the same habit of body; their being preceded by a cachexia in no respect distinguishable for the one and for the other; their coexistence in the same individual; the occurrence of one series in certain individuals of a family, of the other in other members of the same family; their common transmissibility, including that of the cachexia or diathesis; the apparently indifferent development of either amongst the offspring of parents, one or both of whom may have manifested one only of the two forms of affection. Facts like these, some of which are strikingly illustrated by histories reported in M. Legrand's work (as e. g. by cases 52 and 53), and of which we are persuaded the personal experience of all our practical readers will have furnished them with instances, appear to us to demand, that far more substantial arguments than have hitherto been brought forward, whether of statistics or of logic, shall be adduced, before the common nature and origin of tubercle and scrofula, to which they so strongly and, in our apprehension, so conclusively point, may be considered as disproved. A belief in this generic identity we conceive to be still the prevailing one amongst our countrymen; nor should we, even at the instigation of a work honoured by the approbation of the French Academy of Medicine, have been disposed to give so much space to an examination of the arguments brought against it in that production, had we not been. mindful of the powerful influence likely to have been derived to the contrary belief by the statements of Mr. Phillips, whose work, as a whole, deserves to be regarded as the most complete and valuable monograph on the subject of Scrofula in our own, or probably in any other, language. The arguments of this able writer were principally statistical, and were examined, and we think satisfactorily disposed of, in the pages of one of our predecessors; they are also met by very pertinent objections in the little work of Dr. Madden which stands at the head of this article; and we have no intention of alluding to them any further. But believing as we do, that the pathology of tubercular disease cannot be advantageously investigated, apart from that comprehensive view of its phenomena which depends upon an admission of its essential identity with scrofula, we have thought it desirable to defend this position from the more recent attacks upon it contained in M. Legrand's pages.

ART. XIV.

1. Obstetrics: the Science and the Art. By CHARLES D. MEIGS, M.D., Professor of Midwifery in the Jefferson Medical College at Philadelphia, &c. &c. With 121 Illustrations on Wood.-Philadelphia, 1849. Svo, pp. 686.

By

2. Parturition, and the Principles and Practice of Obstetrics. W. TYLER SMITH, M.D. Lond., Lecturer on Obstetrics in the Hunterian School of Medicine.-London, 1849. Feap. 8vo, pp. 396.

IN continuation of our review of these works, we have to notice particularly the more practical subjects which are discussed in them. And in doing so, we shall chiefly be engaged with Dr. Meigs; not only on account of his acknowledged experience as an obstetric practitioner, but also because the scope and construction of his treatise require it. We have already devoted much space to a critical analysis of Dr. T. Smith's

views; and as we regard the practical portion of his work as altogether subordinate to the physiological, we shall not at any length allude to it.

Dr. Meigs has illustrated many parts of his work with diagrams, most of them simple outlines like M. Chailly's; and in general they are well selected and instructive. In connexion with the planes of the pelvis, he has added four useful outline figures from Wigand, showing different inclinations of the superior strait of the pelvis. His side view of the pelvis has an anatomical error, which we have seen in several other works: the anterior lip of the os uteri is made shorter than the posterior lip; this should be reversed. We doubt, too, the propriety of representing the vagina as an open cylindrical canal, because in truth, during life, the two walls closely approximate, and form an important column of support to the uterus. To watch through the aperture of a speculum the way in which the vagina contracts as the instrument is withdrawn, affords a sufficient demonstration of this fact.

The mechanism of the different cranial positions, of which Dr. Meigs enumerates six, is divided, after the manner of the French, into a series of movements of the foetal head, viz. flexion, rotation, extension, and restitution. This is a clear way of describing the passage of the head in childbirth, and one which is readily appreciated by students. In the fourth position, where the occiput is directed to the right sacro-iliac synchondrosis, Dr. Meigs accords with Professor Naegele, and all well-informed accoucheurs, that the occiput moves round to the right acetabulum spontaneously; although this movement of internal rotation sometimes requires, according to Dr. Meigs, to be aided by the accoucheur's hand, or even by an instrument. The way in which the child is born when this movement is not accomplished, is shown by a diagram; and we confess in our own experience, that it is far better to leave the selection of the two to nature, than to make any attempts to rectify it. We doubt very much whether the hand alone can ever accomplish it; and it may well be questioned whether the movement, in cases where this kind of assistance has been given, would not have been accomplished without it. It is, we believe, a judicious practice, if instruments are employed at all, to be content with supplying the force, in accordance, of course, with the proper axes of the pelvis, and to leave the way in which the child's head will pass out entirely to nature. If the large movement of rotation can be made, it will take place of itself; and if it is not spontaneously effected, it is better to deliver with the forehead first. Our own experience, at least, has led us to this conclusion. Dr. Meigs agrees with Dr. Naegele and others, in considering their fourth position as the next in frequency to the first, viz. where the occiput is forward, and to the left. He states this as the result of his registry of presentations and general clinical experience, but without giving the relative number.

