Book - Umbilicus (1916) 4
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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 IV. Umbilical Hemorrhage
Causes of umbilical hemorrhage.
Instances of umbilical hemorrhage in the new-born.
Umbilical hemorrhage in patients after infancy.
Hematoma of the abdominal wall near the umbilicus.
To discuss thoroughly the enormous amount of literature on this subject would occupy many pages. I shall merely give the salient facts, and report enough cases to give a clear idea of the fatalities resulting from umbilical hemorrhage.
The manner in which umbilical hemorrhage is checked, even though no ligature be applied, is probably explained by Fig. 64. The inner longitudinal muscular coat contracts and thickens, thus tending to obliterate the lumen of the vessel. We know that in many animals, in fact in practically all, the cord is bitten or torn off, no ligature being applied.
Craig (1894), in his article on Umbilical Hemorrhage, quoted J. Foster Jenkins, who in 1858 published a monograph giving the histories of 178 cases, and mentions Grandidier, who had collected 202 cases. In about one-third of the cases the hemorrhage occurred in female children; in two-thirds, in male children.
Craig states that the time of greatest danger is when the cord comes away — from the fifth to the fifteenth day. As the chief causes of hemorrhage he mentions a faulty condition of the blood, pathologic conditions of the vessel-walls, hemophilia. He adds that a condition of ill health or anemia in the mother, due to any cause, produces, to a certain degree, a like condition in her offspring.
Without any premonition of the impending danger, the clothes are found soaked with blood. In 41 out of 175 of Craig's cases the hemorrhage was preceded by jaundice. The most dangerous hemorrhages occurred at night. About 90 per cent of the children die. Where jaundice and hemophilia are present, the condition is most hopeless (Craig).
Cumston, in 1905, writing on infections of the umbilicus in the new-born, says that certain accidents, such as late umbilical hemorrhages arising from the changes in the vessels, are often due to hemophilia, hereditary syphilis, and a kind of hereditary family predisposition. These conditions have been observed by Boissard.
Demelin (quoted by Cumston) divides umbilical hemorrhages occurring secondarily or spontaneously into the three following groups: (1) Hemorrhage due to an arteritis occurring about the time the cord falls off. (2) Hemorrhage occurring in acute degeneration of the infant, "with icterus of infective origin. (3) Hemorrhage in cases of septicemia of the newly born, which is produced by the same mechanism as holds in cases of congenital syphilis following umbilical inflammation.
Gallant, in 1907, gave a good resume of the subject of umbilical hemorrhage, and added an excellent table of the reported cases.
Runge (op. cit., p. 197) says that cases of umbilical hemorrhage in which, on anatomic examination, no syphilis was present, have been reported by Wachsmuth, Weiss, Hryntshak, Fischel, and others.
According to Mracek, the hemorrhage is caused by disease of the small and large veins. In the walls, especially of the veins, is found a thickening due to multiplication of the nuclei. He found the lumen narrow, and in several cases completely closed.
Runge (p. 198) asserts that septic diseases of the new-born have been proved to be the cause of idiopathic bleeding by the observations of Weber, Ritter, and Epstein. Capillary hemorrhages are relatively common in septic cases, but in addition severe bleeding from various organs has been observed in septic diseases of the new-born, especially in foundling hospitals. Epstein found bleeding 24 times in 51 children suffering from a well-developed acute septicemia. Runge notes that, in cases in which bleeding took place, there was often gangrene of various parts of the surface of the body. In cases of general septicemia there is a tendency toward hemorrhage; various organs may be affected, and as a result we may have bleeding from the umbilicus.
The hemorrhage is sometimes noted a few hours after birth. In each of the three cases recorded by Kommerell the bleeding occurred a few hours after birth, but all the infants recovered.
In his first case the mother reported that her first child had had severe umbilical hemorrhages, and she had asked the
midwife to be particularly careful. The midwife accordingly had tied the cord twice with firmness and extra care, and, when she left, it was in good condition. Later, however, a severe hemorrhage occurred. The bleeding ceased spontaneously and the child recovered.
