No.263.

LONDON, SATURDAY, SEPTEMBER, 13. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY,DELIVERED AT GUY’S HOSPITAL BY

DR. BLUNDELL.

LECTURE XXXIX.

Strictures on the Diseases of Young Children. I

OF the diseases of infants, it is not mydesign to treat at large, as such an under.taking would lead me into longer disquisitionsthan the limits of our course will admit.In this and the following Lectures, how-ever, I shall endeavour to make a few stric-tures on this important topic, confining my-self, in the main, to that sort of informationwhich may be of use at the bed-side, begin-ning with those affections which belong tothe department of surgery.When labours are laborious, in conse-

quence of resistance to transmission,whether from rigidity, coarctation, or unfa-vourable position of the foetus, it happens,not infrequently, that the scalp becomesintumescent, the tumour commonly lyingto the one or other side of the vertex.-This swelling rarely requires art, thoughfomentations and lotions may sometimes beused as placebos, the tumour wasting, inmost cases, in the course of a few days, sothat the part soon acquires the natural ap-pearance. Accumulation of the scalp, andperhaps effusion into the cellular web be-neath, appear to be, in most cases, thecauses of the intumescence. With theseswellings of the scalp, inflammation and

suppuration are now and then combined,though rarely; these, so far as I have hi-therto seen, doing very well, as treated onordinary surgical principles. Suppurationis, I suspect, generally external to the ten-don of the occipito-frontalis muscle. In-flammations of the scalp in infants are, per-haps, more dangerous than similar inflam-mations in the adult, as the vascular com-

munications between the inner and outersurfaces of the cranium are numerous andfree.The cranial bones, as may be seen in

this faithful model, are exceedingly move-able, and hence, in laborious labours, theyfrequently become displaced ; the occipitalbone being pushed, perhaps, beneath the

posterior edge of the parietals, or the mar-gin of one parietal bone becoming lodgedbeneath the margin of the other ; not to men-tion that the whole cranium may be thrownback upon the occipital region, or so dislo-cated, that the summit rises preternatu-rally above the basis, as may be seen in thecrania of certain savages, when deformed bybarbarous art. Now, in these compressionsof the brain,the foetus is not infrequently stillborn; and you use the warm bath and theartificial respiration, with little effect be-

yond the excitement of a few sighs, and alittle unavailing respiration. It is to be ob-served, however, that the death of the foetusseems to depend upon some other causethan the mere force of the compression, asfœtuses may be born still when the colloca-tion of the bones is little altered ; or theymay breathe, struggle, and cry, directly theyenter the world, although, from the defor-mity of the head, and the intumescence ofthe scalp, and its evident and forcible

compression during transmission throughthe pelvis, irreparable injury of the brainseemed, at first thought, to be inevitable.Whatever the apparent injury of the head,therefore, attempts should be made to re-suscitate the child by the bath and pipe ; nocase ought to be left, as desperate, till theseactive resuscitants have been found on trialto fail. The mobility of the bones seems torender unnecessary the replacement of themby active surgical means. Accordingly, ofthese means I have had no eahet ience in thecases under consideration, and I forbear,therefore, to give an opinion respectingthem.In facial presentations, the form of the

features sometimes suffers but little; but, inmany instances, in consequence of accumu-lating blood, and swelling, and a certainparalytic weakness of the neck, which allowsthe head to fall about unsupported, the ap-

738

pearance of the face becomes frightful, notto say hideous. These cases, however,generally do well ; in the course of a fewdays or weeks the parts recover their healthycondition, and you are surprised to see a

countenance, at first so disfigured, adorned,at last, with all the pleasing graces of in-fancy. The head may be steadied by tapesannexed to the cap and the dress below,and much attention must be given to its duesupport during nursing. The swelling’may,I believe,in general, be committed to nature;time and patience will accomplish the rest.

