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Home , Angiomatosis, Rectal foreign body

1040 REVIEW ARTICLE: RECTAL BLEEDING Canad.Nov. 4,1961,M. A. vol.85J.

The left ventricle, the and the , served a most useful purpose. She has been the and hence the perfusion and the health of the means of synthesizing the departments of medi- myocardium, the cerebral and renal parenchyma, cine, surgery, anesthesia, biochemistry, pathology, all may have been compromised by the hyper- psychiatry and over a common problem. tension due to a specific cause and these changes, In our turn, I hope we have helped her. including , may become irreversible. Some think that irreversible hypertension in these REFERENCES to secondary renal involvement. 1. BARBEAU, A. et at.: Union med. Canada, 87: 165, 1958. instances is due 2. KVALE, W. F. et at.: J.A.M.A., 164: 854, 1957. In our patient, renal function was grossly normal 3. VON EULER, U. S. AND STR6M, G.: Circulation, 15: 5. 1957. 4. GrrLow, S. E. et at.: Am. I. Med., 28: 921, 1960. but there were definite hypertensive retinal 5. Annotation: Laacet, 1: 967, 1960. 6. WALLACE, L. AND MCCRARY, J. D.: J.A.M.A., 157: 1404, changes, and left ventricular hypertrophy, and her 1955. 7. CARMAN, C. T. AND BRASHEAR, R. E.: New England J. following operation did not return Med. 263: 419 1960. to normal although it was greatly diminished. It is 8. AXELROD, J.: Physiol. Rev., 39: 751, 1959. 9. DRUJAN, B. D. et at.: Canad. J. Biochem. i Physiol., 37: suggested that false negative Rogitine tests in some 1153, 1959. 10. VON EULER, U. S.: Noradrenaline, Charles C Thomas, cases of pheochromocytoma may be due to the Springfield, Ill., 1956. 11. CROUT, J. R. AND SJOERDSMA, A.: Cire.tlation, 22: 516, fact that irreversible hypertension is already 1960. 12. STRAUS, R. AND WURM, M.: Am. J. Olin. Path., 34: 403, established. Considering that hypertension of any 1960. one should attack 13. HOFFER, A. AND OSMOND, H.: J. Neuropsychiat., 21: 1961. cause may become irreversible, (In print) the remedial and specific causes without undue 14. MANGER, W. M., WATKIN, K. G. AND BOLLMAN, J. L.: Chemical quantitation of epinephine and norepinephrine delay. We do not know at the present time what in plasma, Charles C Thomas, Springfield, Ill., 1959. will 15. BELKIN, A., MACQUEEN, D. 0. AND DUFFIN, J. D.: Canad. course the hypertensive M.A.J., 64: 442, 1951. take in our patient. 16. Idem: Ibid., 71: 59, 1954. 17. FoRssELL, J. AND MALM, P.: Acta med. scandinav., 163: DR. NANSON. Thank you, gentlemen, for your 55, 1959. attention. Our time is up, but I think you will agree 18. FERTIG, H. H. et at.: Ann. mt. Med., 35: 1358, 1951. 19. KING, S. E. AND BALDWIN, D. S.: Am. ,J. Med., 20: 217, that this patient with pheochromocytoma has 1956

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RECTAL BLEEDING IN INFANCY of all patients under the age of 16 with rectal AND CHILDHOOD* bleeding or melena in two Edmonton hospitals only 63 charts were made available. None of the personal ROBERT A. MACBETH, M.D., F.R.C.S.[C],t cases were included in the records provided be- Edmonton, Alto. cause they were discharged as Meckel's diverti- culum, thrombocytopenic purpura and gastroin- FEW SYMPTOMS cause a mother to seek medical testinal angiomatosis. A complete review of local attention for her child with greater dispatch than experience was therefore virtually impossible. The does that of the appearance of fresh or altered excellent classification of Koop7 has consequently blood associated with the stool. This is indeed been selected as the background against which fortunate for, while the cause may be inconse- selected cases will be discussed in an attempt to quential, this symptom may herald the presence of clarify the differential diagnosis and treatment of serious disease requiring urgent therapy and even rectal bleeding in infancy and childhood. emergency surgery. The recent occurrence of three instances of severe SYMPTOMATOLOGY bleeding from the in children in my practice has prompted me to examine the records of such There is rather universal agreement that a care- cases in this area and survey the rather meager fully elicited history is frequently the most valuable literature on the subject. It soon became apparent part of the evaluation of any case of rectal bleeding. that the standard coding of discharge diagnoses of The following points must be established, if at all hospitalized patients did not make it possible for possible. record librarians to provide charts of patients on a basis of their presenting complaint with any 1. How Much Blood Has Been Passed? consistency. In response to a request for the records This information may help with the diagnosis but is even more important in the assessment of *Presented at the Annual Meeting of the Saskatchewan the urgency of the situation. It must constantly be Division of the canadian Medical Association. October 18-21, 1960. and the Annual Meeting of the Alberta