases, however, there were complications which undoubtedly were dependent upon the arteritis. In 16 cases these were of a septic nature. In one case, in addition to the arteritis, there was an abscess of the vein in its lower portion.
These anatomic results are in opposition to the findings of Buhl, according to whom, in cases of arteritis, the secondary changes were found in the abdominal
UMBILICAL INFECTIONS IN THE NEW-BORN. 91
cavity. Widerhofer and P. Mtiller emphasize the frequency of peritonitis. This complication Runge found only 5 times — in 9 per cent, of the cases. He never found a perforation into the abdominal cavity from the diseased vessels, as described by Bednar.
The pathogenesis is taken up on page 101. From the pathologic findings there can be no doubt that umbilical arteritis is a wound infection which has its point of origin in the umbilical wound and which gives rise to a general sepsis. Buhl explains the unfavorable effect produced by puerperal infection upon the umbilicus and upon the changes in the vessel-walls which had already existed in the intra-uterine life. Runge, in discussing the possibility of the transference of septic material through the placenta, draws attention to the fact that in the cases of 24 patients there was not a mother who during pregnancy or during or after labor had had any septic phenomena, and in the remaining cases only now and then had such symptoms been noted.
Symptoms. — A characteristic symptomatology is wanting (Runge) . We have no clinical picture from which we can make the diagnosis in the living child. Usually the death is unexpected. The child appears perfectly normal. Suddenly it becomes restless, refuses nourishment, collapses, and dies. An accident may be thought of. The autopsy shows arteritis. In every case, however, the umbilical wound showed some inflammation; usually it was covered with pus, although the general condition of the child was not changed. Then there were sudden restlessness, crying, collapse, and death. Since most of these cases occur in groups, the diagnosis was finally reached without any special difficulty.
More rarely the course of the disease is prolonged. In these cases the indications of a severe general infection nearly always become evident. The children have fever, loss of weight, increasing weakness, and symptoms of collapse. That the severe symptoms are due to disease of the umbilical vessels there is at times no evidence, especially if, as is frequently the case, the umbilical wound shows little or no inflammation or has healed completely. If, on the other hand, an ulcer of the umbilicus is present, a diagnosis of a general infection due to an extension of the umbilical disease is readily made. In all cases, nevertheless, where there is disease of the umbilicus, the danger of inflammation of the arteries exists. The diseased organs do not always present the characteristic picture. A lobar pneumonia is easily recognized by percussion and auscultation. Small disseminated foci, however, Runge was never able to diagnose. Where marked distention and pain of the abdomen are noted, peritonitis is probable, but, according to Runge's experience, in the first days of life this is not easy to diagnose. Marked icterus indicates hepatitis, which may, however, prove to be not serious. From Runge's table it is seen that the eldest child dying of arteritis was eighteen days old, the youngest, four days. The largest number of deaths occurred on the eighth day.
Prognosis. — No positive data can be given. In the case of premature children, the outlook is very grave. Of the 55 children autopsied, 21 had been born prematurely. In 50 cases in which inflammation of the umbilical arteries was found, 21 (42 per cent) of the infants were premature. Runge says that premature children who develop arteritis nearly always die; in the case of a child born at term, the possibility of recovery exists.
Etiology. — Runge says that contact of the umbilical wound with septic material, but not necessarily only after the cord has come away, may be the cause
92 THE UMBILICUS AND ITS DISEASES.
of the disease. The most virulent infection seen by Runge was in a case in which the cord had not yet been completely loosened. The infection has always been most prevalent in lying-in hospitals and foundling institutions, and has occurred in groups, whereas in private practice it is rare. Runge also draws attention to the fact that it was often associated with an epidemic of puerperal fever, but maintains that there may be an epidemic of inflammation of the umbilical vessels entirely independent of any puerperal infection. He had observed such an epidemic in the obstetric department of the Strassburg Hospital, in 1876, and in the obstetrical department of the Charite Hospital in 1880. In both instances the health of the mothers was splendid.
Prophylaxis. — Absolute cleanliness is essential. If arteritis is once established, little or nothing can be done.
In discussing inflammation of the umbilical vein Runge says that Bednar and Widerhofer consider phlebitis the more important and more frequent disease, whereas recent authors, such as Epstein, Birch-Hirschfeld, and others, dwell upon the preponderance of arterial infection. Birch-Hirschfeld, in 60 autopsies of septic infection which had extended from the umbilicus, found phlebitis 11 times, in 4 instances a simple thrombus of the vein; whereas in 32 cases the arteries alone, and in 3 cases both arteries and vein, were simultaneously affected. In all his autopsies Runge met with phlebitis only twice without arteritis; he regards phlebitis of the umbilical vessels as a much rarer affection.
Autopsies in which inflammation of the veins was found . — Runge says that the condition is usually similar to that found where arteritis exists. The perivascular connective tissue is edematous, the adventitia thickened, and the vessel tortuous; there are punctiform hemorrhages. On transverse section of the vessel, pus, bloody pus, or pus-like masses escape from the lumen. The longitudinal section of the vessel shows an extension of the disease into the inner surface. The intima is cloudy; in places it has been destroyed, and there are deep ulcers which have eaten out large areas of the vessel-wall. The disease extends usually along the entire length of the vein from the umbilicus to the liver, which may itself be implicated. According to Widerhofer, Glisson's capsule alone may be implicated; or the portal vein and its branches may show changes similar to those noted in the umbilical vein. Most writers on phlebitis draw attention to the fact that the perivascular tissue is first involved, and that the vessels are invaded secondarily. A general septic condition is the rule, and peritonitis and parenchymatous hepatitis are very frequent.