IIaighton, by dividing the 8th pair ofnerves successively, at the interval of a fewmonths, proved satisfactorily, that nervousstructure may be repaired. The recovery ofthe sciatic nerve in Koscioscow, after severeinjury inflicted by a Russian bayonet, hasalready been made the subject of remark.Violence has no place in a wise midwifery,yet now and then it breaks unawares intoour operations, and seldom without mis-chief. In presentation of the nates, as Iam informed, under rough management, theanterior crural nerve has been severely in-

jured, and less rarely, perhaps, in thosecases in which the arms have been abstract-ed with difficulty, the axillary plexus hasbeen severely bruised ; an iron hook, or arude finger, are said to be the usual instru-ments by which injury is inflicted-bewareof violence, therefore ; but should injurybe sustained, remember that the case is notwholly desperate ; the nervous structure,unless extensively injured, may, perhaps,recover itself. Much is to be expected fromNature in these cases-little from art.-Comfort the 1*riends with these reflections.

In a scientific midwifery, violence hasno place ; this apothegm cannot be too fre-quently repeated. Even tempered effort isnot without its dangers : it is a sort of ele-

phant in the battle. Sometimes, however,fractures of the fœtal skeleton occur duringdelivery, and the bones which most fre-quently suffer, are those of the thigh andthe hind arm, to which may be added theclavicle, and perhaps the bones of the pel-vis, and the maxilla inferior. The mereaction of the uterus may, perhaps, breakthe foetal bones; but Nature, provident inher operations, has rendered this accidentrare. More frequently under preternaturalpresentations, when, in the drowsy moment,undue force creeps upon us, fractures of thethigh or arm, or clavicle, occur in rude at-tempts to extricate the limbs. 11 I alwaysbreak the thighs," was the downright, un-blushing, declaration of a female practitioner,when stating to Dr. Lowder her method ofmanaging the presentations of the nates.I love her honest plainness. Even Sir An-

thony’s language could not be more explicit.- Beware.

In ordinary deliveries, it is unnecessaryto examine whether the bones are fractured; -,but in all preternatural cases, where, fromthe difficulty of the birth, a fracture maybe suspected, examination should be made.On the general principles of surgery thesefractures may be treated ; much constitu-tional irritation does not attend the processof reparation. As nutrition at this age is

rapid, repair is rapid. From cutting a tooth,an infant may suffer more, and more dan-gerously, than from a fracture of the femuror the humerus. Four cases of fracture, twoof the humerus, and two of the thigh-bone,all ultimately doing well, have been narrat-ed to me by my friends. Might not splintsbe made conveniently of softered paste-board, or papier muché ? Many a wittythought has issued from a French snuff-box;perhaps this may be made a useful one.

Hernia of the brain is sometimes formedwith the foetus, as these preparations show;but I forbear to dwell on this monstrosity,as, in the present state of knowledge, itadmits no remedy. More frequently wefind at birth, on the parietal bone, an en-cysted tumour, larger than half a pullet’segg, and which may take place to the rightor the left of the sagittal suture. That achasm of the parietal bone, leading intothe cranium, never exists at the basis ofthis tumour, I am not prepared to assert;but in general, that part of the bone wliic4corresponds with the inner table is corn.

plete, the external leaf being alone deficient.The defect of the external table, however,gives rise to extensive superficial excava.tion, the margin of which may be felt allround at the base of the cyst, and this mar.

gin is liable to lead the uninformed into anopinion, that there is a large chasm openingdown into the brain, to the great alarm ofthose who are about the little patient.

