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do we not necessarily increase the hæmorrhage, and place the patient in a worse condition than before? We must frankly confess that, whilst we are open to conviction on this point-nay, are anxious for it-we do not think that any of the cases adduced by Dr. Barnes sufficiently establish the point. Indeed, the latter sentences of the extract we have last given, admit that it will not necessarily do this, but “ that the uterine vessels may pour forth blood until the hæmostatic resources of nature or art come into play.” In cases of slight flooding this may possibly not signify much, but surely in many of the cases of alarming hæmorrhage such an increase might make the difference between life and death. We have seen many in which every additional ounce lost was a matter of extreme importance. Might it not be better to have recourse to the hæmostatic resources of art, until uterine contraction is established, without further detaching the placenta ?
3. When regular pains exist, with the placenta down to the edge of the os uteri, as in many of the cases related by Dr. Barnes, we see less objection to his proposal. The cervix will be freed thereby to contract and close the open mouths of its vessels, and the rupture of the membranes will increase the pains, and bring down the child's head. But even supposing there be no objection, we may still ask, Is it necessary! We have repeatedly treated such cases by rupturing the membranes, and the exhibition of the ergot of rye, and as yet we have always found the hæmorrhage cease, and have never been obliged to introduce the hand and deliver.
If the placenta extend balf over the os uteri instead of being limited to its edge, we think that Dr. Barnes's plan may be very useful, for unless the pains are very strong, the small covering portion of the placenta may be an obstacle to the descent of the head, even after the waters are evacuated; whereas, if it were freely detached, it would be easily pushed into the vagina by the head, and labour facilitated. If the pains were good, we should have no fear of much increase of the hæmorrhage.
4. The severest test of any new proposal would be the cases of central implantation of the placenta, where the hæmorrhage is always excessive, and which every pain increases. The extent of detachment by the pains alone will probably be much greater; it may be two or threefold as much as in lateral placenta ; and if we may judge from our own experience, these cases have been by far the most formidable that we have met. It is true that in such cases the uterus is in action; but may it not be reasonably doubted whether the presence of the placenta would not prevent such a contraction as will arrest the hæmorrhage? And, in such extreme cases, should we be warranted in incurring the risk of even a moderate addition to the flooding? If detachment of one side of the placenta will lead to that portion being protruded into the vagina, with or without a little help, it might be advantageous, as it would permit the descent of the head after the waters were evacuated; and this peculiarly in cases where the loss has not been great, and where the os uteri is not very dilatable. It has been frequently remarked--and our own experience has corroborated the observation, that in the extreme cases, the os uteri is generally so much relaxed that the introduction of the hand can be effected without much force.
We must ask pardon of the reader for these observations ; but in placing before him the very ingenious views of Doctor Barnes, we have felt it right to test their applicability to some of the cases of daily practice. If we have thrown out doubts, it has been because as yet the novel method has not been sufficiently tested; and where life and reputation are at stake, no step should be taken but upon adequate grounds.
We have read Dr. Barnes's book carefully, and with very great pleasure. It has increased our respect—which was very high before--for his accurate knowledge, his professional acumen, and his ingenuity. Though belonging to an older school than Dr. Bårnes, we are not too old to learn, and we shall thankfully receive from him proofs that our caution bas been unnecessary, and our doubts unfounded.
1. A Practical Treatise on the Diseases of Children. By J. Forsyth MEIGS, M.D.,
Fellow of the Royal College of Physicians of Philadelphia, &c. Third edition, carefully revised--Philadelphia, 1858.