Division of the kept in mind that the loss of a quantity of blood Canadian Medical Association. September 25-28, 1961. tDepartment of Surgery, University of Alberta, Edmonton. which in the adult would be inconsequential may Canad. M. A. J. 1041 Nov. 4, 1961, vol. 85 REVIEW ARTICLE: RECTAL BLEEDING well constitute a massive hemorrhage in a small I. Syndromes Characterized by the Passage of infant. The loss of 40 c.c. of blood by a 6-lb. new- Bright Red Blood and Associated with Anal born, for example, is roughly equivalent, on a basis Pain of its effect on circulating blood volume, to a hemor- In this group one might include: (i) Fissure-in- rhage of 1000 c.c. in a 150-lb. adult. ano. (ii) Fistula-in-ano. (iii) Rectal prolapse. (iv) . (v) Rectal . 2. How Long Has the Patient Been Bleeding? Diagnosis here is seldom difficult and can usually This information, like that of the amount of be very simply -confirmed by examination of the blood passed, is usually more helpful in assessing perianal area and digital examination of the rectum. the gravity of the situation than in establishing the Of this group fissure-in-ano is by far the com- precise diagnosis. monest lesion. Out of 36 cases discharged from the Edmonton General Hospital over the last nine years with a diagnosis of rectal bleeding, 26 or 3. What Colour is the Blood? 72% were due to demonstrable anal fissures. In The colour of the blood passed depends on three office practice the preponderance is even greater. factors: (i) The proximity of the source of bleeding Fissures appear to occur in two forms: to the anal orifice. (ii) The rapidity with which it 1) Multiple minute superficial erosions which is conveyed from the source of bleeding to the are commonly seen in association with infantile anal orifice. (iii) Whether it has been in contact diarrheas, debilitating illnesses and where poor with acid secretions which give it a brownish perianal hygiene is apparent. Ten such cases colour as a result of the formation of acid hematin. were recorded but doubtless many more occurred It is not an uncommon error to fail to consider which went unmentioned in the discharge sum- these latter two considerations, for while it is (true mary and were therefore uncoded. The average that bright red bleeding usually indicates an ano- age of these patients was 9 months and the average rectal or at least a colonic lesion, large quantities duration of symptoms 4 weeks. In this type of of blood in the small intestine may be transmitted case the fissuring was usually ,of secondary im- along the bowel rapidly enough that it presents portance, the blood loss was minimal, and the at the anus as bright red in colour. erosions rapidly healed when the primary condition was corrected. Among the measures utilized to 4. Is the Blood Mixed With the Stool or Only minimize the perianal irritation, fastidious local on the Surface? hygienic measures, various analgesics and antibiotic Bleeding into the small bowel or colon above ointments and exposure to a heat lamp seemed to the sigmoid is usually intimately mixed with the be effective symptomatic measures. stool owing to the action of intestinal peristalsis 2) In addition to the group with multiple super- on the liquid or semi-solid feces. We have been ficial erosions were a group of 16 infants and surprised on reviewing charts to note how often children with the well marked symptomatology this information is missing, either because the and physical findings of a single anal fissure as because seen in the adult. In five of these the fissure had question was not asked or more commonly all the clinical features of a "chronic" anal fissure. the informant was unable to answer it. The age range in this group was 6 months to 10 years with an average of 4.4 years. The duration 5. What is the Relationship of the Passage of of symptoms varied from one month to nine years. Blood to the Passage of Stool? Four of the five patients with chronic fissures The significance of this can be best appreciated underwent surgical excision. The remaining 11 when specific disease entities are considered. cases had typical single acute ulcers that responded to conservative treatment. 6. Are There Any Associated Symptoms? Typical of the monotonously similar case histories The presence or absence of associated symptoms is that of a 7-year-old girl who was admitted to hospi- and their nature is probably the most helpful in- tal in 1955. Her mother stated that she had tended to formation in the establishment of a precise diag- be constipated since birth and had complained of pain nosis. The presence of abdominal or anal pain, at the time of defecation for five years. This pain had been much more severe for the past two years and nausea and vomiting and evidence of spontaneous frequently the stool was streaked with a small quantity extra-intestinal bleeding are among the more re- of bright red blood. For six months nocturnal anal vealing associated symptoms. pain