It is not wise to press the brains of a younginfant with a tiglit’bandage, for, as our infor-mation now lies, this will, I presume, be

acknowledged, on all hands, to be a dange.rous experiment. Do not, therefore, in thesecases, apply a bandage to the cranium, forthe bones being mobile, any pressure madeon them might be transferred to the brain,which lies beneath. Do not hastily puncturethese tumours ; the two surfaces of the cra-nium, external and internal, communicatefreely by the emissory vessels: the brain ofthe infant is prone to inflammation, andfrequently these inflammations prove fatal.Durate et rebus vosmet servate secundis.Time and patience cure a vast number ofevils, physical, mental, and moral, and thesetwo Catholic remedies, accompanied byplacebos, are, perhaps, the best which maybe employed here. Astringents and stimu-lants, however, do seem to be tried with novery doubtful advantage; and port wine,lees,

739

and aluminous solutions, are alternative to-pical remedies which, from my little expe-rience in these cases, I should feel disposedto recommend. Let your first applications beweak, for the infant skin is tender and proneto mortify; as the parts may bear, the in-tensity may be increased. The lees may bediffused through bread, so as to form a poul-tice ; of the alum you may make a lotion,beginning with a scruple, to six ounces ofwater. The alum failing, let the lees betried. Glairy fluid issues when these cystsare punctured ; at least, if I may infer ge-nerally from a single case, which used to berelated by Dr. Haighton.

In young infants, the nymphee, or .thelabia pudendi, are occasionally coherent ;the labial cohesion being easily discrimi-nated, while that of the nymphs requiressomewhat closer inspection. When thelabia are opened, the nymphse being incohesion with each other, in consequenceof this separation, the nymphæ are laid flatover the orifice of the vagina, and theblood being pressed out of the vessels, thewhole structure becomes pale and scarcelydistinguishable from the surrounding parts,so that, at first glance, it seems as if therewere no nymphne, and as if the vaginalorifice did not exist. The gradual approxi-mation of the labia under which the nvmphsebegin, as it were, to form afresh-the in-terposition of a probe easily passed alongbehind between the cohering nymphae, andthe entrance of the vagina-the declarationof the nurse, that the orifice of the vagina,though now totally vanished, was originallyobvious enough, as in other children, (forthe disease is not usually congenital)-theseare the principal diagnostics by which thecase is discriminated. A knife in thesecohesions is rarely required; mereseparativepressure is, in general, sunicient to disjointhe parts; or when the probe has been

properly placed, so as to bear upon the

connexion, this may often be gently tornasunder, by merely advancing the instru-ment : take care that the cohesion is not re-newed.

With imperforation ofthe genitals, infantsare sometimes born, and this with two con-ditions of the parts within, for it sometimeshappens, that the internal genitals are

more or less deficient, while, in othercases, they are formed perfectly enough,withthe exception of the barrier, which closesthe access from the inferior parts to the su-perior. When the inferior organs are im-perforate and imperfect, it ought always tobe our first consideration, whether those or-gans which lie above, are in a healthy stateor not-the ovaries, I mean, and womb andvagina. It would be too much to assert,that the determination of these points is

wholly impracticable, even during the first

two or three years of infant life; but itshould not be forgotten, that the most com-modious season for deciding this vt-ry im.portant question, is after the period of pu-berty is gone by. If the ovaries exist in

perfection, the womanly changes occur, anclto omit the development of the external

system ; the hips spread, and the bosom.swells, and the charms and graces whichembellish the sex are found to gather aboutthe whole person ; the mind also, from un-known causes, undergoing that consenta-neous change, whereby it becomes not iusen-sible to corresponding desire. From theovaries, as their centre, all these effects areemanating, and their manifestation is thebest proof that these important organs exist.Propter sola ovaria mulier est quod est ; tothe maxim of Paracelsus, thus modified, Ihearttly assent. Again.A few years, not to say a few months,

after puberty, we may, moreover, easily de-termine, in most cases, whether the uterusand upper part of the vagina exist or not;for if these parts are not wanting, the

symptoms of monthly action will be per-ceived, and, after a time, the secretion ac-cumulating, both the womb and the uppervagina will become dilated, and, on carefulexaminations, by a competent operator, boththese organs, when distended, may be dis-

tinctly felt ; and thus, it seems, from a re-view of the whole subject, that it is after

puberty that we shall most successfully in-quire respecting the condition of the geni-tals within the pelvis. Nor is this to be

regretted, for, till the period of puberty.these organs are of no use.