In Kommerell's second case the midwife had tied the cord a second time and the father had seen that it was properly done. During the night the child was restless; in the morning it was very pale, and there had been severe bleeding from the cord. The hemorrhage stopped spontaneously and the child recovered.
The fact that these bleedings occurred several hours after birth, according to Kommerell, is easy of explanation. After being cut the blood-vessels contract,
Coturacte ct> ; Itmgitdfdinal | m use lei- closing til iH ,'iLuThen ,■:'■:.
Fig. 64. — Natuhe's Method op Checking Bleeding fbom the Umbilical Arteries. On the left we have transverse and longitudinal sections of an artery showing the intima, the thick longitudinal muscular coat, and the outer circular coat. When the vessel is cut across in the living, the longitudinal muscle probably contracts, as indicated by the arrows, forming an effectual barrier to the further escape of blood. Were it not for some such mechanism as this, many animals would perish, since in their case the cord is left to take care of itself.
108 THE UMBILICUS AND ITS DISEASES.
while at the same time the blood-pressure is diminishing. The intra-abdominal portion of the umbilical artery continues to pulsate after pulsation has ceased in the extra-abdominal portion. If, now, the soft mass within the umbilical pedicle loses in energy, while in the intra-abdominal part the umbilical vessels are still filled, hemorrhage can readily occur.
Kommerell reports another case in which, several hours after the midwife had tied the cord, fatal hemorrhage occurred. The midwife was sentenced to eight days in jail. Kommerell then goes on to discuss the responsibility in such cases. In Sibert's case the infant died of umbilical hemorrhage thirty hours after birth. The cord was three-quarters of an inch in diameter. On account of "unusual excitement" in the cord, tying was delayed. Sibert saw the child twenty hours after birth. It was pale and was bleeding from the umbilicus. The ligature was not found when the cord was examined. A second was applied. After a time the bleeding recurred. The mother's health during gestation had been bad. There was no history of a hemorrhagic diathesis.
The hemorrhage may occur two or three days after the birth of the child, or an interval of several weeks may elapse before bleeding is noted. In Craig's case, for example, oozing from the umbilicus was noted on the second day. There may be hemorrhages at irregular intervals, extending over a period of from a few hours to two or three days, or, as in Garcin's case, the hemorrhage may be so severe that the child dies in a few minutes after the bleeding has been detected.
In some cases the bleeding is intermittent, in others, constant. Stuart's description of the bleeding in his case is graphic: "It reminded one of the water bubbling through sand at the bottom of a spring; only the oozing and welling up from the stump of the cord were very deliberate and slow."
CAUSES OF UMBILICAL HEMORRHAGE.
The most frequent causes of umbilical hemorrhage appear to be heredity, infection, and syphilis.
Heredity.- — ■ Tajdor, in 1893, reported three cases occurring in one family; the mother's first cousin had lost two children from umbilical hemorrhage.
Infection. — Umbilical infection, with its subsequent general infection and jaundice, evidently plays a very important role in the development of hemorrhage from the umbilicus. In Chapter III it has been noted that, before the days of asepsis, when outbreaks of puerperal sepsis developed and many mothers succumbed, there was a correspondingly large percentage of umbilical infections in the new-born. Fortunately, this is in large measure a thing of the past. Thus Garcin, in 1903, when reporting a fatal secondary hemorrhage from the umbilicus eight days after birth, could say: "I have never had one like it, although I have officiated or assisted in upward of a thousand obstetrical engagements."
Syphilis. — Runge says that not only Grandidier, but also other authors, have noted syphilis in the parents of children that have developed umbilical bleeding. Several writers have described in detail the syphilitic changes that were present in the children during life and after death, and are inclined to regard this disease as the etiologic factor. Behrend described a "syphilis hemorrhagica."