724. 2. Recherches sur les Maladies des Enfants Nouveau-Nés. Par V. Seux, Médecin-en
chef de l'Hospice de la Charité de Marseille. Arts., Du Pouls chez les Nouveau
Nés-Entérite simple.- Paris, 1855. pp. 288. Researches on the Diseases of New-born Children. By M. Seux, &c. Arts., On the
Pulse in New-born Children.-Simple Enteritis. 3. Der Abdominal-Typhus der Kinder. Von EDMUND FRIEDRICH, Doctor der Medicin
und Pract. Arzt zu Dresden.-Dresden, 1856. pp. 102. The Abdominal Typhus of Children. By E. FRIEDRICH, M.D., &c. 4. (1. Fièvre Typhoide. (2.) Généralités sur les Catarrhes, Congestions, Phlegmasies
et Ramollissements de la Membrane Muqueuse Gastro-Intestinal. (Articles contenus dans le . Traité Clinique et Pratique des Maladies des Enfants.' Par MM. RILLIET
et Barthez.—Paris, 1858. Tomes i. et ii. pp. 655, 663.) (1.) Typhoid Fever. (2.) Catarrh, Congestion, Inflammation, and Softening of the
Gastro-Intestinal Mucous Membrane. (Articles contained in the Practical and
Clinical Treatise upon the Diseases of Children.' By MM. Rilliet and Barthez.) 5. An Inquiry into the Nature of Typhoidal Fevers, based upon a Consideration of
their History and Pathology. By HENRY FRASER CAMPBELL, A.M., M.D.-Phila
delphia, 1857. 6. On the Identity or Non-Identity of Typhus and Typhoid Fever. By GEORGE
YATES, M.R.C.s., Surgeon to the General Dispensary, Birmingham. (Midland
Quarterly Journal,' Oct. 1857, p. 200.) 7. Ueber die Veränderung der Peyer'schen Drüsengruppen und der isolirten Darm
drüsen bei ganz kleinen Kindern. Zweite Abhandlung über die Veränderung der Peyer'schen und isolirten Darmdrüsen bei Kindern im zarten Alter. Von Dr. E. Hervieux. (*Journal für Kinderkrankheiten, Band xxvi. s. 131 ; Band xxix. s.
213. 1856, 1857.) On the Changes undergone by the Glands of Peyer, &c., in very Young Children. A
Second Treatise upon the Changes undergone by the Glands of Peyer, dc., in Early Age. By Dr. E. HERVIEUX, of Paris. Translated from the French in the German
Journal for Diseases of Children’ for the years 1856-7. 8. Bemerkungen über Dr. Carl Schneeman's Schrift: Die Fett-einreibungs-Methode in
ihren Heilwirkungen gegen Scharlach- und Masernkrankheit. Von Prof. MAUTHNER,
in Wien. ("Journal für Kinderkrankheiten,' Band' xxi. s. 289.) Remarks upon Dr. Schneeman's Essay upon the Infriction of Fat as a Therapeutic
Agent in Scarlet Fever and Measles. By Professor MAUTHNER, of Vienna. (“Journal for Diseases of Children,' vol. xxi. p. 289.)
Nearly ten years have elapsed since we introduced Dr. Meigs to the notice of our readers. At that period pædiatrics had just entered upon a stage of advancement which, happily continuing, has caused this department of pathology to keep pace with the most progressive branches of the science and art of Medicine. Before that time the well-known work of Dr. Underwood was the authority concerning the numerous ills that children are subject to. But latterly it became displaced by the far more scientific treatise of Drs. Evanson and Maunsell—a work which, considering the way in which the diseases of early life were studied in Great Britain, was one of considerable merit, though very much of a compilation. Year after year the afiche of each hospital displayed upon its face the comfortable assurance that it continued to be the anxious duty of the lecturer upon midwifery to initiate the student into a knowledge of the Diseases of Women and Children." What amount of information was ever proffered upon the latter subject we are yet ignorant of. We ourselves passed through the usual
novitiate, but the “ Diseases of Children” were known to us only as a myth. Were others more fortunate? We doubt it. Even at the present day—but we will not be personal; though we must say it would look better, for the future, to say the least of it, to discontinue pædiatrics as the mere caudal appendage of the obstetric physician. On the Continent, the systematic investigation of the diseases of early life had already made great progress—as evidenced by such works as those of Gölis, Billard, Berton, Barrier, Meisner, Valleix, &c.; and since the eighteenth Floreal of the tenth year of the Republic, Paris could boast of a hospital for sick children. But abroad a new era of progress commenced with the appearance of the now classic work of MM. Rilliet and Barthez (1843). Few voluminous treatises have more rapidly attained a safe and worthy hold of the profession than have theirs; and we do these writers no more than justice, when we say that the present high development of this branch of practical medicine owes very much to their influence. In this country, the publication (1848) of the Lectures of Dr. West was certainly the means of spreading amongst the profession generally a scientific knowledge of the information then possessed by a few persons of the diseases of infancy and childhood. The success of the treatise of MM. Rilliet and Barthez rise to several more or less successful compilations or réchauffés upon the Continent; whilst here, the Lectures of Dr. West have prompted to the same proceedings. The scope and merits of these various undertakings, both British and Foreign, have, as they appeared, been brought before the notice of the readers of this Journal, together with such references to the more important articles in the very useful German Journal for the Diseases of Children' as might serve to keep such as were interested in pædiatrics fairly au courant with the progress of the day. In continuance with such views, we again bring forward Dr. Meigs, with a commentary upon some of the more important essays which have lately appeared upon the important subject of typhoid fever in the child. When we before subjected Dr. Meigs to critical revision, we felt compelled to animadvert upon one or two drawbacks which existed to the utility of his treatise. glad to find that in the present edition several of them are materially diminished. In the first place—though still much of a compilation—his work has the advantage of the results of ten years' practical experience. Secondly, in place of that undecided indefinite way of discussing treatment followed in the first edition, we have here a clearer and more precise style adopted; and we now learn what Dr. Meigs has done, and what he believes should be done-instead of, as before, only what he would do. Further, several articles have been re-written, new ones added, and the work generally sought to be made a repertory of the latest researches in its particular department. But it is yet capable of much improvement. It is true we have so constantly MM. Rilliet and Barthez before our mind, that we become rather fastidious critics—the more so as we freqnently feel disposed to inquire, where would be most of the works published within the last fifteen years, if these able investigators had themselves chosen to remain silent ?