If the internal genitals are wanting, thecase admits of no remedy ; throughout life,the individual remains a mere girl-neitherdesiring marriage, nor becoming it ; but ifthe parts above are well-formed, a c’.osureof the vagina, above or below, constitut-

ing the only defect of organisation, insome cases, at least, the ailment may be re-lieved and removed, merely by dividing thepartition. Before puberty, whatever maybe the wish of friends, it is unwise to

attempt this, for we are ignorant of thestate of the womb, vagina, and ovaries,and the parts are too small and too tenderto be well fitted for the knife; but whenpuberty is gone by, and the condition ofthe pelvic ,isceIa is known, and the va-

gina and womb, dilated by the accumula-tion, are become accessible to the knife ;the operation, in many cases, may be per-formed easily enough ; and if the openingbe sufficient to allow of impregnation, how-ever small it may be, delivery, which natu-

I rally lays open this part oi’the person, may,

with a little help from surgery, thoroughlyaccomplish the rest. Of constricted vagina,I mean in conjunction with parturition, it

740

has been my lot to see some bad cases ; thestricture was divided, and they have allhitherto done well.

If you open the mouth before a mirror,and raise the tip of the tongue, you mayobserve a sort of ligature, which, while itallows free motion to the tip, assists, how-ever, in conjunction with other bonds, inrestraining its more extensive movements,and this ligature is called the frænum. Inever saw a case in which the fraenum leftthe tongue too loose, though reputed casesof this kind have been put on record ; andit is said that the tongue may be partiallyswallowed in consequence, so as to lodgeover the rima glottidis, and occasion suffo-cation. Cases, however, are common, inwhich the frasnum is pushed forward to thevery tip of the tongue beneath, giving riseto tongue-tying, as it is called, a diseasenot uncommon, even in female infants.

Nurses, usually themselves profuse ofwords, have a great horror of this restraintof the tongue, and making their exordium inthe received formula of " Lord, Sir," (a nur-sery translation of the classical aedepol oftheir predecessors, or of the more dignifiedP. C. of Roman oratory,) breathless andalarmed they come down at length upon theperoration, and " esse videantur" the child’stongue is tied ! Tongues are not always tied,when nurses please to fancy so; and it iswell, therefore, to be in possession of diag-nostics, by which the disease may be known.Now the tongue is free, for all its functions,if the tip may be advanced beyond the outermargin of the lip, and, moreover, if it maybe placed upon the roof of the mouth,liberation being requisite, if the confinementbe such as to restrain from either of thesemovements. Those who are in the habit of

examining the frænum of the tongue in

healthy children, can tell, at first look, whe-ther it require a division. Acquire thisartist-like glance, for it may be of use toyou. There is one right way, and manywrong, in doing most things ; and thus itis with the division of the fra’,num-a little

operation, which, if ill-conducted, may occa-sion trouble to you, and danger to the in-

fant ; a wound of the ranine vessels, beneaththe tongue, sometimes producing a fatal

bleeding. To divide the fraenum, you oughtto be provided with a pair of scissors, withrounded tips, and which will cut well totheir extreme ends. Try them on a bit ofdamp paper. The nurse, moreover, oughtto hold the head firmly, with the face up-wards, when the child will frequentlyscream ; for at no age are we fond of re-straint ; and, at this moment, when the in-fant is pushing fortli a long-continued cry ofthirty or forty seconds, the operator, takinghis place behind the top of the head, finds themouth wide open, and the tip of the tongue

a little raised, so that, inserting the first andsecond fingers of the left hand, he can

easily place one upon either side of thefraenum beneath the tongue, when, both lipand tongue being protected from the scis-sors, the frsenum may, in a leisurely man-ner, be divided to any extent deemed

necessary. Do not hurry. If nurses andmothers are very firmly persuaded, thoughwithout reason, that the tongue is tied,to satisfy them you may touch the frænumwith the scissors ; the operation, if well

done, is of no pain. Do not cut the frænumtoo far ; do not wound the ranine vessels,or the salivary ducts. If a child be sufferedto grow to the age of eight or ten yearsbefore the tied tongue be liberated, it maynever afterwards acquire a free use of theorgan. This is shocking neglect. It wouldbe easy to contrive a pair of scissors ex-pressly for the division of the frrenum jthey ought to be without points, and shouldcut at the tip only, to the extent of half aline. Whatever is worth doing at all, is worthdoing well; this must be my excuse for

’ dwelling so minutely on this small but deli.cate operation.

