THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

JULY, 1849.

PART FIRST.

Analytical and Critical Reviews.

ART. I.

By

1. 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. Fcap. 8vo, pp. 396.

2. 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. 8vo, pp. 686.

It seems to us not a little strange that writers who show a considerable amount of acuteness on other topics, should continue to entertain such vague and confused ideas with respect to the relation between Science and Art, as are presented by the authors of the two works before us, in the opening sentences of their respective treatises. According to Dr. Tyler Smith,

"Labour: the study of the act of parturition itself, and of all that relates to the prevention or alleviation of the pangs and dangers in which women bring forth children, and to the preservation of their offspring, are the principal aims of the Obstetric Art." (p. 1.)

We do not precisely understand the relation of the first word in the above quotation to the rest of the sentence from which it is separated by a colon; according to all ordinary rules of punctuation, it is entirely isolated; and although certain clever writers of fictitious or imaginative works have lately broken through all these for the sake of effect, we shall set our face against the introduction of any such method, or rather want of method, into treatises in which the clear and sober exposition of truth is the only object. Leaving the word Labour, then, to stand alone, like the monosyllabic noun-verb which in the Chinese language forms a sentence by itself, we shall inquire into the meaning of the remainder of the passage. Inverting the sentence, we find Dr. Tyler Smith asserting that

7-IV.

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"the principal aims of the Obstetric Art" are "the study of the act of parturition itself, and of all that relates to the prevention or alleviation of the pangs and dangers in which women bring forth children, and to the preservation of their offspring." In our apprehension, this is rather a definition of the science, than of the art, of obstetrics. The object of the art is to alleviate the sufferings, and preserve from the dangers, incident to the performance of the function in question; that of the science is to know how to alleviate. The art consists of a set of rules for practice, deduced from the scientific study of the function in its normal and abnormal conditions; and these may be successfully applied by a practitioner, who knows nothing of their rationale. On the other hand, the science is evolved from the philosophic contemplation of the phenomena presented by clinical observation, guided by an acquaintance with the general principles of physiology; and this may be successfully pursued by a man who has never conducted a case of labour for himself. Although we are far from thinking that a mere observer is the man best qualified for such a pursuit, yet, on the other hand, we are confident that he would be much more likely to contribute towards the advancement of the science, and the consequent improvement of the art in precision and certainty, than the mere practitioner who isolates this department of biology from every other, and looks at the parturient woman as a being with whom no one but himself has anything to do.

Let us see whether Dr. Meigs is more successful in his definitions. The following are his opening sentences:

"Midwifery is the art of assisting women in labour.

'Obstetricy comprises the sciences of anatomy, physiology, and pathology, as relates to the reproductive organs, and the arts of therapeutics and surgery, as applied to sexual affections in women.

'Midwifery is an Art.

Obstetricy is a Science.

"A Midwife or Accoucheur is one who assumes the conduct of cases of labour. "An Obstetrician is a physician, who, in addition to a general knowledge of physic and surgery, adds the special information that is necessary for one having the peculiar charge of all sexual affections, whether in the department of midwifery proper, or in other complaints of the sex.

Notwithstanding obstetricy is composed of several different branches or sorts of knowledge, it claims to be considered as a distinct science.” (p. 17.)

In these oracular dicta, we have an attempt at greater precision of statement; and we believe that, by a little amendment, they may be made to express the true view of the subject. We will take Dr. Meigs's definitions of Obstetricy as the Science, and Midwifery as the Art; and inquire what are their respective provinces. Obstetricy, strictly speaking, consists of those departments of the sciences of anatomy, physiology, and pathology, which relate to the reproductive function; but as the obstetric practitioner is the one generally consulted upon the diseases and injuries to which the female sexual organs are liable (unless these diseases, like syphilis, be purely constitutional in their nature), the whole pathology of these organs (with the exception we have named) must be considered as included under the designation of obstetrics. Now so far as obstetrics is a science,—in other words, to use the definition of Mr. John Mill, as it consists of a collection of truths, whose language is " this is, or this is not; this does,