We shall now proceed to notice some of the principal changes and additions made to the work since its former appearance. The first in occurrence is the “ Introductory Essay on the Clinical Examination of Children." Upon this point we could scarcely expect much novelty, nor have we found it, preferring, too, the manner of M. Bouchat's more free and facile sketches. There is room for a few remarks notwithstanding. Aluding to the pulse and rate of the circulation in very young infants, Dr. Meigs follows M. Billard, giving it as from 101 to 102 in the minute, qualifying the assertion that though this was the average frequency in 40 children, it was less than 80 in 18, in 14 between 100 and 125, and in 6 between 130 and 180; all these children presenting the appearances of good health. Upon this subject great difference of statement has existed. Floyer fixed the number of pulsations of the new-born child at 134 in the minute, Haller at 140, Sæmmerring at 130, Valleix the minimum at 76, the maximum at 104, Trousseau, minimum, 96, maximum, 164; whilst Jacquemier numbered from 96 to 156 pulsations in children twenty-four hours old, and M. Lediberdier 140 to 208 in those born only four minutes. This great variation of 132 recorded, lately induced M. Senx to re-investigate the matter, and the résumé of the tabulated results of the observations of 75 cases is as follows:
" The existence of 164 pulsations in the new-born child during repose does not in itself imply a state of disease-in fact, the palse may vary in health and quietude from 80 to 164 pulsations in the minute. Nevertheless, the numbers comprised between 120 and 140 are those more frequently noted in nearly half of the cases. Next come those between 100 and 120, then those above 160, and finally those below 100. The sex, constitution, the greater or less salubrity of the habitation, and the time of year, do not exert any influence upon the frequency of the pulse. The latter is more frequent during the first hours of life, but then, from the first day to two months, no differences can be determined as really due to the age of the child.” (p. 12, op. cit.)
Both M. Seux and Dr. Meigs rightly prefer expressing by the term “ irregularity" that change in the rhythm of the infant's pulse alluded to by M. Bouchut as an intermittence. We assume, from the conjoint observations of M. Seux and Becquerel, that this irregularity is far less frequent in new-born children than in those above a year old, and the greatest irregularity occurs when the pulse is lowest, as in sleep. According to Dr. Meigs, the chief practical bearing of this fact is that
“We should be careful not to lay too much stress upon slowness and irregularity of the pulse as signs of tubercular disease of the cerebral meninges, unless they are observed during the waking state, and in connexion with other symptoms, particularly with vomiting, constipation, and severe headache.” (p. 36.)
The following remarks are worthy of remembrance :
“ Violent and obstinate crying is almost always caused by severe pain-such as the pain of ear-ache ; indeed, obstinate and long-continued crying lasting for hours is rarely met with, except from one of two causes--ear-ache or hunger. The cry of ear-ache is often incessant and unappeasable, the pain being generally constant and not paroxysmal, as are most other pains. It is to be silenced only by the application of remedies to the ear or by the internal administration of opiates. I have known an infant three months old to scream with ear-ache for two days and nights, with only short lulls of a few hours, when brought under the influ. ence of large doses of laudanum. As soon as the ear began to discharge, the cry ceased. I am constantly called to see infants and young children who have been crying most violently for hours, and who are thought to have colic or to have hurt themselves, and who are, in fact, tortured with that most violent of all pains, ear-ache. I have met with few instances in which such severe and constant crying has depended on other causes, for though children scream violently and obstinately froin hunger and thirst, they may always be quieted by the supply of either want, whilst in ear-ache, the infant generally refuses the breast, or takes it only for a few instants, and then lets go to resume his almost automatic scream.” (p. 25.)