had interfered with sleep. General examination was negative. Marked anal spasm was present but a DIFFERENTIAL DIAGNOsIs deep indurated anal fissure could just be seen in the midline posteriorly. The day after admission excision Once the history has been obtained in as com- of the fissure and anal dilatation was carried out and plete detail as possible, it seems to us a useful she was discharged two days later. There was no procedure to consider the differential diagnosis mention of any anal complaints when this girl was under certain broad groups, although the distinc- re-admitted one year later because of an upper respira- tions are obviously artificial ones. tory tract . Canad. M. A. J. 1042 REVIEW ARTICLE: RECTAL BLEEDING Nov. 4, 1961, vol. 85

There were no cases of fistula-in-ano or hemor- episodes when he was re-admitted for tonsillectomy rhoids in the charts reviewed and these conditions at age 6. Although the bleeding in this case was mini- are noted by most writers to be extremely uncom- mal it should be noted that on occasion it can be is massive. Two of the 12 cases presented with ex- mon in infants and children. The diagnosis sanguinating hemorrhage .vhich necessitated immediate relatively simply confirmed by inspection, rectal transfusion and resuscitative measures. and anoscopic examinations. Cases of bleeding due to foreign bodies inserted The occurrence of multiple polypi of the juvenile into the rectum have been recorded in the litera- type should not be confused with the distinct ture although we found none among our cases. entity, multiple familial polyposis. In the former The diagnosis is apparently invariably made on instance there is said to be no risk of malignant rectal examination and removal results in complete transformation and local excision is the ideal treat- cure. ment. The one such case that occurred in this Three cases of bleeding associated with rectal series warrants brief comment. prolapse occurred in the University of Alberta Hospital series but the bleeding was minimal, often In 1954, this 3-year-old girl was admitted to hospital noted only as a slight ooze on the toilet tissue, and for investigation of rectal bleeding of sufficient severity xvas invariably an inconsequential accompaniment to depress her hemoglobin to 10.6 g. or 73% of normal. of the obvious primary condition. Replacement of A palpable at 5 cm. was removed through the the prolapse and regulation of bowel function, with sigmoidoscope and two other polyps that had been or without strapping of the buttocks depending on demonstrated by barium in the the laxity of the sphincter, resulted in cure of the were removed by and colotomy. Re admis- bleeding along with cure of the prolapse. sion for investigation of persisting episodes of bright red rectal bleeding 8 months later revealed no source of bleeding. She was admitted again in 1958 when II. Syndromes Characterized by the Passage of she was 7 years of age because of a two-day history Bright Red Blood Without Associated of profuse rectal bleeding. Her hemoglobin on this Symptoms occasion was 9.4 g. or 65% of normal. After blood trans- Foremost among this group are: (i) Solitary and fusions had restored her blood volume to normal multiple juvenile polypi. (ii) Multiple familial barium enema examination revealed the presence of sigmoid intus- four polypi. One polyp at 3 cm. was removed through polyposis. (iii) Chronic recurrent the sigmoidoscope and three at laparotomy and susception. (iv) Neoplasms. (v) Meckel's diverti- colotomy, one in the sigmoid colon and two in the culum. transverse colon. All polypi were of the juvenile type. Rectal polypi are probably the commonest cause There has been no further bleeding in the last three of painless bleeding per rectum in infants and years. children. In the University of Alberta Hospital series of patients with proven bleeding polypi the There were no cases of multiple familial poly- age varied from 3 months to 8 years with an posis in this series. It is of interest to note that average age of 2.7 years. There was an equal distri- although this disease is hereditary it is not con- bution between the two sexes. In these 12 cases genital. Seventy-seven per cent of the cases in the the polyp was palpable on rectal examination in 1951 series from the Mayo Clinic9 occurred between nine and found only at in three. the ages of 20 and 39 years and only 8.4% occurred Barium enema examination was done in nine pa- before the age of 20. The series of McKenney'0 tients, but only in three of these was there any had a somewhat higher incidence in childhnod, radiological evidence of polypi. five of his 21 cases occurring before the age of 12. Eighty per cent of the 95 cases reported by the The following case history is representative. At 3 Mayo group had rectal bleeding and was years of age this boy had never had a sick day. In Multiple familial the five-week period prior to his admission to hospital a common associated