Symptoms. — Runge mentions fever and icterus, and agrees with Widerhofer that inspiration is short, expiration is prolonged, and the breathing more rapid than normal. The movements of the thorax are scarcely detectable. The abdominal musculature is nearly always contracted. The abdomen, particularly in the upper portion, is distended. Pressure in the region of the umbilical vein causes pain, which accounts for the drawing up of the legs. The child is restless, but more or less toxic.
In conclusion (p. 116), Runge gives a full bibliography on diseases of the umbilical vessels.
Erysipelas in the first days of life . — Runge (p. 158) says that in the earlier days erysipelas of the new-born was wrongly included with puerperal
UMBILICAL INFECTIONS IN THE NEW-BORN. 93
infection of the new-born, and that some of the cases of septic erj'thema were classed as instances of erysipelas. Clinically, there are two forms of erysipelas in the newborn. One of them is a true erysipelas. In the table of children dying from umbilical arteritis, erysipelas was noted twice — once on the abdomen and once on the face. According to Gusserow, the course of such a double infection — erysipelas associated with septic inflammation — is always fatal. The second form of erysipelas attacks children that have heretofore been healthy. The infection spreads partly from the umbilical wound and partly from some slight injury of the genitals. Erysipelas in the new-born almost always causes death.
SEPTIC PYEMIA AND INFECTION OF THE UMBILICUS OF THE NEW-BORN.
Cohn, writing in 1896, says that although these diseases are not so common as formerly, they are not rare. He then goes on to report two interesting cases:
Case 1. — Umbilical Phlebitis; Phlegmon of the Forearm; Spontaneous Rupture of the Purulent Phlegmon Through the Umbilicus; Recover 3'. — A. S. was brought to the clinic when fourteen days old. On the second day the umbilical cord had been tied for a second time by the midwife because it was thought to be too large. On the fourth day it came away during the bath. About the thirteenth day the mother noticed that the left hand of the child was red and swollen. Local applications were made, but the swelling did not diminish. By the afternoon it had reached to the forearm, and by evening to the elbow, and early the next day up the arm. The child had fever, was very restless, and cried a great deal, especially on being disturbed. On admission it was found that the umbilicus was drawn in and in the depression was some slight secretion. The forearm was markedly reddened and swollen, and any movement caused great pain. Swelling and fluctuation were noticeable in the neighborhood of the wrist-joint. The back of the hand was edematous and swollen. At operation not much pus was evacuated, but the tissue of the forearm showed infiltration, which reached to the hand, so that it was necessary to lay open the musculature of the thumb and of the ball of the little finger. Further operations were subsequently necessary. Later on the mother noticed to her surprise that the umbilicus was fully a "segment of a finger" high, and that it was bluish red; that there was swelling for at least 5 cm. in the neighborhood of the umbilicus, and that it was edematous and painful. Pressure caused a discharge from the umbilicus of a thin, fluid pus. Following the introduction of a probe the escape of pus was much more free. The probe could be carried upward 4 cm. and beneath the abdominal muscles. From the mother it was now learned that the umbilicus had up to this time always shown a little purulent discharge. At the end of a year the child was well and the umbilicus was well drawn in.
Case 2 . — Umbilical Phlebitis; Phlegmonous Erysipelas; Suppurative Peritonitis; Death. — Paul B. The cord came away on the fifth day, but as a piece, 2 cm. long, remained attached to the abdomen, it was tied off by the midwife with a white thread. After this the wound is said to have suppurated for about six days and then remained dry. Five days later, over the ankle-joint of the left leg definite swelling and redness were noted. Two days later redness was noted on the right leg; still two clays later the scrotum and the surrounding parts were swollen, and it was with difficulty that the
94 THE UMBILICUS AND ITS DISEASES.
child could urinate. On the following day it was found necessary to open the left ankle. The redness and swelling over the back and the extremities had extended. Four days later vomiting began. The abdomen was distended, being as hard as a board. The abdominal walls were glistening, and the veins were markedly distended. Any movement of the body occasioned pain. The umbilicus was closed, dry, and not prominent. The buttocks were covered with an erysipelatous inflammation, chiefly noticeable along its advancing margin. This extended to the nipple line and nearly to the scapula. Along the lower border of the scrotum was an ulceration the size of a five-pfennig piece, covered with yellow, smeary material. The child died.
At the autopsy, which was performed the same day, the umbilical wound was found healed. There was edema of the abdominal wall. The peritoneum was thickened and showed a purulent inflammation. When the abdominal cavity was opened, there escaped a yellowish, clear fluid, which contained white flocculi, seropurulent in character. From a quarter to half a liter of fluid lay between the distended intestinal loops. The umbilical vein was found markedly distended, especially in the neighborhood of the liver, where it was almost as thick as the little finger. It contained yellow pus. The purulent contents of the vein could be followed to the portal vein, and on section to the liver. Pus escaped from a large branch of the portal vein. The liver was enlarged and showed cloudiness. Cocci in chains were detected.
Cohn then refers to several other epidemics, and quotes Epstein, who wrote in 1888 from the Foundling Asylum in Prague. This author says that the mortality was 30 per cent in preantiseptic days, and that it had dropped to 5 per cent, but that, from January, 1887, to April 30, 1888, out of 116 children that had died from a total of 1816 that had been received, in not less than 36 (31 per cent) the histologic diagnoses showed that the sepsis had started as an inflammatory infection of the umbilicus and of the umbilical vessels. Miller, quoted also by Cohn, found that in the Moscow Foundling House from about 6 to 8 per cent of the children died of a purulent process, the great majority of these septic infections emanating from the umbilicus. From the Innsbruck Clinic, Ehrendorfer reported 1764 cases occurring from May 5, 1888, to the end of April, 1892. Of these infants, 95 died and 81 came to autopsy. Of this number, 16 — about 20 per cent of the cases that came to autopsy — showed infection of the umbilical arteries or veins.
