tubercle, notwithstanding its general impoverishing effects upon the blood, does not, at least in its early stages, destroy the inflammatory element, and, accordingly, inflammatory complications are here both frequent and pernicious. Let us see how far these statements are borne out by the facts. That there is a marked elevation in the proportion of fibrine in phthisica! blood, undoubtedly comes out, as the mean result of all analyses. Yet when we find out of the twenty-one cases examined by MM. Andral and Gavarret, showing a lower amount of this element than the physiological mean established by their researches (2:10 per 1000 in one case, and 2-90 falling, at second observation, to 270 in another), there may be some doubt whether the observed augmentation is an essential characteristic of the disease. On the other hand, in a table extracted by M. Legrand from the 'Gaz. des Hôpit.,' and there copied from an English journal, which exhibits the results of twelve analyses of the blood of scrofulous patients by a Dr. Nicholson, we find that though the proportion of fibrine falls as low, in one case, as 120 per 1000, yet in two instances it is at the physiological mean (3). And, on further consulting Dr. Glover's analyses of the blood drawn from patients affected by external scrofula,-which were conducted on the method employed by Andral and Gavarret,—we are struck with the fact that in the cases of eleven males, the fibrine reached a mean of 3·132, and in six females, a mean of 3.585. Now does not a candid consideration of these facts, taken in conjunction with the well-known and easily explained occurrence of bronchitis, and of circumscribed inflammation around the tubercular deposits, in phthisis, tend to this inference; -that both forms of disorder are essentially characterised by an impoverishment of the blood-by a spanæmia, which includes the fibrine as well as all the other solid constituents of this fluid, until some intercurrent inflammation, so much more prone to occur in a vital organ than in the seats of external scrofula, exerting its characteristic effect, raises the proportion of fibrine up to and above the normal standard? That the spanæmia in which the two orders of affection agree, is the only essential change in the blood, and that the fluctuating proportions of fibrine in which they differ, are contingent upon accidental circumstances, is further confirmed by the fact, that in the pneumonia and bronchitis of phthisical patients, the fibrine of the blood does not attain so high a figure as in cases happening to those who were previously in good health, and that when inflammation attacks a patient affected by scrofula, this element undergoes an augmentation which, allowing for its previous depression, is equally proportioned to the seat and severity of the attack. It should be remembered also that the fibrine effused in the inflammations both of scrofulons and tuberculous subjects, manifests a similarly defective elaboration and plasticity. For ourselves, we cannot see any reasons for attributing an essential defibrinating influence to scrofula, which do not equally apply to tubercle; there are no facts within our knowledge which go to show any differences in the amount of fibrine in the blood of the scrofulous, and of those having tubercles in a quiescent condition; and the differences, in this respect, which afterwards make their appearance, seem susceptible of an easy and satisfactory explanation, independently of any real or supposed difference in the essential tendencies of the two affections.

We need scarcely prolong this discussion by dwelling upon the indications presented by the urine. M. Legrand allows that the changes which

occur in this fluid are altogether secondary, and chiefly expressive of those complications, inflammatory and febrile, and of that general waste, which attend tubercular disease in its progress, or of the anæmic state which exists both in the scrofulous and tuberculous. The only particular to which he points special attention, is the frequent presence of albumen in the urine of scrofulous patients, and its " very rare occurrence in the tuberculous" (p. 398): a circumstance which in his view explains the almost constant diminution of albumen in scrofulous blood, and the frequent occurrence of dropsy in that form of disease, and the rarity of both these states in the tuberculous. But the grounds on which he considers this albuminous condition of the urine to be so common in scrofula, appear very defective. Reference is only made to the analyses of Becquerel, who speaks of the presence of albumen in the urine of the scrofulous as merely an accidental circumstance. The uniform deficient cy of albumen in the blood, on the other hand, we have already stated, was asserted of no less questionable data. We have also had occasion to dispute M. Legran l's former assertions,-strangely at variance, as they seem to us, with what he here says of the urinary changes in scrofula and tubercle, respecting the association of albuminuria with these affections. We have no doubt that albuminuria occurs as a complication both of the external forms of scrofula and of internal tubercle; or, we should rather say, that it is itself, in one of its forms, a manifestation, like tubercle in the lungs or caseous deposit in the cervical glands, of one and the same diathesis. And, doubtless, whenever it occurs with either one or the other of these affections, it will be likely to be attended with a diminution of albumen in the blood-serum. But as to any such regular and characteristic occurrence of correlative changes in the blood and urine as M Legrand assigns respectively to scrofula and tubercle, we cannot, upon such evidence as he adduces, accept them as by any means proved, or even rendered probable.

We have now brought under the consideration of our readers all those marks of difference between scrofula and tubercle, which M. Legrand puts forward as of essential significance. And in examining them, one by one, with reference to the hypothesis they are supposed to illustrate, we have shown, as we hope, how little weight they are entitled to, as evidences of generic diversity; so that whether we investigate the structural characters of the matters deposited in scrofula and tubercle,-or take into consideration the occurrence of glandular enlargement, without internal tubercle, or of internal tubercle unattended by glandular enlargement,-or compare the history of the scrofulous affections of the bones with those ascribed distinctively to tubercle,-or examine the reactions of scrofula and tubercle upon other diseases, or of other diseases and of the state of pregnancy upon them,

or inquire into the differences which mark their progress and termination respectively,—or into the morbid liabilities of the scrofu lous and tuberculous-or, lastly, take cognizance of the changes wrought in the blood and urine of those who are affected with these disorders, we find nothing that is not, to say the least of it, equally explicable on the opposite theory of generic identity. And we fall back upon this theory, as the only one which is adequate to explain such remarkable facts as are recorded by M. Legrand himself, and by which the most striking analogy is shown to exist between the two series of phenomena;-such facts as their occurrence in

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. 8vo, pp. 686.

2. Parturition, and the Principles and Practice of Obstetrics. By W. TYLER SMITH, M.D. Lond., Lecturer on Obstetrics in the Hunterian School of Medicine.-London, 1849. Fcap. 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. have already devoted much space to a critical analysis of Dr. T. Smith's

We

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 fatal 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 catalogue 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,