Abortion. The chapter on Abortion in Dr. Meigs's work is short and defective, and much in contrast with the elaborate lectures on this subject by Dr. Tyler Smith. The influence of the excito-motor power in conveying impressions from different parts of the system, through the spinal cord to the uterus, and inducing abortion, is here well illustrated. Without recognising, says Dr. T. Smith, the paramount influence of the nervous system in the causation of abortion, we deal only with surface physiology. Hence he has simplified the large and diversified subject of the

causes of abortion, by ranging them under two heads. 1. The excentric causes which act by irritating the extremities of the spinal nerves; and, 2, the centric causes in which the spinal centre is mainly concerned.

Among the excentric causes we find irritation of the mammary, trifacial, vesical, ovarian, rectal, vaginal, and uterine nerves; and, although in this catalogne we find no more than what are usually included as the accidental causes of abortion, yet Dr. Smith's mode of describing them, as practical illustrations of the excito-motor theory, is novel and interesting.

Among the centric causes are blood-poisons, the exanthemata, syphilis, scrofula, mercurialization, carbonic acid, specific uterine excitants, and emotion.

We do not propose to follow Dr. Smith into his description of the operation of these various causes; but we notice that he speaks in a very cursory manner of the diseases of the os and cervix uteri. He hints, indeed, at their having been forced into a too prominent position, as though they were the main and almost the exclusive causes of abortion. Dr. Meigs does not even mention them; and in speaking of their treatment in the prevention of abortion, Dr. T. Smith only says, that "it is sufficiently simple, consisting of local abstraction of blood, and occasional. cauterization of the diseased sites; every possible care being taken to prevent local and constitutional disturbance following upon the treatment." Indeed, if we were to judge of the relative importance of the various causes of abortion by the care and pains with which they were described, we should say that Dr. T. Smith attributed greater importance to irritation of the mammary and trifacial nerves, than to these local complaints; which is perhaps to be accounted for from their affording apt illustration of his physiological views of the synergic relation between these remote parts. Perhaps the rarest cause of abortion is irritation of the trifacial nerve, and about the next is mammary irritation. And yet we think he has shown a good deal of forecast in the following statement.

"I ought to state, that while I do not doubt the frequent occurrence of inflammatory disorder, and its consequences in the os and cervix uteri in pregnancy, still the organ has so recently become the subject of common visual examination, that I do not think the variations of colour, size, hardness, and the state of the circulation which may be consistent with moderate health in different classes of life, are as yet satisfactorily made out; and thus many cases may be set down to disease which are not truly and decidedly morbid; and in some cases of this kind, abortion has been positively excited by the treatment pursued to prevent it." (p. 144.)

Our own experience very much coincides with this; and we think that Dr. T. Smith ought to have shown far greater caution in keeping with this opinion of his, than by recommending, in a loose and unpractical way, "the local abstraction of blood, and occasional cauterization," as the simple way of treating these cases. We believe that a soft granulating surface around the os uteri produces very little irritation indeed; and if it were left alone, would rarely, if ever, cause abortion. If, however, the deeper tissues of the canal of the cervix are inflamed, then far greater irritation is occasioned; but then it must be noticed, that as long as this state lasts, pregnancy very rarely occurs. We believe we are enunciating a practical fact when we say that such a condition of the os and cervix, whether of induration or ulceration (as a simple granulating surface is constantly called, and familiarly spoken of to patients), as does not occasion sterility,

will rarely cause abortion; provided always, that the disease is not mixed up with some syphilitic or cancerous taint. The great danger is in overtreatment.

We cannot but observe, too, that syphilis, as a cause of abortion, has not received from either author a sufficient degree of attention. It is of little practical value to speak of such a disease as syphilis, in general terms, as causing abortion; and our present knowledge of the disease, in this relation, requires a more minute description of it. Every one understands that if a woman, having had a primary sore, retains so much of the poison as to exhibit any of the recognised forms of secondary or tertiary signs, her offspring will be either killed by it in utero, or born with marks of it. This is an elementary fact. But supposing a man to have been cured of primary sores, and have only a very slight appearance of secondary symptoms, say a little discoloured spot or two on the inside of the hand or edge of the scalp,-can he transmit the poison to the ovum, through the semen, without the woman having any known marks of syphilis; and can the taint then remain so long, as to cause a succession of abortions? Again, supposing the husband to be cured of his secondary symptoms, can he still retain so much of the poison as shall infect the ovum, though no trace of it shall be apparent on him or his wife; and may the death and abortion of the early foetus ensue? We might refine on this inquiry, and still not overstep the limits within which this poison may be said to range in destroying the early ovum. The character of the ovum, under these circumstances, is an important part of intra-uterine pathology. There is oftentimes a well-marked change on the surface of the placenta ; thick white patches, which we believe to be a primary disease of the placental decidua, and particularly of the cells of which it is composed. The ovum undergoes a slow death; the fœtus, at an early period, is frequently wanting when the amnial sac is opened; it appears to have broken up, and disappeared by liquefaction. The preventive treatment of abortion under the more disguised states, is full of clinical interest. Ought one or both parents to undergo mercurialization? and how long ought they to be separated, and pregnancy prevented? We cannot, of course, do more than hint at this inquiry; but we feel that our authors have virtually omitted one of the most widely diffused causes of abortion, in not having critically and at length examined this subject.