Tyrtaeus was lame, and Byron. Veryfine children are sometimes born with de-fects of the lower extremities ; and whereall the -parts of the foot and leg are dulyorganised their may be a misplacement, thefoot being turned too much outwards or

inwards, as here shown. The infant growthis amazingly rapid ; a young child will tri-

ple its weight in six or eight months afterbirth ; it will double its length in two orthree years ; and, during the first monthsespecially, the bones containing but littleearthy matter, become as obsequious to ex.ternal impressions as the future mind. Inthe cases under consideration, think ofthis. When the foot is distorted, it may, Isuspect, be frequently drawn to its properbearing. Any apparatus which, without

materially disturbing the circulation, tins theeffect of continually urging the limb towardsa healthy relative position of its parts, maybe tried, with benefit, in these cases. Thetin boot, however, here demonstrated,answers this purpose very well, and themode of employing this instrument I nowdemonstrate. (Demonstration.) The appa-ratus ought to be examined once or twiceevery day.Do not needlessly interrupt the circula-

tion by your bandages. If the inner ban-dage be coated with mild adhesive plaster,it will retain its place with less pressure." Can you not wait a few months beforeyou tease the dear child with these ban-

dages and instruments ?" This questionis sometimes put by mothers in a tone ofsupplication. The best answer is bi-literal

. no-no, not a month, not a week, a day,

741

needlessly. If the bearings of the limb areto be rectified at all, it must be while the

bones are yielding, and the organs are

rapidly growing. At the end of the firstyear the cure may, perhaps, be impractica-ble. Think of the facts before stated. Ihave been told of cures which have been

accomplished in the course of some eightor ten weeks; but never having had casesof this kind under my permanent care, Icannot decide from personal observation.Vari and Valgi are the classical appellationsof these infants. The two patrician familiesof ancient Rome, probably, derived theirnames from these deformities.Infants are sometimes born with an um-

bilical hernia, as large as a full-sized orange,most of the intestines lying fortli beyondthe abdominal coverings, invested solely bythe peritoneum ; for it deserves remark,that there is generally, if not always, a

very large aperture through the musclesand common teguments in these cases, andthrough this aperture the hernia pushes.The preparations circulated demonstrate,clearly, both the hernia and the aperture.Lowder used to relate a case, in which thehernia, being of middle size, the perito-neum became encased with cicatrix, and animperfect cure was obtained; but, in gene-ral, death is the only effectual remedy inthese cases-death, of which we have thatinstinctive aversion (horror, if you will,)necessary to prevent us from deserting thepost of life on every slight occasion ; butwhich, after all, in conjunction with gene-ration, becomes an admirable contrivanceof creation, whereby structures, unfit forfurther service, are decomposed, to bemodelled afresh in renawed perfection.-The tomb and the womb together consti-tute a sort of chrysalis. In death we are

disorganised-in generation renewed, andthe magic of Medea’s chaldron is passingcontinually under our eyes. When we at-

tempt to contemplate death, does not thisinstinctive horror delude the judgment, and,to our own advantage, magnify the evil? Isit not a part of the design of Nature, that,like some other affections, (love, for exam-ple,) this feeling should delude us ? Is dis-solution really so great an evil as---but’,I ask pardon for this digression.Itevenons a nos m.)utons. When, as very

frequently happens, the umbilical hernia isno larger than the tip of the finger, thecommon teguments, I think. usually coverit, and we may cure the disease either byligature or pressure. When the chord drops,as usually, a few days after birth, if thenavel protrude, we may lay over the frontof the abdomen a broad slip of adhesive eplaster, so as, in part, to repress the intes-tine ; and then, directly on the navel, may beplaced a thin plate of tinfoil, about as broad i