Runge says that this form of syphilis only rarely affects children. When the disease is noted at birth, it is most frequently encountered in premature children,
UMBILICAL HEMORRHAGE. 109
who, if not born dead, die almost immediately or live only a few hours, rarely a day. In these cases, in addition to the marked changes, which are usually those found in syphilis, can be noted numerous hemorrhages under the skin and in the internal organs. Sometimes there are hemorrhages into the stomach and intestine, into the peritoneal cavity and the meninges.
When such children live for a longer period, there occur new hemorrhages in the skin or in the various organs. Runge cites the case of a child showing marked syphilitic changes, in which hemorrhage occurred from the edges of the anus and from the tip of the tongue, and finally, on the eighth day, from the umbilicus. The blood came out of the skin, just as drops of sweat would do, and on the ninth day marked icterus developed and the child died. At autopsy extensive syphilitic changes were found in the internal organs.
Astringents, such as silver nitrate, tannic acid, and iron persulphate, have been used with little or no effect. Adrenalin has proved of little value.
Attempts have been made to check bleeding by encircling the umbilicus with a catgut or silk ligature, or by transfixing it with two straight needles placed at right angles, and tying a ligature beneath them. In this way temporary cessation of the bleeding has occasionally been effected, but it soon recurs. Our hope for the future seems to lie, in large measure at least, in bringing about a coagulation of the blood. The condition being, in some cases at least, analogous to melsena neonatorum, a practical line of treatment should be sought for along the same lines.
The following case recorded by Reichard is of interest, although the bleeding was not from the umbilicus, but from the bowel. It will be noted that a child of this mother had died of hemorrhage on the fourth day.
Spontaneous Hemorrhage of the New-born, with Recovery. — V. M. Reichard * reported the following case:
"Spontaneous hemorrhage of the new-born is so obscure and so fatal a disease that any experience pointing the way out is worth recording. All treatment detailed in the literature of the subject is so difficult a technic as to require either special skill or special apparatus or both. In view of these facts the following case is worthy of report:
"Mrs. R., aged forty-two, white, was delivered rapidly and easily of her ninth child at 4 p. m. August 26, 1912. She was not in labor more than thirty minutes, and the baby was born fully half an hour before the attendant's arrival. The child, a girl, weighed nine and one-half pounds and appeared perfectly well and normal. Of the eight children previously born, two had died, one, the first-born, of some bowel complication at four months; and one, the fourth, of hemorrhage on the fourth day. The ninth child was well for thirty-six hours, when the nurse found her listless and flaccid. On examination it was discovered that a large quantity of blood had been passed by bowel. Some of the blood was red, but a much larger part was dark and tarry-looking. I saw her at 9 a. m., August 28th. The child was then of a deep lemon color and in profound shock. She had vomited some blood. During the day she had half a dozen bloody stools, and at 9 p. m. the pulse was rapid and weak. She had been very languid and relaxed all the day, though she had taken the breast at three-hour intervals. At 9 p. m. she was given about 15 c.c. of
- Reichard, V. M.: Jour. Amer. Med. Assoc, October 26, 1912, 1539.
110 THE UMBILICUS AND ITS DISEASES.
normal horse serum subcutaneously. August 29th and 30th small amounts of blood were passed, but each time the amount was less, running possibly from half an ounce down to a teaspoonful. At 7 p. m. on the thirtieth the child was given 20 c.c. of normal horse serum, and from that time on there has been no blood. Both injections were made into the buttocks, one on each side. On September 1st the stools were the usual yellow color of a nursing infant, and have continued so ever since. On September 16th, when last seen, she was a splendid specimen of baby, skin clear and healthy, and nursing well, bowels regular, stools natural, and every evidence of perfect health.
"Twenty cubic centimeters is a fairly large subcutaneous dose for an infant, and in this case put the skin on the stretch decidedly. This tension subsided rapidly, and in an hour's time the tumor had disappeared."