Eross, also quoted by Cohn, found that, out of 1000 infants born in the Obstetric Clinic in Budapest, in over 320 (32 per cent) the mummification of the umbilicus took place normally. In 680 (68 per cent) there were not only deviations from the normal, but often marked pathologic changes at the umbilicus, such as inflammation and the formation of ulcers. Routine temperature observations further demonstrated that, of the 680 infants, 220 had a rise of temperature, and 5 of these died during their stay in the clinic.
Cohn speaks of the use of alum, of tannin, and of sugar, and comes to the conclusion, as a result of various investigations, that it is wiser to avoid bathing the child after the first day, until the cord has come away. He speaks of treating the cord by the dry method, not even allowing it to be exposed to the air.
UMBILICAL INFECTIONS IN THE NEW-BORN. 95
UMBILICAL SEPSIS IN THE NEW-BORN OCCURRING AT THE NURSERY AND CHILD'S HOSPITAL, NEW YORK, DURING 1896.
S. W. Lambert, in his interesting description of an epidemic occurring in New York, says that the obstetric department of the Nursery and Child's Hospital lost five babies from umbilical sepsis during 1896. The epidemic occurred in July, August, and September. During the three months there were 40 children born, and of these, only 4 remained free from fever; the remainder developed a temperature of 100° F. or over. The real epidemic was characterized by a peculiar skin eruption and was coincident with the delivery in the ward of a woman who became very ill with a virulent sepsis from which she died. I shall briefly outline the fatal cases.
Case 1 . — The child lost weight from the date of birth to the fifth day and died on the twenty-second day. In this case the right foot became swollen and the heel and toes gangrenous. At autopsy the umbilicus appeared to be normal, but in the umbilical vein there was a fusiform clot, three inches in length, also small clots in the arteries, and beneath them small collections of pus in the tissues. Cultures from the pus in the tissues gave staphylococci.
C a s e 2 . • — This child was born after a dry labor of fifty-eight hours, lost 17 ounces in three days, and died on the twentieth day. At autopsy, the umbilical vein appeared normal, but the right hypogastric artery was swollen and reddish for three-fourths of an inch from the umbilicus. On manipulation grayish-brown, grumous pus escaped from the umbilicus. A probe was readily introduced into the artery. The pus yielded pure cultures of Staphylococcus aureus and albus. The cord was still adherent.
Case 3 . — *The infant had lost 14 ounces in weight by the fourth day, and was jaundiced during the first week. At autopsy there was noted a fusiform swelling of the right hypogastric artery just below the umbilicus. This contained bloody pus. The left artery and the umbilical vein were normal. The cord was attached to the umbilicus, and at its base was an excoriation extending an inch in each direction. No cultures were made.
Case 4 . — The labor was normal. The child had lost 12 ounces by the fourth day and died on the twelfth day. A pemphigoid eruption was noted on the neck on the fourth day, and spread rapidly over the shoulders. The cord came away on the sixth day. At autopsy the umbilicus, when opened, was found to contain a discolored, yellow, liquid mass, which seemed to extend through into the artery and vein.
Case 5 . — The cord came away on the tenth day. The umbilicus contained pus. There was no autopsy.
TETANUS IN THE NEW-BORN.
Prior to the aseptic treatment of the cord, children often developed tetanus through the umbilicus. The cases usually occurred singly, but now and then there was an epidemic with a high mortality. At the present time umbilical infection with this organism is rare, except in countries in which the natives have no medical attention and are accustomed to treat the cord in a very crude and primitive fashion.
Runge's description of the symptoms of tetanus in the new-born is so lucid that I will quote it in detail:
On page 145 he says: "In this vicinity it is not frequent, in fact in the obstetric
96 THE UMBILICUS AND ITS DISEASES.
institutions, since the introduction of antisepsis, it has become very rare. On the other hand, in some places tetanus is endemic. The new-born in the tropics, and especially children of the colored races, are frequently attacked by it. The probability is that this infection is due to a lack of cleanliness." On page 148 he says that, within two years, according to Keber, in the practice of one midwife who cared for 308 infants, 99 died of tetanus. This was in the years 1863 to 1865.
Symptoms. — "The trouble manifests itself suddenly. The lower jaw remains stiff, and is kept only a short distance from the upper. The muscles are so strongly contracted that it is impossible to open the mouth. At the same time there is a change in the countenance. The forehead is markedly furrowed, the space between the lids smaller, the lips are pressed together and often drawn up in a snout-like fashion, showing radiating folds. There is marked drawing together of the musculature of the back, bringing the head backward and producing an opisthotonos. Owing to contraction of the abdominal muscles the abdomen becomes as hard as a board, and is usually deeply drawn in. The extremities are affected also by the contraction, but to a less extent. The arms are drawn up, the hands clenched to form fists. The legs are stretched, the toes abducted. In wellmarked cases the body is as stiff as an iron plank (Soltmann) . One can grasp the child and lift it up as one would lift a statue. The commencement of the tetanic convulsion, especially where the disease is advanced, may be brought about by any disturbance of the child, by an attempt at nursing, by a change in its position, or by a strong current of air. Later the intervals between attacks become shorter and shorter, and finally the contraction is continuous.