i as a shilling, to be retained in situation

by a second adhesive bandage, which, com-pletely surrounding the abdomen, may lieover the first, Once or twice daily the efirmness of the apparatus ought to be in-spected. When it becomes necessary tochange, have every thing in readiness, and,if possible, do not excite screaming whenthe apparatus is removed, lest the navelshould start, and the aperture should beenlarged afresh. If the child grimace., as ifabout to cry, an assistant should be at hand,to place a finger over the umbilicus, and toresist the eruption of the hernia; but, un-less this eruption be expected, it is betternot to touch this part. Umbilical herniais of slow cure by compression, and, amongthe lower classes especially, the necessaryattention and perseverance may be want-

ing. In some cases, then, we may findit convenient to attempt the cure of thedisease by pushing back the intestine, andclosing the sack at its root with a liga-ture. Great care must be taken not to

include the bowel. I am afraid this opera-tion is not unattended with danger, evenwhen the bowel lies clear of the ligature;think well befoie you have recourse to it.This operation reminds one of the ancientremedy of the empirics; they used to callit the " royal stitch."

Infants may be affected at birth with dropsyof the spinal theca, concurring with variety inthe anatoiiiicil condition of the parts. Some-times the dropsy is in the thecawholly ; some-times in the theca and the cranium too ; andthe dropsies may communicate. The spinalmarrow may, I believe, be perfect, or thecauda equina may be more or less deficient ;the nerves of the lower limbs and pelvisbeing formed, nevertheless, in all their per-fection, and stretching into the cavity ofthe spine to terminate, as Burns has justlystated, not in the marrow, but in that partof the theca which lines the correspondingarches of the lumbar vertebrae; the nerves,in fact, originating, or rather coalescing, utthe theca of’ the spine. BVhcn the archesand spinous piocesses of the certebrae arewanting througltout the chain, so that thespinal canal is completely open bebiitd fromend to end, the spinal marrow is, I sus-

pect, generally deficient altogether; and,indeed, the disease scarcely belongs to thatwhich I am now considering ; but in spinabifida generally, there is a deficiency on thehack of the lumbar vertebræ only, forming achasm, at which one or two fingers maybe passed down into the cavity of the

spine ; and above, and perhaps Leloiv, to

some littie extent, the spinous processesseparate into two lateral pieces, so as to

become forked, whence the disease is fre-

quently denominated spina biti:ia. " I)umres manent fugiant verba. " The appella-

742

tion is not, perhaps, a good one ; but ifwe understand one another, the terms

may pass. Life is short-our time may belaid out on more important matters. Overthe lumbar chasm, we may find the parts inone of two very different conditions; forsometimes on this part there is a large tu-mour, bulky as a small orange, covered witha dark rosy red skin, marbled with a leadenlivid tins and, in other cases, we find uponthe chasm a circular brown wrinkled scar,broad as a half crown, and flat, appearances Iwhich are excellently well shown in thepreparation before us. An infant may beborn with this tumour lacerated and open.Hydrocephalus, in conjunction with this

disease, may become very obvious, in con-sequence of the enlargement of the cranium,and the widening of the sutures and thefontanels. Mr. Bryant, of Kennington,showed me a fine examnle of this.