In .Reichard's case the employment of horse serum gave good results. Serum in another form was employed by Chartier in a case of umbilical hemorrhage, with recovery of the child.
It is also possible that the newer and simpler methods of transfusion may yield good results. These children are, as a rule, too far gone to permit of the linking-up of a vessel with that of a donor.
INSTANCES OF UMBILICAL HEMORRHAGE IN THE NEW-BORN.
Umbilical Hemorrhage in the New-born. * — Hemorrhage occurred two days after the cord came away. During the first three days the weight of the child diminished from 2910 to 2480 gm. There were also vomiting and diarrhea. On the seventh day there was an umbilical hemorrhage and the child became blanched. The umbilicus was cauterized with nitrate of silver. The same evening another hemorrhage followed, and several drops of 1 : 1000 adrenalin were applied. The next morning free hemorrhage still persisted. The child was absolutely colorless, the pulse hardly perceptible. Thirty cubic centimeters of the serum were injected, and two hours later 20 c.c. of serum gelatin. On the next day another injection of 20 c.c. of serum gelatin was given. The child made a good recovery.
Chartier employed a sterilized solution of 25 gm. of gelatin in 1000 gm. of Hayem's serum.
Umbilical Hemorrhage. — C. F. Craig f reports a fatal case : " On the second day blood oozed from the umbilicus where the cord was attached. Compresses were applied, and the bleeding ceased. On the third morning the umbilicus appeared to be in good condition, but the child had vomited blood several times. On the following morning there had been no more vomiting, but the child was jaundiced. A few hours later there was more bleeding from the umbilicus and the child died in the course of a few minutes."
Hemorrhage from Umbilicus. — Fry J reports the case of a colored child weighing seven pounds and four ounces. On the eighth day the cord came away. On the twelfth there was bleeding from the umbilicus. Compresses and
- Chartier: Omphalorragie grave, traitement par le serum gelatine, guerison. Arch, de m6d.
des enfants, 1905, viii, 477.
t Craig, C. P. : The Medical News, 1894, lxv, 569.
J Fry, Henry: Omphalorrhagia Neonatorum. Amer. Jour. Obst., 1907, lv, 856.
UMBILICAL HEMORRHAGE. Ill
an abdominal binder were applied. On the following day a solution of 1:10,000 of adrenalin chlorid was used, and forty-eight hours later a purse-string of catgut was tried. The bleeding still continuing, two hours later two needles were passed through the umbilicus at right angles, the tissues were constricted with a silk ligature, and five grains of calcium lactate were given every four hours. A temporary cessation of the hemorrhage ensued. Styptic collodion was tried, and a compress of 10 per cent gelatin solution, changed every two hours. A dram of gelatin solution in two drams of normal salt solution was injected under the skin. The blood on the second day showed: Red corpuscles, 3,500,000; white corpuscles, 9000; hemoglobin, 70 per cent. The hahy died four days after the onset of the bleeding.
Fatal Secondary Hemorrhage From the Umbilicus Eight Days After Birth. — In Garcin's* case the hemorrhage from the umbilicus began on the eighth day after birth. The labor, which was uncomplicated, occurred on October 23, 1902, and the cord came away in a normal manner. On October 31, the child was bleeding to death from the umbilicus. The father discovered blood on the bed when going to work. On the doctor's arrival the child was just alive. The hemorrhage was promptly controlled by compresses of sterile gauze saturated with suprarenal extract. The child, however, died in a few minutes.
A Case of Fatal Umbilical Hemorrhage.! — The infant died of umbilical hemorrhage thirty hours after birth. The cord was three-quarters of an inch in diameter. On account of "unusual excitement" in the cord, tying was delayed. Sibert saw the child twenty hours after birth. It was pale and was bleeding from the umbilicus. The ligature was not found when the cord was examined; a second was applied. After some time the bleeding recurred and the child died. The mother's health during gestation had been bad. There was no history of a hemorrhagic diathesis.