In his remarks upon the “ Examination of the Abdomen,” the author recommends a plan as first proposed by M. Valleix in the case of young infants, and by which tenderness upon pressure may easily be recognised. The
child is to be carried suddenly before a bright light, one of its greatest pleasures apparently consisting in gazing at such a thing. It almost always ceases to scream and continues quiet whilst thus attracted. Seizing such an opportunity, the attendant should
pass his hand under its clothes, and applying it directly over the abdomen, he may first learn by a rapid palpation of its surface its general characters, and then ascertain by sudden and decided pressure whether the stomach be abnormally sensitive. If the pressure cause pain, the child will cry out at the moment, while at the same time a sudden contraction of the countenance will assist in showing the perception of some painful sensation. Should the child, on the contrary, continue to gaze fixedly at the light without heeding the interference of the physician, it will be fair to assume there is no inflammatory tenderness present.
The several chapters relative to affections of the upper air-passages have been re-arranged and re-written. The conclusion to which Dr. Meigs has come is that,
“There are but three distinct diseases of the larynx, which deserve to be considered as separate and distinct affections; these are simple ordinary erythematous inflammation of the larynx, unattended with spasm of the glottis, or, as that symptom has been emphatically named, laryngismus; simple erythematous inflammation of the larynx, attended with laryngismus, and called most properly, spasmodic simple laryngitis, or more commonly, simple false spasmodic or catarrhal croup; and, lastly, pseudo-membranous inflammation of the larynx, properly namedpsendo-membranous laryngitis, and more commonly called true or membranous croup.” (p. 62.)
Laryngismus stridulus, or “spasm of the glottis,” is viewed by the author as " but one of the many symptoms that mark the dependence of the disease upon disordered action of the reflex portion of the general nervous system.” We cannot entirely coincide in Dr. Meige's opinions; our own views may thus be expressed 1stly. There is a more or less acute and sthenic form of inflammation of the larynx chiefly or almost alone, or of the trachea, with more or less involvement of the larynx, bronchia, &c., accompanied by croupose deposit or membranous exudation. This disease commences in the parts below the epiglottis, and constitutes the ordinary disease known as “croup,” in bleak northern climates like our own. 2ndly. There is a low asthenic and less acute form of inflammation, accompanied by a darker coloured, softer, and more pultaceous deposit, commencing in the parts above the epiglottis (uvula, tonsils, throat, &c.), which afterwards spreads into the air passages, destroying life. This affection constitutes the ordinary croup of many malarious regions, is the common form of croup in a great part of France, and in this country is more frequently seen as complicating the exanthemata, or as occurring in warm, damp autumns, and near the banks of low rivers and streams. It is the diphthérite or diphtheritic croup" of authors. 3rdly. There is a disease marked by symptoms intermediate between laryngeal or tracheal croup and “ laryngismus stridulus." It partakes of a certain amount of the inflammatory action of ihe former and of the nervous symptoms of the latter, the intensity and ratio of which vary in different instances. In some cases the spasmodic element is exceedingly prominent, whilst in others the inflammatory one is so decided as to give rise to apprehensions for the safety of the child. În some cases a chronic form of this malady is continued even for months. Certain instances of this variety of laryngeal disorder are confounded with the exudative one, or croup; whilst others in which the spasm of the glottis is severe, are often regarded as examples of laryngismus stridulus. This disease constitutes the “spasmodic laryngitis” of many authors. Lastly, there is laryngismus stridulus, or "spasın of the glottis,” a secondary functional disturbance following in the train of more primary or of organic changes of diverse kinds. Dr. Meigs discusses at considerable length the question of "tracheotomy" in "pseudo-membranous laryngitis.” He is an advocate for its performance under proper circumstances, and concludes by remarking that
" Even if we adopt the worst view of the case, and conclude that it is impossible by any means now within our reach to determine the extent to which the exudation may have invaded the air-passages, it is still very doubtful whether for that reason we ought to abandon the operation. In effect it has been well established by numerous observations which have already been detailed, that the membrane extends into the bronchia only in a third of the cases, leaving two-thirds in which it remains limited to the larynx alone, or to the larynx and trachea. The question becomes, therefore, one of expediency, whether to leave two-thirds of the patients, some of whom inight be saved by the operation, to perish without an effort to save them, because one-third must probably die, or to perform it almost without a prospect of success in a third for the sake of the chance of saving some of the remaining two-thirds who must otherwise die.” (p. 116.)
Upon this subject we may refer the reader to a paper read by Dr. Fuller before the Medico-Chirurgical Society at the beginning of last year, an abstract of which will be found in the Medical Times and Gazette' for February 7th, 1857.* The next addition to our author's treatise is a pretty full chapter upon “atelectasis pulmonum, or imperfect expansion of the lung." Following the majority of recent
+ See also Ranking's Abstract, vol. XXV. p. 61.