If the medulla spinalis be defective, I

presume the case admits of no effectual

remedy ; but when this is sound, and thedisease is, in other respects, favourable, acure is not impossible ; and for this, asfor some other useful practical additions tosurgery-surely well worth whole volumesof mere musical and well-turned periods,our race is indebted to a man whosename conveys his eulogy-I mean Sir

Astley Cooper. To him, and to my distin-guished colleagues, his successors, I mustrefer you for a fuller exposition of themethod of operating’ ; suffice it to remark,that the tumour is punctured with an in-strument like a glover’s needle, and dayafter day, by little and little, the fluid is

gradually drawn away ; the aperture beingsecured, more or less effectually, after

every drawing and pressure being kept upby means of bandage, or otherwise. Fortyor fifty times, as I leatn, it may be necessaryto repeat the punctures ; the cyst filling re-peatedly, but continually shrinking, till, atlength, after a succession of operations, thecyst contracts into a sort of cicatrix lyingover the chasm, to be afterwards protect-ed by truss. To open the cyst extensively,and discharge the water at once, is, 1 be-lieve, highly dangerous. In the course of

twenty-four hours, death ensued in a case ofthis kind, narrated to me by one of mypupils. The tumour was mistaken for ab-scess. The cases with the brown flat searare not fit for this operation. In hydrocepha-lie cases, there is little to be hoped. Infantsleft to their fate, in this disease, perish afterdifferent intervals. They may live for

weeks, months, or years. They may evenreach to man’s estate, always labouringunder the disease. If the marrow be de.fective, the lower parts of the body may bedefective in feeling. Dr. Haighton used torelate the case of a boy, who would thrust

pins into the skin with little suffering. Acu-puncturation sometimes occasions little pain,even in the healthy.To be born with an imperforate œsopha-

gus, would seem to be a terrible calamity;for what more terrible than the fate of L’go-lino, especially when this is painted in thedark deep colouring of Dante, the Rem.brandt of poetry. Physical eviis, however,are, I suspect, oftener more intolerable inprospect than in sufferance. Nature, tomake us bestir ourselves, threatens like astep-dame, but corrects like a tender mo-ther. When the imperial clemency con-

ceded the arbitrium mortis, the Roman no-bles, if my memory serve, not uncommonlygave preference to death from hunger. Forsixteen long days and more, a young infantmay pine under the starvation of an imper-forate gullet-sleeping, waking, weeping,wasting, greedy for the breast, grieved orangry when disappointed ; and yet, afterall, to judge from the unaffected expres-sions of the feelings, it may be fairly doubtedwhether its sufferings from thirst and hun.ger exceed those produced by many of thesmaller infant ailments; and surely theywill scarcely bear a comparison with thosethat result from the suffocating symptomshereafter mentioned. Those who are placedin situations which expose them to starva-tion, ought to remain inert; under thesecircumstances, the less wear of mind andbody the better. When a town is besieged,I imagine that the daily consumption offood might be considerably diminished, ifthose, whose operations, mental or bodily,can contribute nothing to the defence,would imitate those fasting women, ofwhom the public has at times heard so

much, and lie vegetating on a sofa. Ac-

cording to the Italian poet, Count Ugolino,who, together with his children, perishedfrom hunger in the tower of Pisa, after sur-viving all of them, died on the eighth day;but infants, when famished by this disease,being in a state of comparative quietude,they may sometimes remain alive for two orthree weeks, as I learn from a case relatedto me by Mr. Hallam, of Newington, who

first drew my attention to this disease.When the oesophagus is imperforate, all

the pains of strangulation may be sufferedevery time the infant attempts to swzilloiv.It takes the pap greedily, a small effort of

deglutition follows, and then in a few se-conds the countenance alters, and the placidlook of infancy changes for that of distressand agitation ; and the breath is inter-

cepted, and the face darkens, and the chestheaves, and the muscles quiver, and convul-sions, followed by a dead quiet, ensue; thechild remaining in a state of asphyxia, tillthe verv sight of it, as you watch returning

life, shortens the breath with anxiety, and

743

engthens the seconds to minutes. At lengthyou think it is all over, when, as you risefrom the chair, a small struggle is perceived,and the food taken is emitted from the mouth,life and breath being again restored, to be

again miserably interrupted, should the at-tempt be repeated. Infants thus treatedsuffer many deaths. Severer symptoms arenot produced by strangulation with the rope.Food, therefore, or the breast, ought not tobe offered when these violent symptomsresult. Life might, perhaps, be prolonged,by injections into the bowels ; but the mindat this tender age being wisely constituted,without the instinctive fear of dissolution-of no use to a being which cannot help itself-a few hours or days are not desired ; andwhy should we attempt to add a little spaceto existence, and to prevent that death whichnature uses as the only effectual remedy forthe disease ?