Three Cases of Umbilical Hemorrhage Occurring in the Same Family. J — Case 1 . — A female infant, thirteen days old, seen on September 29th. She was the eighth child of a healthy family. The mother's first cousin had lost two children from umbilical hemorrhage. The child was a fine large baby. The cord was very thick, and did not separate until the seventh day. Before the separation a visitor had seized hold of the front of the child's clothing, and after that time the navel had been inclined to weep. The bleeding was more severe on the thirteenth day. The umbilicus was dusted with tannic acid. On September 30th the bleeding continued. On October 1st the hemorrhage was profuse. The child died at 5 a. m. October 2d. During the illness it was noted that the elbows and ankles were becoming discolored.
Case 2 . — A female child, eight days old, seen on December 19th. She was the tenth child. The umbilical cord had not come away. The clothes were stained with blood, and the child was blanched. Above the umbilicus for one inch the surface was red and the skin abraded. The blood was oozing from this area, and also welling from the umbilical scar. Styptics were of no avail. Two harelip pins stopped the bleeding. Two days later, however, the bleeding again commenced, and the child died three days after the onset of the hemorrhage.
Case 3 . — November 10, 1887, male child, ten days old. This was the
- Garcin, R. D.: Virginia Med. Semi-Monthly, vii, April, 1902-March, 1903, 376.
t Sibert, D. E.: Arch, of Pediatrics, 1884, i, 307.
t Taylor, James: Bristol Med. and Chir. Jour., 1893, xi, 237.
112 THE UMBILICUS AND ITS DISEASES.
twelfth child. The cord came away on the seventh day. On November 10th a patch of dark-colored blood was noted on the dressing from the navel. On November 12th, a bruise was detected on the shoulder. In this case the child was well six years later.
Taylor says this disease appears to be more common in male children, and that the tendency to hemorrhage is transmitted through the female members of the same family.
Fatal Umbilical Hemorrhage in the New-born.* — A woman, who had been weakened greatly by several pregnancies occurring in rapid succession, developed jaundice, and her child was delivered four weeks too soon. The woman died several hours later from hemorrhage.
The child was weak. Forty-eight hours after birth it developed jaundice. It did not take the breast well. In the night between the third and fourth days bleeding came on in the umbilical region, from between the cord and the umbilicus. The child died.
Hemorrhage From the Umbilical Cord on the Tenth Day .f — ■ The baby was ten days old. Two hours before Stuart saw him there had been a hemorrhage from the umbilicus. The cord in this case had come off on the fifth or sixth day, and blood was oozing and welling up drop by drop from the apparently non-ulcerated but healthy-looking stump. Stuart says: "It reminded one of the water bubbling through sand at the bottom of a spring; only the oozing and welling up from the stump of the cord were very deliberate and slow."
Monsel's solution, silver nitrate, powdered tannic acid with subsulphate of iron, and transfixion of the stump were tried, but with no result. The child died the next morning. Stuart says: "A remarkable feature of this case was the location of the collateral hemorrhage in the eyes, from the conjunctival mucous membrane, when the bleeding seemed to be controlled for a time at the umbilicus."
UMBILICAL HEMORRHAGE IN PATIENTS AFTER INFANCY.
We have records of two cases, one reported by Strecker and one by Colombe. Strecker's patient was a small, pale lad of eleven, who two days after jumping down a short distance was seized with bleeding from the umbilicus, associated with alarming abdominal symptoms. As the patient recovered, the cause of the bleeding was never discovered.
Colombe's patient was a woman thirty-six years old. She had a small nodule at the umbilicus, and from it severe bleeding took place. The bleeding ceased with the removal of the nodule.
Umbilical Hemorrhage at Eleven Years of Age.J — John S., aged eleven, a small, pale, blond boy, on March 9, 1902, jumped from a porch floor to the ground, — about three feet, — but felt no ill effects. On March 11th he complained of pain at the navel, and blood was discovered coming from it. The umbilicus with the surrounding tissue for one inch was much higher than the rest of the abdominal wall. An elastic truss was applied. On March 12th there
- Sadler: Todtliche Blutung aus dem Umfange des Nabels bei einem Neugeborenen.