"The respiratory muscles are usually not markedly involved at first. As the disease progresses, however, dyspnea develops; the child becomes cyanotic, and, owing to contraction of the muscles of the throat, swallowing becomes impossible. The laryngeal muscles are often affected, so that the cries of the child are interrupted or it cannot give any vocal evidence of its great pain.
"The pulse-rate is usually increased, from 160 to 200; the temperature is elevated, and may reach 41° to 42° C. Defecation and urination are only rarely much disturbed. The course of the disease is usually unfavorable. The attacks increase in number, and finally the intermissions between them become very short. A severe grade of cyanosis supervenes, and as a result of the impossibility to take nourishment there is marked emaciation. Death may take place on the first or second day, but it usually occurs between the fifth and sixth days. Recovery is rare. In favorable cases the attacks gradually diminish in strength and in duration. Occasionally bones are broken, muscles are torn, and paralysis of individual muscles occurs."
After reading the records of the appalling epidemics of fatal umbilical infections that occurred from the earliest days of medicine up to the era of asepsis, one instinctively turns back to those two modest scientific investigators, Louis Pasteur and Joseph Lister. More than any others, these two have been the direct means of saving the lives of thousands upon thousands of new-born babes, and have in a large measure removed the nightmare of childbed fever.
The above detailed report of the records of so many epidemics may seem somewhat superfluous, in view of the fact that in the future we shall, fortunately, have
UMBILICAL INFECTIONS IN THE NEW-BORN. 97
little to fear from this quarter. Such reports, however, will serve to emphasize the powerlessness of the older physicians in the face of such emergencies. Moreover, it is clearly evident that even at the present time an insidious umbilical infection occasionally exists and that it may lead to the child's death, before the original focus of infection has ever been suspected. In every instance of illness in a new-born infant it should always be the rule to inspect and, if necessary, reinspect the navel.
TREATMENT OF THE UMBILICAL CORD.
This subject is dealt with so fully and satisfactorily in the text-books on obstetrics that it would be superfluous to discuss it in any detail. It will not be out of place, however, to consider a very interesting paper by R. L. Dickinson,* entitled, "Is a Sloughing Process at the Child's Navel Consistent with Asepsis in Childbed?" Although the article was published in 1899, it has not received the attention it merits. "This paper is a plea for the application, in amputating the cord, of the surgical principles that govern other amputations. The following principles are directly opposed to the prevailing practice, but would seem to bear upon the matter:
" (1) Mass ligature should be avoided. Hemorrhage follows the present method occasionally, because shrinkage of the gelatin loosens the seizure. Ligatures belong on bared vessels.
" (2) A hernial opening should not be closed by a granulation scar. Primary union is readily substituted.
" (3) If the location of the future line of demarcation is known, removal should be practised at or beyond that point. In the case of the funis, one knows where the line of separation is to be.
" (4) That form of operation should be chosen which will do away with sloughing or pus production. Prevention of suppuration, of putrefaction in the stump, and of systemic infection has been attempted by means of numberless devices and dressings, spread through a voluminous literature of failure. Removal alone is prevention. The obstetric nurse will then no longer go from a pus dressing on the baby's abdomen to the fissured nipple, the perineal wound, the catheter, or, in small maternities, to the vulva of the woman in labor.
"And, conversely, septic maternal discharges will cease to endanger the child's open wound.
"To frankly sever the cord at the skin margin, with ligature of the vessels or suture, one or both, brings about safe, clean, prompt healing. Even the pressure of a pad and an adhesive strap may suffice. Thereby the navel of the second day looks like the navel of the tenth or fifteenth day under other methods. After succeeding with many cases of complete primary amputation, the writer found that Flagg had recently published the method in part."
Dickinson then gives a most painstaking and thorough review of the literature, draws attention to the large number of children that die of a sepsis starting from the umbilicus, when the family physician, even after the death of the child, is totally unaware that the infection commenced in the umbilicus or that the death was due to sepsis.
- Dickinson, R. L.: Amer. Jour. Obstet., 1899, xl, 14.
THE UMBILICUS AND ITS DISEASES.
He then describes his mode of amputating the cord: "Elaborate detail concerning the various methods classified above is hardly necessary. A typical example of each class may be given :
"Preliminaries to All Three Methods.— As the child's trunk makes its exit, a sterile or clean towel is so applied to the abdomen that the cord and the umbilical region make no contacts once outside the grasp of the vulvar ring. The trunk is wrapped in the towel as the baby is laid down or resuscitated. As soon as pulsation grows feeble, the cord is clamped beyond the towel between two Keith forceps and cut. Artery clamps have an insufficient bite for large cords. The child is laid aside until the placental stage is completed and the perineum has received attention.
"The material is prepared. The choice of method is made, and now the child is laid on a table. A towel is wound about its arms, and another about its legs, to keep it quiet and to insure a clean field. The towel is unwrapped from about the abdomen. The nurse draws the cord out by the forceps that has been placed six
Fig. 62. — (After Dickinson.)
Fig. 1. — The scissors free the cord from the skin, and then push up the sheath and the jelly.
Fig. 2. — The trousers-leg slipped upward with the gelatin, exposing the vessels. The ligature is placed as low as possible.
Fig. 3. — After ligature and cutting away.
Fig. 4. — The stump rolls in at once.
Fig. 63. — Method of Teeating the Umbilical Stump at Birth. (After Dickinson.)
Fig. 5. — Removal of cord at one snip of the scissors, the fingers holding the stump, as shown in the next cut.