symptom. his mother noted a small quantity of bright red blood polyposis must, of course, be recognized for what on the surface of his stool on three occasions although it is, a premaligant lesion. The high incidence the child had no spontaneous complaints. His two older of malignant transformation makes radical surgical brothers and his parents had never had any bowel excision mandatory. complaints. On examination a mobile, pea-sized polyp One should possibly mention, in passing, the was readily palpable at fingertip level in the rectum. rare Peutz-Jeghers syndrome in which gastroin- The long pedicle appeared to arise from the posterior melanin anal wall. Unlike most of the cases of polypi, barium testinal polyposis is associated with patchy enema examination in this case did demonstrate the pigmentation of the oral mucosa. While the polypi polyp. The hemoglobin was 13.3 g. or 91% of normal. in such cases are characteristically situated in the At sigmoidoscopy under general anesthesia the polyp small intestine and the clinical presentation is usu- was seen readily 4.5 in. from the anal margin and the ally that of small bowel obstruction, rectal bleeding pedicle sectioned at its base with a coagulating Frank- of feldt snare. The pathological report was ulcerated occurs with considerable frequency. In 60% benign rectal polyp of the juvenile type, 1 cm. in the 52 cases collected by Staley and Schwartz.2 the diameter. There was no history of further bleeding onset of symptoms was before the age of 20 \.ears. Canad. M. A. J. REVIEW ARTICLE: RECTAL BLEEDING 1043 Nov. 4, 1961, vol. 8.

Chronic recurrent sigmoid intussusception was were males .vith exsanguinating rectal bleeding in not recognized in any of our cases and is, as far whom the diagnosis of angiomatous malformation as can be determined, a new entity described by was made only at laparotomy. In both, recurrent Kiesewetter, Cancelmo and KoopY They suggest hemorrhages have occurred which, to date, have that in some children the normal redundancy of been successfully treated by blood transfusion with- the sigmoid colon is exaggerated allowing it to out further surgical intervention. In neither of these intussuscept into itself on straining. The intus- cases were cutaneous or naso-oral telangectasis susception is asymptomatic unless the succulent present, nor was there involvement of the limbs. leading point is traumatized by the presence of The future of these unfortunate children is un- constipated stool giving rise to minimal bright red certain. bleeding. The diagnosis is made by observing the A Meckel's diverticulum accounted for five of intussusception through an adult sigmoidoscope 113 cases of rectal bleeding reported by Kiese- and the treatment involves bowel training and wetter, Cancelmo and Koop." At the University of softening and lubricating the stool by means of oral Alberta Hospital, this lesion has been recognized mineral oil. Kiesewetter believes this type of lesion and removed from only 13 children under 16 years accounted for the symptoms in 18 of 143 "rectal of age in the last 10 years. In five of these the bleeders" investigated by him. removal of the diverticulum was incidental, the Benign and malignant neoplasms may occur in laparotomy having been performed for some other the large and small bowel of infants and children disease. In eight the diverticulum was the site of and although such lesions are extremely rare in the pathology which made surgery necessary, four this age group no consideration of rectal bleeding because of bowel obstruction, three because of would be complete without mention of this possi- hemorrhage and one because of acute . bilitv. In this connection it is of interest to note In the series reported by Gross,5 bleeding was the that "bleeding is very unusual (in children with commonest presenting symptom and occurred in colonic carcinoma) in contrast to adults in whom 33% of a group of 149 children. Eighty per cent it is the most common finding."'3 of the patients in Gross's series were under two Probably the most common childhood tumour of years of age and the patients in this area presenting the gastrointestinal tract which may give rise to with bleeding were all under one year of age. The bleeding, often profuse, is the . In addition usual sex incidence of Meckel's diverticulum is to the angioma many would also classify under about 70% males to 30% females, but all patients tuITh)tlrs of the gastrointestinal tract a wide variety below the age of 16 at the University Hospital were of angiomatous cumiditiuns which might better be males. classified as systemic diseases or congenital vascular The following case history is classical except that anomalies. Shepherd" in a very beautifully illus- (luring the minor prodromal bleeding episodes, trated paper has classified these lesions occurring which are frequently absent, the bleeding is more in the gastrointestinal tract as follows: commonly dark in colour.