Schmidt's Jahrb., 1840, xxvii, 177.
t Stuart, A. R.: The Medical News, 1895, Ixvi, 159. t Strecker, J. E.: The Medical World, 1903, xxi, 211.
UMBILICAL HEMORRHAGE. 113
was another umbilical hemorrhage, and the abdomen was markedly distended, almost to the bursting point. Opiates were given. The patient vomited bile, mucus, and fecal matter, and was in a state of collapse. On March 13th the abdomen was less tense, but at 4 p. m. there was a still more alarming hemorrhage. Calcium chlorid was given. On March 15th an operation was contemplated, but was put off, as the patient was better. On March 25th the patient seemed well. In this case there may have been hemorrhage into the abdomen coming through the umbilical opening. As the patient recovered and no operation was performed, it is impossible to determine the nature of the case with absolute certainty.
A Small Vascular Tumor at the Umbilicus; Hemorrhage. Recovery.* — This patient was a woman thirty-six years of age. She was in good health and had had a child at nineteen. About ten years before admission the patient had noticed a small tumor, the size of a grain of wheat, at the umbilicus. This had gradually increased in diameter. It was purple, rather soft, painless, but inconvenient. About a week before her admission it was the size of the end phalanx of the little finger.
Two years before coming under observation there had been hemorrhage from the tumor. The blood had come in jets. This bleeding had lasted for two days, but had not been continuous, and had been controlled with iron perchloric!. Three days before admission she had had a second hemorrhage. Perchlorid of iron was again used. The volume of the tumor could be compressed to the diameter of the femoral artery, and the bleeding was intermittent. The patient was in a sea of blood. She was pale and apparently in a serious condition. Forceps were applied, and the area ligated en masse, but control was difficult, as the bleeding was from the bottom of the umbilicus. Seven days later bleeding occurred again. A new ligature was applied, and the bleeding stopped and never returned. The tumor disappeared. The origin of this condition remained unknown.
HEMATOMA OF THE ABDOMINAL WALL NEAR THE UMBILICUS.
This condition is exceptional. Hartz, after giving a splendid resume of the various methods of treating the umbilical cord, says that Westphalen mentions a hematoma of the umbilicus due to a double rupture of the umbilical vein.
On January 10, 1903, in consultation with Dr. Thomas Linthicum, I saw a middle-aged woman who had a marked cardiac lesion, which had been associated with swelling of the extremities and with dropsy. She also gave a definite history of gall-stones. In April, 1902, she had had erysipelas which had lasted four weeks, and shortly afterward had had swelling of the wrists and noticed an abdominal enlargement. Two weeks later jaundice developed, which lasted three or four weeks. About this time cardiac symptoms were noted. Later on she was seized with a violent pain in the left leg, which lasted several hours and then extended to the right leg, reaching from the hip to the toes. Dr. Wells said that the circulation had stopped in the leg. When Dr. J. M. T. Finney saw her a few days later pulsation was again perceptible in the leg, but he agreed with Dr. Wells that the trouble was in the arterial circulation. The patient was ill for weeks, and when she was able to sit up, the limbs became markedly swollen. On December 15, 1902, she
- Colombe: Tumeur vasculaire de l'ombilic; hemorrhagie, guerison. Gaz. med. de Paris ;
1887, lviii, 245. 9
114 THE UMBILICUS AND ITS DISEASES.
was seized with a severe pain, which seemed to be in the region of the liver, and on December 18 she was thought to be dying. After the circulation stopped in the leg black spots, evidently subcutaneous hemorrhages, developed. These were noted from time to time, but were most marked in December. They varied in size from that of a cent to that of two hands. A gradual improvement followed, until she was admitted to the hospital for operation.