Fig. 6. — The fingers still hold the stump while suturing.
Fig. 7. — One form of suture.
Fig 8. — A suture ligature.
or eight inches away from the navel. Her hands need not be safe, but the operator's are prepared as for an operation.
"A. Simple Ligature. — With blunt-pointed scissors snip all around the skin margin, avoiding the place where the vein shows near the surface (Figs. 62 and 63) . At this place it is not always easy to cut the sheath without opening the vein. The sheath and gelatin are stripped backward with as much jelly as possible. The vessels thus span the gap, standing alone. A fine silk or catgut ligature, around all three or about the vein alone, is placed. The ends of the vessels are cut short, and the cord is off. The stump tends to roll inward. No antiseptic solution should have been used unless one has ground for fearing gonococcus infection. No powder is to be used. A dry gauze pad under the binder suffices. Scissors, ligature material, and one or two forceps are needed, besides the gauze for sponge or dressing. Fine silk cuts itself out, the end of the tied vessel seeming to reorganize. This method is much more sure to control bleeding than mass ligature of a cord.
"B. Suture. — The cord is drawn upward by the nurse as before. The cuff of the skin is caught between the palmar surfaces of the left thumb and index
UMBILICAL INFECTIONS IN THE NEW-BORN. 99
finger, and one closure of the scissor-blades severs the cord through the capillary ring (Fig. 63). A reflux of blood comes from the cord. Without letting go with the left hand, an artery clamp pulls the vessels up ; the needle is taken up in the right hand, and a simple continuous stitch is run across and its ends are tied together; or a subcuticular (Kendal-Frank) is put in place. If it is desired to ligate as well as to sew with the same silk, one loop of the stitch sweeps around the arteries and the other about the vein. Superficial bites may be taken in order that the little stitch of fine silk will cut itself out.
"Capillary oozing, or a few drops from the vein, are arrested by a little pressure from a plain sterile gauze dressing under a binder. Scissors, a sharp cutting needle to penetrate rather tough skin, fine black silk, gauze, and artery forceps are needed. The timid may place the stitch or stitches before cutting at all, as Dr. George R. Fowler suggested to the writer.
" Objections to Complete Primary Amputation. — (1) Increased danger of contact-infection, owing to operation on parts supplied with lymphatics, as compared with the ordinary ligation of vessels and jelly on parts having no nutrient capillaries or absorbents.
" (2) Lack of drainage in case of infection.
" (3) Danger of concealed secondary hemorrhage (hematoma) after the suturing method.
" (4) Inaccessibility of vessel-ends in case of bleeding, as compared with facile placing of second ligature where stump is long.
" (5) Tharisk of striking an umbilical hernia.
" (6) As this is surgery, it is not yet adapted to the general practitioner, and to the midwife only the pressure method can be trusted, if that method proves safe.
"To admit most of these objections is to confess that we, as instructors and surgeons, fail in our attempt to drill the student in hand cleaning and instrument boiling and avoidance of unclean contacts, and that, as to this generation of general practitioners, we give them up. Our method requires hands no cleaner than for a vaginal examination, and far less wound knowledge than for the repair of that perineal injury which zigzags through fascial and muscular planes, their anatomy disguised by stretching and edema.
"Even in the matter of secondary hemorrhage not controllable by pressure, any one can roll open a superficial wound, draw up its center with an artery forcep, and seize and ligate an oozing vessel end. A hernia at birth calls for closure of the canal by sutures in any case. Hernia is exceedingly rare at this time (Tarnier and Budin) , though common enough a month or two later.
" After-care. — A small square of plain gauze lies on the wound and may become adherent to it. Over this a larger dressing is placed, and a moderately snug binder is pinned or sewed on. As with any other clean wound, the dressing must not be changed except for cause. The baby is not tubbed for a week until union is secure.
"The first washing immediately after the operation has been just sufficient to get rid of any vernix caseosa that is present, and during the week no general washing is needed.
"Flagg speaks of his case healing under a scab. This is produced by the dermatol. It is better to permit drainage. Sanious oozing, as from any fresh wound, usually occurs. In some instances, on rolling the wound outward on the third or
100 THE UMBILICUS AND ITS DISEASES.
fifth day, the inverted skin-cuff is found to be moist. It may be that there is a watery discharge from the gelatin within the ring of skin. Some of the inversion of the stump may be prevented, and a handsomer flush result secured by taking off part or all of the skin-cuff. Dry primary union is thus more certain. Most adult navels are dirt accumulators — accumulators not easy to clean. Deep inversion, with the line of union solidly fixed, 1 to 1.5 cm. below the level of the skin of the abdomen, may be found by the ninth day if the whole skin projection is used as flap."
I wrote Dr. Dickinson asking what his experience had been in the ten years intervening since his paper, and received the following answer :
"Your query about my immediate amputation of the cord did me good. Nothing ever fell as flat and as hard as that proposition. The principles of surgery don't apply to the only operation done on every living being, savage, civilized, or fourfooted. I can be satisfied to wait, but the method will not be general till every practitioner can do a little clean work. Meanwhile I have gone straight on with the second procedure. The cord is lifted by nurse or assistant. A really sharp curved needle, armed with No. or No. 1 catgut or fine silk or linen, is passed into the very tough skin, beginning below the navel, just where the skin-cuff rises from the bellywall. It circles beneath the skin, and comes out above at the base of the skin-cuff. The needle reenters close to its first entrance and circles the remaining half, coming out near the original second entrance. It is an over and over stitch of a round space that sweeps about the circle as well, thus acting as suture and encircling ligature in two bites and one tie. The stitch is placed before the cord is cut.