The use of instrumental aid in withdrawing the ovum is referred to by Dr. Meigs, who speaks favorably of Dr. Dewees's hook and of Dr. Henry Bond's forceps. He wisely enough limits their application in the following remarks:

"While I lay before the student these instruments for the extraction of the dead ovum, I ought to warn him against too facile a disposition as to the employment of them, and to assure him they will often disappoint his expectations, and sometimes, where they do succeed, lead to evil consequences as to the mother. The ovum, in abortions, inhabits the body and fundus uteri. The cervix stands guardian as the facultas retentrix over the deposit, and reluctantly yields it a passage. In doing so, the conical neck of the womb must become a cylindrical canal, into which the fundus and corpus uteri thrust their intolerable burden. When this cylindrical canal hath received into its calibre a small ovum, or the remains of one, it has, of itself, little or no power of expulsion, but merely grasps the ovum and holds it fast. It holds it sometimes for many days. I have found it to hold the ovum in this manner for many consecutive days, because the very os uteri would not let it

escape, refusing to yield, chiefly, perhaps, because no dilating pressure was applied. In the long run it yields, the os tince becomes wide open; and then, a bearingdown effort, a fit of coughing, or straining at stool or urine, drives it forth into the vagina. Now, until the canal has become truly cylindrical, Dr. Bond's forceps and Dr. Dewees's hook are not to be employed without much care and gentleness. For the most part it is better to wait until all is prepared, and then remove the object with the index-finger." (pp. 215-16.)

In those tedious and dangerous cases of abortion, where the ovular membranes lacerate early and the decidua peels off only by degrees, with fetid discharges and recurring hemorrhages, we have found a stream of tepid water thrown into the uterus very useful, not only in clearing the cavity of the womb itself from the decomposing matter and so removing a source of disease, but also in favouring the separation and expulsion of the collapsed membranes. Cases of this kind extend over six or eight weeks or more, before the uterus is cleared; and the patient becomes sadly debilitated. Hooks or forceps are of no use in such instances.

Conduct of labour. Under this title Dr. Meigs has given a comprehensive summary of what may be required of the accoucheur, not only in natural but in many cases of difficult labour. "The conduct of labour," he says, "might refer to any, and so to all possible events in midwifery : for midwifery after all is but the conduct of labours." Hence he not only in separate paragraphs gives the general rules and precepts on the management of labour,-such as attention to the bowels, position of the patient, the support of the perineum, &c. &c.,-but he considers also the treatment in cases of obliquity of the uterus, the effects of a "badly-shaped sacrum and pubis," and the management of the placenta when retained and adherent. There is of necessity little that is novel in these matters; it is enough that the sound and judicious principles which have guided the best accoucheurs should be here adopted: but we willingly acknowledge a very pleasing style in their description, which is in general free from Dr. Meigs's former conceits, and retains all his raciness and apt illustration. He has an earnest way with him, when speaking of the most elementary subjects, which fixes the attention and adds much value to the work as a text-book for students; indeed it is obviously the result of much practical acquaintance with the art of teaching.

There is only one subject contained in this chapter which we feel it necessary to allude to, and that is the use of ether and chloroform in midwifery.

Anæsthesia in midwifery. It is now more than two years and a half since (January 1847) Professor Simpson, of Edinburgh, first employed the vapour of ether in a case of delivery by turning where the pelvis was deformed; and the result of this was, that the labour was terminated without the woman feeling pain, without impairing the force or frequency of the contractions of the womb, or the consentaneous movements of the abdominal muscles, either during the labour or after it, and without injury to the child. Before the year was out, Dr. Simpson's strenuous advocacy of this mode of saving women the pain of labour had induced other obstetric practitioners to employ it; its use was not confined to difficult or instrumental cases, but it was exhibited in natural labour; and after a series of experiments on other anaesthetic agents, devised and carried out with the greatest perseverance and at some personal peril, Dr. Simpson