(1) Osler-Remmdii Disease (Heredity Telangi- This 9-month-old male child was admitted to the ectasis of the and Mucous Membranes) University of Alberta Hospital in August 1959. The Clinically this disease is characterized by recur- infant had been perfectly well all his life although his rent epistaxis and the appearance of angiomatous mother had occasionally noted small amounts of bright lesions of the skim. of the face and mucous mem- red blood mixed with the stools during the preceding branes of the nose, tongue and lips. It is of par- five months. On the day of admission two large loose ticular interest to the surgeon because it is fre- bowel movements, apparently composed completely quentlv complicated by profuse rectal bleeding of bright red blood, were passed and the child showed from similar visceral lesions. A family history is evidence of moderate shock. Blood was administered frequently obtained. by the family doctor, and the child referred to the city. On arrival there were no physical findings of note (2) Parkes Weber-Klippel Syndrome (Hemangi- except that the child was p4le and bright red blood was noted mixed with the stool on rectal examination. ectatic Hypertrophy of the Limbs) The hemoglobin was 8.7 g. or 60%. An additional 600 This syndrome is occasionally complicated by c.c. of blood was administered in three transfusions over the next 36 hours by which time the stool was visceral angiomatous lesions. normal in colour and the hemoglobin was 83% of normal. Barium enema examination was negative and (3) Solitary oi' Multiple Angiomatous Lesions of four days after admission, at laparotomy, a Meckel's the Gastrointestinal Tract diverticulum was discovered and excised. The specimen The extreme difficulty encountered in the diag- demonstrated an ulcer at the base of the diverticulum nosis and treatment of such lesions has been im- mm. in diameter. The child's postoperative course pressed upon us by the recent occurrence of two was quite uneventful and there have been no further such cases in children in the Edmonton area. Both episodes of bleeding. Canad. M. A. J. 1044 REVIEW ARTICLE: RECrAL BLEEDING Nov. 4, 1961. vol. 85

III. Syndromes Characterized by the Passage of child was discharged. However he continued to Bright Red or Dark Blood in which the pass tarry stools intermittently. The child was re- Associated Symptoms are of Prime Concern admitted three months later because of recurrent and Importance hematemesis and at laparotomy the only lesion In this group are included: (i) Intussusception. present was an inflammatory reaction in the serosa (ii) Mesenteric . (iii) Volvulus. (iv) of the first portion of the duodenum consistent with Colitis. (v) Peptic Ulceration. the presence of an underlying peptic ulcer. He was Little need be said here about the first three subsequently placed on a rigid ulcer regimen and in this list, for the clinical syndrome is quite has remained well for the last six months without characteristic and the rectal bleeding is usually, further evidence of bleeding. although not invariably, a relatively minor con- sideration. IV. Syndromes Characterized by the Passage of The occurrence of severe episodic abdominal Altered Blood Per Rectum Without pain in a child 3 to 11 months of age associated Associated Symptoms with vomiting, pallor and followed by the passage In this group one might include: (i) Swallowed of the typical "current jelly" stool is diagnostic of blood. (ii) Swallowed foreign body. (iii) Eso- intussusception when physical examination reveals phageal varices. (iv) Reduplications of the bowel, a sausage-shaped mass in the right upper quadrant although it is appreciated that the speed of transit and an "empty" right lower quadrant. Mesenteric of the blood through the bowel may well be thrombosis is extremely rare in children but must sufficiently rapid to give rise to red rectal bleeding. be considered as a possible cause of strangulating Swallowed blood may appear at the anus after obstruction with rectal bleeding. Midgut volvulus bleeding from the nose, or surgical or accidental commonly occurs in the first three weeks of life trauma to the nose and mouth, in which case the and although profuse rectal bleeding has been origin is obvious. The blood usually is intimately recorded as the presenting complaint in this disease,3 mixed with the stools, small in amount and black it is more commonly absent than present because in