"The cord is cut just at the skin margin, under a little traction, in order that most of the jelly may come away in the scissors. Then an anatomic forceps slips the loop of the middle part of the stitch over the center of the raw surface, and one ties. It falls out or is nipped out in two or three days.
"The only contraindications are unclean contacts between exit of child's navel and operation, umbilical hernia, and a circulation badly started, so that there is back pressure in the vein.
"I have never seen oozing or temperature in my own cases. The only case I know of that did badly is a baby whose navel was sutured by an intern in a Brooklyn hospital, that died after some temperature, with a clean navel and no autopsy."
Buckmaster, in 1906, suggested a treatment of the cord very similar to that carried out by Dickinson, although he was evidently unaware of the latter's work.
Buckmaster in substance said that for several years he had been impressed with the idea that if the umbilical wound could be made to heal by first intention, it would be of great advantage. He made no claim to priority in suggesting a method by which this could be done, and said that he did not know who deserved credit for such a suggestion, since the more reasonable the plan, the more likely it is to occur to a number of men. He had tried the new plan in 8 cases : in 6 the results were all that could be wished for. In 2 cases of the 8 there was a slight trouble in the healing of the wound, but not enough to affect the general result. In all cases the wound was closed in ten days, and instead of a cicatrix, there was a slight linear scar. These children had been started in life without an umbilicus, and he has, therefore, used the term " anomphalosis " as the title of his article. His operation is as follows :
"With a sharp pair of scissors free the belly-wall, reflected on the cord like a cuff, and push it back. When this has been done, the cord may be divided. Sometimes
UMBILICAL INFECTIONS IN THE NEW-BORN. 101
an artery may spurt a little, but torsion or a thin catgut ligature will quickly control the hemorrhage. It will be noticed that in cutting through the cord near the wall how much more fibrous tissue is found than one would expect.
"The condition now present is a circular pit surrounded by a ridge of skin, the top of which is raw. By drawing two points on opposite parts of the ridge from each other, the circle is changed to an ellipse. The sides of the ellipse are now drawn together by sutures, preferably silver wire, and in from six to ten clays the wound is closed, practically by first intention.
"The condition is like an amputation of an arm: in both cases we have a flap which is made from the skin and which covers the stump. Since I first commenced to discuss this procedure among my friends who are interested in obstetrics I find that many have tried it. But while they have no good objection to the procedure, it did not seem to impress them favorably. I believe time will change all this. Xo anesthetic is necessary, because the child suffers next to nothing, but the operator should work quickly and not where the mother or non-professional spectators might, through their ignorance, fancy the child was maltreated."
Simple Surgical Treatment of the Umbilical Stump. — The method recommended by Nadory * complies with the three requirements of Ahlfeld, i. e., that there be positive prevention of an infection, protection against secondary hemorrhages, and no necessity for after-treatment. As soon as the pulsation of the umbilical cord ceases the cord is tied tightly with a heavy silk ligature at the line of demarcation between the skin and Wharton's jelly. The cord is then cut short. The stump and umbilical ring are painted with tincture of iodin. The child can be bathed daily if an application of the tincture of iodin is made after the bath. The umbilical stump will fall off on the second or third day. The umbilical funnel heals rapidly (J. Voigt).
CARE OF THE UMBILICAL STUMP— A BACTERIOLOGIC STUDY.
After briefly considering the clinical aspect of the infections and referring to the recent literature on the subject, Adairf gave the results of his bacteriologic examinations. "In order to prove the presence or absence of organisms on and around the umbilical cord immediately after birth, the following procedure was adopted:
"A platinum loop was used to scrape the cord and surrounding skin immediately after birth and before the cord was handled or manipulated in any way. Agar plate cultures were made from the material caught on the platinum loop. All these cultures were made under as nearly the same conditions as possible in the Elliot Memorial Hospital at the University of Minnesota. No attempt was made to isolate the anaerobic organisms.
"There were 65 cases examined in all. In 17 of these there was no growth. Xon-pathogenic organisms were found independently of any pathogens in 33 cases, or over 50 per cent of those examined. Pathogenic organisms were found alone or associated with non-pathogens in 12, or 19.46 per cent. Some variety of staphylococcus was found in 8 instances, and some form of the Bacillus coli group in 4 cases.
- Xadory, B.: Einfache chirurgische Versorgung des Nabelschnurrestes. Zentralbl. f. Gynak.,
1913, xxxvii, 765. Surgery, Gynecology and Obstetrics, November, 1913, 556. t Adair: Jour. Amer. Med. Assoc, August 23, 1913, 537.
102 THE UMBILICUS AND ITS DISEASES.
"The significance of this is evident. The cord and its surroundings show the presence of pathogenic organisms in nearly one-fifth of the cases immediately after birth. This is true where the cases are conducted amid the aseptic surroundings of a delivery room. The percentages might easily be much higher where less rigorous asepsis is carried out. This, of course, is no argument for carelessness in the subsequent handling of the cord, for it may be infected at any time.
"What are the essentials for the growth of organisms? (1) The presence of the germs; (2) the proper degree of temperature; (3) a suitable culture-medium and environs; and (4) the presence of moisture.
"It is evident that it will be very difficult .to eliminate entirely the presence of bacteria, but we can avoid contaminating the parts with germs, and we can assist in their removal by the use of aseptic and antiseptic measures. The body heat furnishes the proper temperature, and, of course, cannot be interfered with.