When, during swallowing, the food passesthe pharynx or hinder cavity of the mouth,muscular action grasps the bolus, and, at

the same time, closes all the passages, withthe exception of the gullet, and, of course,the air-tube among the rest. Observe the

rapidity with which the water, in largegulps, flashes along the oasopliagus of thehorse when drinking. When we are well,and full of appetite, deglutition, like wink-ing, is accomplished with the same promp-titude ; and, therefore, the stay of the food inthe pharynx being less than momentary, theclosure of the passages is unattended withinconvenience. But with infants, in whomthe cesophagus is imperforate, this is not thecase; for, the food entering the pharynx,the rima glottidis becomes cl02ed, and thebolus, involuntarily grasped on all sides bythis muscular cavity, being propelled to-

wards the œsophagus, where descent is pre-vented, the aliment remains in the pha-rynx, spasmodically detained, forming a

sort of gag, till approaching death relaxesthe muscles, opens the passages, sufferingthe food to escape, and the air to return tothe lungs.Ah! if our surgery could triumphantly

interpose with one of its natural miracles-if the art which gives hearing to the deaf,and sight to the blind, and legs to the lame,and patent legs, too, could also help us here!but this may not be. One case of this kindwas dissected by Mr. Hallum ; another inconjunction with him by myself; a third byMr. Burrows, an excellent practitioner inthe city ; and, in all three of these through-out the mediastinum to the extent of severalinches, the cesophagus was unformed, or

represented by a mere ligament, stretchingfrom the closed extremity of the œsophagusto the orifice of the stomach. The trocharand canula; therefore, can be of no service.

Death is the natural remedy. Infants, whodie under this disease, are, I believe, fre-

quently thought to perish from convulsions.As I know myself of three cases,1 presume itis by no means very uncommon. Van Swie-ten describes ana8’ection called a swallowingof the tongue, in which suffocation is said tofollow the attempt to swallow, in conse-

quence of the tongue, too loose in themouth, getting into the cavity of the pha-rynx, and lodging over the rima glottidis.Having never seen this discase, 1 feel in-clined to think that Swieten may have beendeceived by an imperforation of the oesopha-gus. Should swallowing of the tongue reallyoccur-if the practitioner do not reach theinfant till apparent death is produced, thetongue ought to be drawn down into placewith the incurvated shank of a spoon, or any-other convenient instrument; and thoughthe child have lain to appearance dead for

twenty or thirty minutes, artificial respira-tion, and the warm bath, ought to be dili-gently tried. New-born infants may, nowand then, be resuscitated, after they havelain in a state of asphyxia for a good partof an hour. We ought not, therefore, inthese cases to despair too soon.

FOREIGN DEPARTMENT.

EXPERIMENTS ON THE VELOCITY OF

CiRCULATION.

By M. FIERING, of Stuttgart.

Hm.r.E2 and Sauvznes were the first whotried to ascertain, by experiments, withv.’hat velocity the blood is carried throughthe vascular system their calculations, how-ever, were fallacious, as they were foundedon the supposition, that the movement ofthe blood depended exclusively on theaction of the heart. Haller’s conclusions

respecting the velocity of circulation in

frogs, and small fishes, are more correct,as they were confirmed by autopsy ; buthis observations were confined to cold-blooded animals, and we need hardly men-tion how hazardous it would be to infer fromthem the velocity of the blood in warm-blooded animals. The same remark appliesto the experiments of Spailanzani and

Dolhnger. In more recent works on the

subject, the comparison of the quantity ofblood contained in the ventricles of theheart, with the whole mass of the blood, andwith the number of pulsations in a certaintime, was considered sufficient to determinethe relative velocity of the blood ; a method,