colour. Of more interest and possible confusion the bleeding tends to occur into the closed loop is the swallowed blood syndrome observed in the rather than appearing at the anus. In any case the newborn. Maternal blood swallowed by the infant obstructive symptoms rather than the bleeding will be the outstanding feature of the disease. In all at the time of delivery characteristically appears as three of these diseases immediate surgical inter- a reddish stool within seven to 30 hours after birth. vention is indicated except possibly in intussuscep- Because this occurrence may be confused with tion in which a barium enema may be a therapeutic hemorrhagic disease of the newborn it is useful to as well as diagnostic maneuver. observe the action of alkali on the blood passed.' A brief word may be in order referable to colitis Alkali denatures adult hemoglobin to a brown as a cause of rectal bleeding. Many children pass colour while fetal hemoglobin retains its pinkish small amounts of blood along with loose stools colour. in acute non-specific enterocolitis. Of more import- The swallowed foreign body as a cause of gastro- ance and significance is the protracted passage of intestinal bleeding is rare. This is truly remarkable blood, pus and watery stools in cases of the specific when one considers the nature of the various dysenteries, amebic and bacillary. One must add articles which have passed through or been re- to this list chronic idiopathic ulcerative colitis, moved from the gut without the slightest evidence for though more common in young adults this of mucosal laceration. disease is being reported with increasing frequency Portal hypertension with is in infancy and childhood. Its recognition in this age not uncommon in children. It is more commonly group is of particular importance because chronic due to an extra-hepatic block. While melena almost ulcerative colitis may be associated with retardation invariably accompanies bleeding from varices, the of growth and developn.ent and demand consider- massive vomiting of bright red blood which almost ation of extensive surgical resection before the age inevitably occurs is by far the more prominent and of puberty. outstanding symptom of the disease. Duodenal ulcer, like idiopathic ulcerative colitis, Duplications of the bowel are rare but when they is a disease that is being recognized to occur in occur in relation to the small bowel, the common infancy and childhood with increasing frequency.2 site, bleeding per rectum may be the presenting The single case to come to our attention in the symptom. The blood is usually small in amount, University of Alberta Hospital records was a male mixed with the stool and dark in colour though child who was first seen at age 22 months with a it may be massive and red in colour. Palpation of history of abdominal pain, melena and a single the may reveal the presence of a mass. episode of massive hematemesis. No definitive diag- Surgical excision of the duplication is the treatment nosis was reached during that admission and the of choice. Canad. M. A. .* REVIEW ARTICLE: Rlx.rAJ.. BLEEDING 1045 Nov. 4, 1961, vol. 85

V. Syndromes Characterized by the Passage of testinal bleeding the gums should be observed for Altered or Bright Red Blood Per Rectum with evidence of vitamin C deficiency. Rectal bleeding or without Associated Symptoms not uncommonly occurs in leukemia but usually In this miscellaneous group the systemic diseases, only late in the disease when the diagnosis is un- in which rectal bleeding may be one of, or the fortunately all too obvious. sole, manifestation of an underlying bleeding tendency, may be considered. While there are in- SUMMARY numerable diseases which might be so classffied The major etiological factors capable of producing one must be familiar with the five most commonly rectal bleeding in infants and children have been re- encountered, namely: (i) Hemorrhagic disease of viewed and the features of some of these diseases have the newborn. (ii) The purpuras, both nonthrombo- been illustrated with typical case histories. One must cytopenic and thrombocytopenic. (iii) Hemophilia. remember that this symptom, while often of little (iv) Scurvy. (v) Leukemia. consequence, may well indicate the presence of a Hemorrhagic disease of the newborn is the com- potentially lethal lesion. For this reason, the patient must be carefully investigated by means of a complete monest cause