"The devitalized tissue of the cord forms a fine medium for the growth and development of the organisms. This can be removed by ligating or clamping the cord close to the skin margin. It has been pretty well demonstrated that better results are obtained by leaving as little cord as possible. Doubtless the methods of amputation proposed by Dickinson, which in his hands have given almost ideal results, accomplish this most thoroughly.
"The presence of moisture may be controlled by having a small stump of cord and keeping it under conditions which favor rapid drying. Various experiments have been conducted along this fine, and it has been found that exposure to air is one of the best means of accomplishing this end. Hygroscopic powders have been used with some success; good results have been obtained by the use of astringent and inert powders. Equally good, or better, results have been obtained without any dusting powder. Oily dressings have not given as good results. Dry occlusive dressings have been used. Gauze seems to permit of better and more rapid mummification than cotton.
"In order to fulfil these conditions, the new-born babies have been treated as follows at the University of Minnesota Hospital:
"After cessation of pulsation, the cords were clamped near the skin margin, the surrounding skin and cord cleansed with alcohol, and the clamp removed, to be replaced by a ligature in the groove made by the clamp. The end of the cord and the surrounding skin were painted with one-half strength tincture of iodin in some cases, and in others left untreated. A sterile gauze dressing was then tied over the end of the cord. The babies were oiled for three days, then washed, but no tub-baths were given until the navel was healed. Each day the stump and surrounding skin was washed with alcohol and the dressing changed when necessary.
"A study of the clinical courses of these cases subsequent to delivery may be of interest and profit.
"First in order is a consideration of those cases from which cultures were taken. In all there were 65 cases; one of these was a still-birth; there were 3 unsatisfactory cultures, which leaves 61 for study.
"There were 17 cases which showed no growth; of these, 4, or 23.5 per cent, showed a febrile reaction of over 100° F. There was one case with jaundice, and the average maximum weight loss was 209 gm.
"Of the 32 cases from which non-pathogenic organisms were recovered, there
UMBILICAL INFECTIONS IN THE NEW-BORN. 103
were 8, or 25 per cent, with febrile reaction; 3 infants were jaundiced, and the average maximum loss of weight was 188 gm.
"There was a temperature rise in 3, or 25 per cent, of the 12 cases in which pathogenic organisms were found; one was jaundiced, and the average maximum weight loss was 202 gm.
The figures are so close for the different groups that the only conclusion one could draw would be that, so far as this series is concerned, it made little difference whether or not the organisms were present at birth.
" There was no definite evidence of any serious infection of the navel. Two were somewhat reddened without any febrile reaction, jaundice, or marked loss of weight. There were two with some foul odor, one had a febrile reaction of 102° F. and a weight loss of 340 gm. The other had no reaction. Neither had any jaundice. A number of others did not heal so rapidly as usual, but showed no signs of infection. None of these babies died, and all left the hospital in good condition.
"Fifty-eight infants were treated, as outlined above, with alcohol and dry dressings. Of these, 14, or 24.13 per cent, had a rise in temperature to 100° F. or over; 8, or 13.08 per cent, were jaundiced, and of these 4 had fever and there was an average maximum loss of weight of 246.2 gm. The average loss of weight in the febrile cases was 314 gm. Five, or 8.6 per cent, had slight local evidence of navel infection, but none of them had a temperature rise to 100° F. The cord came off in five and one-half days on an average.
"In the second series of cases tincture of iodin was used to paint the cord and surrounding skin. Otherwise the treatment was the same as in the preceding series.
"There were 186 babies treated in this way. The temperature rose to 100° F. or above in 42, or 22.58 per cent, of these; 15, or 8 per cent, were jaundiced, of which 5 had a febrile reaction. The average loss of weight was 228.05 gm. In the cases with fever, this loss amounted to 285.19 gm. Ten, or 5.37 per cent, had slight local evidence of infection of the navel, only 3 of which had any fever. The cord came off in seven and one-half days on an average. None of the babies in either series had any evidence of serious or fatal infection originating at the navel. How many of these febrile cases were caused by absorption of some toxic substance or the entrance of organisms through the umbilicus it is not possible to state. Many conclusions cannot be drawn from this rather small amount of material.
"It is evident that some facts can be stated.
"1. The cord is contaminated with pathogenic or non-pathogenic organisms at or immediately after birth in a large percentage of cases.
"2. It is possible quite effectively to combat serious umbilical infections by comparatively simple methods, as shown by this report of over 200 cases with no mortality from this cause.
"3. There seems to be little choice between the two methods used in these cases.
"4. Jaundice in the new-born child is frequently associated with fever. It would not be illogical to suspect that this might originate by some agent introduced through the umbilical vein or lymphatics.
"5. Febrile reactions are common in the new-born infant, and are associated with other disturbances, such as a high primary weight loss and jaundice. They are due, no doubt, to many causes, but we, as obstetricians, should see that those due to infections entering; at the umbilicus are reduced to an irreducible minimum."
104 THE UMBILICUS AND ITS DISEASES.
PERSISTENT VITALITY OF THE UMBILICAL CORD.
Occasionally the cord does not come away promptly. This is prone to occur if the cord has been tied at a point too far remote from the umbilicus. This phenomenon was very well shown in a case reported by Williams in 1880, and in cases described by Dorland in 1897.
Williams' patient was a child three weeks old. A fleshy outgrowth an inch long projected from the umbilicus. It was rigid, had a raw, granulating appearance, and bled on the slightest touch. It was sensitive and had a little central opening on its free extremity. The dressings were frequently changed on account of a watery oozing. The central depression did not lead into a canal. A strong silk ligature was applied to the base of the projection. The next day nothing was visible but a small shred of dead tissue, which was nipped off after three days. The child made a perfect recovery.