or does not, happen,"-it is perfectly independent of any art; and we cannot, therefore, admit the justice of Dr. Meigs's assertion that the science of obstetricy comprises the arts of therapeutics and surgery as applied to sexual affections in women. These arts, again to use Mr. Mill's definition, are collections of rules, whose language is "do this, avoid that;" and therefore they cannot constitute a department of obstetric science, but belong to the art which is founded upon it. To include the whole of this art under the designation midwifery, would be to make a wide extension in the application of that term; which is usually restricted to the care of the act of parturition, and its antecedent and consequent phenomena. To such an extension there are many obvious objections; and we do not see what else is to be done, than to distinguish carefully between obstetric science and obstetric art,-just as we distinguish between the science and the art of medicine or of surgery,-and to let midwifery continue to relate to that division of the art, which the term has hitherto been employed to designate.

Although we have not considered either of our authors very successful in the formal definitions, with which their treatises respectively commence, yet the distinction between principles and practice is most fully recognised by both in their teachings, as well as in their titles. In fact, Dr. Tyler Smith's object is to give to Obstetric Science a far higher elevation than it had previously attained, by connecting it with those general principles of Physiology of which a large proportion of obstetric practitioners, and too many obstetric writers, are profoundly ignorant. For his labours in this vocation he deserves great credit, whatever we may think of his success; and if we shall find it our duty, in the discharge of our critical office, to express our dissent from several of the doctrines which he has propounded in the treatise before us, we do not the less feel that he deserves the gratitude of the profession, for having pursued the study of obstetric science in a more enlarged spirit than any preceding writer, and for having diligently attempted to improve and extend it.-We quote his preface in full, as expressing what he conceives to be his claims as a discoverer, and as justifying the careful examination of these claims upon which we shall presently enter.

"I began to study Reflex Obstetrics in 1842; and the present work is the result of seven years' close and earnest attention to the subject. I may say truly, that during this time, though much occupied by other matters, it has scarcely ever been absent from my waking thoughts.

"I have no wish to deprecate criticism; but I trust I shall not be considered in the light of one who applics facts and principles already known to his own department of practice. I believe every candid person conversant with the current knowledge of the reflex function, and of obstetrics, when I began to write, must admit that I have both added to reflex physiology, and made extensive applications in practice, which had eluded previous observers. Indeed, reflex obstetrics is a new department of the reflex function and its applications. Taking the whole range of reflex physiology, the cause of labour is only second in importance to the cause of respiration; and no one had perceived that the relation of the ovarian nerves to parturition is the same as the relation of the pneumogastric nerves to respiration; while, in the investigation of the causes of the Genesial Cycles, in the Twelfth Lecture, I have entered upon a new field, altogether distinct from the reflex motor function.

"When I published my first 'Observations,' reflex physiology had not found

even a verbal home in any work on Obstetrics; but I do not think it will be possible to say the same of future works in this department of medicine." (p. viii.)

Dr. Tyler Smith's treatise, like the lectures already published in the 'Lancet,' of which it is almost entirely always made up, is much less an introduction to the study of obstetrics, than an exposition of the author's peculiar views; and is consequently less fitted for the pupil who needs a comprehensive text-book of the science, than it is for the advanced student, who is prepared by his previous acquirements to eliminate its truths from its errors, and to profit by the former without being led astray by the latter. As a treatise on the "Science and Art of Obstetrics," it is deficient in much that the pupil needs to be taught; as a dissertation upon " Reflex Obstetricy," it is replete with interest. The latter title would therefore, in our estimation, have been more appropriate than the former; and we shall discuss the subject-matter of the treatise as if it had been thus designated. This, in fact, will be the fairest method of procedure in regard to the author; for we are sure that he will be best satisfied by our bringing into prominent relief those portions only of his treatise upon which he bases his claims as a discoverer, passing by with little or no mention those which contain no distinct novelty. We shall find that the former will afford such ample food for critical discussion, as to necessitate our restricting ourselves in the present article to the theoretical portion only of Dr. Tyler Smith's work.