When I saw her, just above and to the right of the umbilicus was a deep-seated and apparently cystic mass, fully 16 cm. in diameter. On January 15th the patient was removed to Baltimore. She stood the journey poorly, but under ether the pulse became more regular.
An incision was made to the outer side of the right rectus, directly over the center of the cystic mass. The swelling was due to a large hematoma between the transversalis fascia and the peritoneum. The cavity was irregularly circular, and had numerous little bays running off in all directions. The walls and floor of the sac were thickened, and consisted of granulation tissue. The cavity was filled with dark, clotted blood. I packed this cavity loosely with iodoform gauze.
An incision was now made to the left of the median line, and curved upward to the right. After the gall-bladder adhesions had been separated two gall-stones, each about 5 mm. in diameter, were removed, and the gall-bladder was drained. The hematoma cavity rapidly granulated and closed completely. The gallbladder wound also closed, and the patient was discharged in a relatively good condition.
I have given the symptoms somewhat fully in order that the reader may see that the cardiovascular system was in such a condition that a rupture of one of the bloodvessels was much more prone to occur than in a healthy individual. This hematoma had undoubtedly been due to a rupture of either an artery or a vein.
In a personal communication dated Sydney, Australia, March 14, 1911, Dr. Fiaschi tells me that his father had a very interesting case just before Christmas, 1910. A young woman developed a hematoma of the left rectus above the umbilicus during or just after labor. She came from the country, and Dr. Fiaschi and his father thought prior to operation that they might find a ruptured or suppurating hydatid of the abdominal wall or of the left lobe of the liver.
LITERATURE CONSULTED ON UMBILICAL HEMORRHAGE.
Chartier: Omphalorragie grave, traitement par le serum gelatine, guerison. Arch, de med. des enfants, 1905, viii, 477.
Colombe: Tumeur vasculaire de l'ombilic; hemorrhagic, guerison. Gaz. med. de Paris, 1887, lviii, 245.
Craig, C. F.: Umbilical Hemorrhage, Etiology, Pathology, and Treatment. The Medical News, Phila., 1894, lxv, 569.
Cumston, C. G. : Infection of the Umbilicus in the Newly Born. New York and Phila. Med. Jour., 1905, lxxxi, 81.
Fry, Henry: Omphalorrhagia Neonatorum. Amer. Jour. Obst., 1907, lv, 856.
Gallant, A. E. : Disorders of the Umbilicus with Special Reference to the New-born and the Infant — III. Umbilical Infections. Internat. Clinics, 1907, 17th series, i, 151.
Garcin, R. D.: Fatal Secondary Hemorrhage From the Umbilicus Eight Days After Birth. Virginia Med. Semi-Monthly, vii, April, 1902-March, 1903, 376.
Hartz, A.: Abnabelung und Nabelerkrankung. Monatsch. f. Geb. u. Gyn., 1905, xxii, 77.
Kommerell: Ueber Nachblutungen bei unterbundener Nabelschnur. Aerztl. Rundschau, Mlinchen, 1896, vi, 627.
Reichard, V. M.: Spontaneous Hemorrhage of the New-born with Recovery. Jour. Amer. Med.
Assoc, October 26, 1912, 1539. Runge: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der erst en Lebens tage. Stuttgart, 1893, 56. Sadler: Todtliche Blutung aus dem Umfange des Nabels bei einem Neugeborenen. Schmidts
Jahrb., 1840, xxvii, 177. Sibert: A Case of Fatal Umbilical Hemorrhage. Arch, of Pediatrics, 1884, i, 307. Strecker, J. C: Umbilical Hemorrhage at Eleven Years of Age. Med. World, 1903, xxi, 211. Stuart, A. R.: Hemorrhage From the Umbilical Cord on the Tenth Day. The Med. News,
1895, lxvi, 159. Taylor, J.: Three Cases of Umbilical Hemorrhage Occurring in the Same Family, ©ristol Med.
and Chir. Jour., 1893, xi, 237.
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