Dorland said that within a period of ten months he had two cases in which the cord did not come away readily. He mentioned a case in which the cord had not come away at the end of the eighth week, and was then amputated close to the umbilicus. In this case the tissue was almost cartilaginous. In Dorland's cases the cord did not separate until the ninth and sixteenth days respectively. In Case 1 there was fissuring of the cord close to the abdominal wall. The child, on the eighth day, developed convulsions, a persistent high temperature, and inflammation of the umbilicus. It died on the following day.
In the second case the cord was amputated on the sixteenth day. There was a slight oozing for two days, but the child recovered.
LITERATURE CONSULTED IN THE PREPARATION OF UMBILICAL INFECTIONS IN
No attempt has been made to cover the subject.
Adair, Fred. L.: Care of the Umbilical Stump. A Bacteriologic Study. Section on Obst., Gyn., and Abdom. Surg, of the Amer. Med. Assoc, at the Sixty-fourth Annual Session held at Minneapolis June, 1913. Jour. Amer. Med. Assoc, August 23, 1913, 537.
Bednar, A. : Die Krankheiten der Neugeborenen und Sauglinge. Wien, 1852, 168.
Bergeron, H. : Une epidemie de gangrene de l'ombilic. These de Paris, 1866, No. 59.
Buckmaster, A. H. : Anomphalosis. Trans. Amer. Gyn. Soc, 1906, xxxi, 306.
Cohn, M.: Zur Lehre von den septico-pysemischen Nabelinfectionen der Neugeborenen und ihrer Prophylaxe. Therap. Monatsschr., 1896, x, 130; 192.
Cumston, C. G. : Infection of the Umbilicus in the Newly Born. New York and Phila. Med. Journal, 1905, lxxxi, 81.
Dickinson, R. L. : Is a Sloughing Process at the Child's Navel Consistent with Asepsis in Childbed? An Introduction to the Study of Complete Primary Amputation. Amer. Jour. Obst., 1899, xl, 14.
Dorland, W. A. N. : Persistence of the Umbilical Cord. Phila. Polyclinic, 1897, vi, 254.
Gremillon: Anomalies et des complications de la cicatrisation de l'ombilic. These de Paris, 1895, No. 453.
Hinsdale, G. : Purulent Encephalitis and Cerebral Abscess in the New-born Due to Infection Through the Umbilicus. Amer. Jour. Med. Sci., N. S., 1899, cxviii, 280.
Lambert, S. W. : Umbilical Sepsis in the New-born Occurring at the Nursery and Child's Hospital, New York, during 1896. Med. News, Phila., 1897, lxx, 557.
Lorain, Paul: De la fievre puerperale chez la femme, le foetus, et le nouveau-ne. These de Paris, 1855, No. 161.
Maygrier, M. C: Infection generalisee d'origine ombilicale probable chez un nouveau-nc. Bull, de la Soc. d'obst. de Paris, 1901, iv, 146.
UMBILICAL INFECTIONS IN THE NEW-BORN. 105
Meyer: Puerperal-Infection eines Neugeborenen. St. Petersburger med. Wochenschr., 1891,
xvi, 423. Meynet, C. H. P.: Epidemie d'erysipele et d'ulceration de l'ombilic. These de Paris, 1857, xi,
No. 156. Nadory, B.: Einfache chirurgische Versorgung des Nabelschnurrestes. Zentralbl. f. Gynak.,
1913, xxxvii, 765; Surgery, Gynecology and Obstetrics, November, 1913, 556. Nicaise: Ombilic. Dictionnaire encycloped. des sci. med. Paris, 2. ser., xv (1881), 140. Pinkerton, J.: A Case of Omphalitis, Umbilical, Closure of Ulcer by a Plastic Operation; Recovery with a Firm Cicatrix. The Lancet, 1900, i, 1656. Pollak: Nabelbrand, Darmfistel, Tod. Jahrb. f. Kinderheilk. u. phys. Erziehung, 1869-70, iii,
227. Porak: Infection generalisee chez un nouveau-ne consecutive a une phlebite ombilicale suppuree. Bull, de la Soc. d'obst. de Paris, 1901, iv, 142. Porak, C, et Durante, G. : Infections ombilicales du nouveau-ne. Arch, de med. des enfants,
1905, viii, 449. Ribbert: Abscesse des Gehirns, veranlasst durch Embolien des Oidium albicans. Berl. klin.
Wochenschr., 1879, xvi, 617. Runge: Die Krankheiten der ersten Lebenstage. Stuttgart, 1893, 56. Salge, B. : Ein Beitrag zur septischen Infektion des Nabels des Neugeborenen. Charite-Annalen,
1904, xxviii, 263. Tarnier et Budin: Traite de l'art des accouchements, 1901, iv, 728. Trousseau, M.: De l'erysipele chez les enfants a la mamelle. Jour, de med. et de chir., 1844,
ii, 1. Wassermann, M.: Ueber eine Epidemie-artig aufgetretene septische Nabel-Infection Neugebo rener: ein Beweis fiir die pathogenetische Wirksamkeit des Bacillus pyocyaneus beim Men schen. Virchows Arch., 1901, clxv, 342. Williams, C. R. : Persistent Vitality of the Umbilical Cord. The Lancet, 1880, i, 701. Yot, E. : De l'erysipele innammatoire ou non-puerperal des enfants nouveau-nes. These de Paris,
1873, No. 240.
Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.
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