The corresponding department of Dr. Meigs's treatise presents so little that varies from the beaten track, that a few words will suffice to dismiss it, especially as we had occasion not long since to criticise some of Dr. Meigs's opinions on these subjects, as well as his manner of expressing them. With regard to the style of the present treatise, we have the satisfaction of informing our readers that whilst it presents many of the peculiarities which characterised Dr. Meigs's "Letters to his Class on Females and their Diseases," it is free from the most offensive faults which disfigured that work. The colouring is in fact considerably toned down;' and would perhaps be altogether not more lively than is sufficient to make the book very agreeable reading, were it not that the old affectations every now and then force themselves in, with somewhat unpleasant obtrusion. We noticed on a former occasion (Vol. III, p. 142,) Dr. Meigs's notion that the "corpus luteum" is a vitellary body. On this subject he expatiates somewhat fully in the present treatise; and informs us that, when boiled, the corpus luteum becomes hardened like yelk boiled hard, and that, when roasted, it gives out a strong odour of roasted eggs! From the result of this truly refined and trustworthy procedure, in addition to the microscopic observations formerly referred to, Dr. Meigs deduces what we must regard as a most loose and unphilosophical analogy between the corpus luteum and the vitellus. Their similarity in composition, histological and chemical, however close it may be, does not indicate any real analogy, their position and functions being so essentially different. A vitellus is not a vitellus because it is composed of albumen, oily matter, sulphur, &c., which the chemist finds in it; or because of the floating corpuscles which the microscopist detects; but because it is so placed within the ovum as to afford a supply of nourishment to the developing embryo, which shall be converted into its own textures. This is the essential idea of a yelk or vitellary body; and to give the designation of

vitellary body, therefore, to a substance which is only developed after the ovum has escaped from the ovisac, and even on the exterior of the ovisac which enveloped the ovum, and having no function whatever as regards the embryo, appears to us a complete perversion of language.

We are surprised to find Dr. Meigs greatly behindhand in his knowledge of the structure of the placenta. For anything that his account of it contains, it might have been written ten or twelve years ago, when as yet neither Professors Weber, John Reid, or John Goodsir had unravelled its complicated arrangement. The old questions about the foetal and maternal portions of the placenta, are discussed in the old style; and the author gravely comes to the conclusion that the placenta is entirely a fœtal organ, and that the notion of the passage of vessels, or of maternal blood, from the uterus to the placenta, is all a delusion. He rests his convictions upon the evidence of his own senses, having on more than one occasion seen nothing but "mucous tractus" passing between the two surfaces when torn apart from each other, and having thus satisfied himself of the total absence of vascular communication. When he shall have prosecuted a dissection of the parts in question, under water, and with the requisite slowness and care (that of Dr. J. Reid occupied him several hours a day, for some weeks, we believe months); when he shall have followed, with Professor Goodsir, the development of the placenta, and shall have seen how it is made up of uterine tufts and decidual growth; and when he shall have microscopically examined the placental tissues, injected and uninjected, and shall have accounted for the presence of maternal blood in the placental cells, whilst the foetal blood is restricted to the tufts which constitute the ultimate subdivisions of the umbilical vessels; we will allow him to have an opinion of his own. Until then his assertion of the entirely fœtal nature of the placenta is altogether valueless, and he is bound to teach the opinions. of those who have made such examinations. For ourselves we can say, that having witnessed a considerable part of Dr. J. Reid's dissection, we can bear unequivocal testimony to the correctness of his results; and that having also gone carefully through the microscopical examination of the placenta, we can equally confirm the statements of Professor Goodsir in regard to the combination of foetal and maternal structures which it contains. Dr. Meigs lays great stress on the fact that the whole placenta is thrown off in the human female, instead of the foetal portion only, as in the lower mammalia; but he takes no account of the circumstance that the decidua also, of which the maternal portion of the placenta is only a peculiar development, undergoes the same detachment. In regard to the real nature of the decidua, too, we are surprised to find Dr. Meigs apparently ignorant of the satisfactory elucidation which it has received in this country; he quotes M. Coste and other continental authorities glibly enough; but for him Professors Sharpey and Goodsir have observed and described in vain, and the decidua reflexa is still pushed before the advancing ovum as in old times.

We are sorry to be obliged to speak in these terms of Dr. Meigs's sins of omission. He takes up many other novelties with such delight and earnestness, that we are sure that he cannot be unwilling to receive information or correction; and we should therefore recommend him to work up his physiology a little better from the later general treatises in which these discoveries are embodied. We shall now quit him for the present,