of gastrointestinal bleeding in the history and a painstaking physical examination, with first week of life and is usually associated with special attention to the specific diagnostic features of bleeding from other sites. It is due to a multiple those diseases capable of giving rise to this symptom. coagulation factor deficiency and is treated by the In addition, sigmoidoscopy, barium examination of the administration of vitamin K and fresh blood. gastrointestinal tract and blood studies for coagulation In the purpuras the rectal bleeding is usually defects will often be necessary to establish or confirm only one of many hemorrhagic manifestations. the diagnosis. Occasionally emergency laparotomy will be indicated for life-endangering massive hemorrhage Recently a 10-year-old girl was seen who had an where the preoperative work-up has of necessity been idiopathic thrombocytopenic purpura for four years incomplete. In such cases an intimate knowledge of and in whom a satisfactory remission had not been the many and varied pathological lesions capable of achieved with adrenal steroids. She was admitted to causing rectal bleeding and of their treatment may well hospital with a 12-hour history of profuse bright red be life-saving. rectal bleeding. Her platelet count was 11,000 per c.mm. on admission and after a period of reassessment REFERENCES and preparation with several blood transfusions, splen- 1. APT, L. AND DOWNEY, W. S., JR.: J. Pediat., 47: 6, 1955. ectomy was performed. Her initial platelet response 2. BIRD, C. E., LIMPER, M. A. AND MAYER, J. M.: Ann. Burg., was most gratifying and the count returned to normal 114: 526, 1941. 3. DEL JUNCO, T. AND FRANCO, R.: Ibid., 147: 112, 1958. in seven days. It is now only seven months since her 4. JACKMAN, R. F., BARGEN, J. A. AND HELMHOLZ, H. F.: operation and we are anxiously following her progress Am. J. Ds8. Child., 59: 459, 1940. 5. GRoss, R. E.: The surgery of infancy and childhood, in the hope that the remission will be maintained. W. B. Saunders Company, Philadelphia, 1953. 6. KIESEWETTER, W. B., CANCELMO, R. AND Koo., C. E.: J. Pediat., 47: 660, 1955. The diagnosis of hemophilia is usually suspected 7. KooP, C. E.: Pediat. Olin. North America, 3: 207, 1956. from the family history and the past history 8. LYONS, A. S. AND BARoNoFsKY, I. D.: B. Olin. North of America, 40: 999, 1960. previous hemorrhagic episodes. It is confirmed 9. MAYo, C. W., DEWEERD, J. H. AND JACKMAN, H. 3.: Burg. by the demonstration of the typical Gynec. 6 Ob8t., 93: 87. 1951. coagulation 10. MCKENNEY, D. C.: Am. .7. Burg., 46: 204, 1939. defect. 11. SHEPHERD, J. A.: Brit. .7. Burg., 40: 409, 1953. 12. STALEY, C. J. AND SCHWARZ. H., II: Internat. Abstr. Burg., Scurvy is an uncommon disease today, but where 105: 1, 1957. In: Burg. Gynec. . Ob,,t., July 1957. avitaminosis is suspected as a cause of gastroin- 13. WILLIAMS, C., JR.: Anin. Burg., 139: 816, 1954.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO PREVENTION OF ECLAMPSIA Knowing that there are symptoms of toxiemia, however mild, present, which may rapidly grow worse, what treat- Since it is late on in the toxmmia that the kidneys are ment should be adopted? For very slight cases, probably affected, the examination of the urine for albumen as a calomel and soda, grs. ii, every second or third night, guide to the condition is worse than useless. In most of the followed in the morning 'by a hot seidlitz, and the cutting large modem clinics the urine is examined for urea. It out of meat and increasing the amount of milk taken, will matters not what the urea may 'be split up into, if the be enough. In more severe types of toxiemia, it will be normal amount of about 472 grains a day be diminished necessary to give the patient a hot p.ick one day and a it is necessary to give treatment to the patient or the condi- purgative the next. Iron and digitalis, a skim milk diet tion may rapidly go on from bad to worse. I believe that and absolute rest in bed, are indicated. If the case becomes this precaution is an absolute essential in every case of progressively worse and the treatment fails to improve the pregnancy, and symptoms of a toxmmia severe enough to tooaemia, it then remains to consider seriously producing an kill may arise at any time after two and a half months, abortion or premature labour.-H. L. Reddy, Caned. M. A. and some go as far as to say any time after six weeks. J., 1: 1067, 1911.