rate from pulmonary disease where much in-door female industry is required; the greater liability to cholera, diarrhoea, and fever where impure water is drunk, and especially the valuable fact connected with the surface wells of London. The difference in the female pulmonary death-loss traceable apparently to work at home and work in the factory, the probable connexion of pauperism with high death-rates, both pulmonary and zymotic, and the important results of the experiments of Drs. Barker and Letheby.

Under the second of these heads, we would call to mind the Paper of Mr. Neison respecting the causes of pulmonary disease in the army, the disproof of fever being either, in large proportion, a disease of mature life, or of very crowded localities, as compared with others; and the fact that croup is not found to have the highest death-rate in damp and cold situations. Moreover, that consumption is more fatal in the comparatively mild climate of the southern English counties, than in

the northern.

Lastly, as regards anomalies, we have them abundantly enough. Cambridgeshire has a high pulmonary death-rate without palpable reason. Stoke and Walstanton show no cause for giving different mortalities from lung disease, nor can we tell why the Welsh coalmining districts should differ in this respect from their English neighbours. Birmingham, Nottingham, and Leicester, if liable to diarrhoeal outbreaks, have an exemption from cholera, apparently from no merit of their own; and when we come to the differences in the male and female death-rate from the nervous diseases of children, as well as the differences in the general death-rate itself, we are completely at fault; neither is our perplexity lightened by finding that scrofula is a more fatal disease in the generally healthy than in the unhealthy districts.

To these anomalies we may add another not yet alluded to, the fact that the "waterguard" and the waterside officers of Her Majesty's Customs, although exposed to much vicissitude of weather, and to the constant influence of Thames emanations, do not suffer from a high rate of mortality.

*

Perhaps sufficient has been said to show that although many and valuable are the facts which we have acquired, especially were they practically used, we are as yet but on the threshold of the science of hygiène, and that, as Dr. Greenhow remarks, "the entire subject is barely opened by the present inquiry."

In addition to investigations respecting crowding, occupation, drainage, &c., climate, domestic habits, the structure of the houses, the food, the topography and geology of the districts, must be examined, as well as every circumstance which can affect health, before we shall be in a position to ascertain correctly the causes and the practical bearings of the death-rates of England.

Such minute and local investigations are evidently beyond the power of one man, and the necessity is at once apparent that local "medical officers of health" should be appointed throughout the entire kingdom, from whose reports, rendered in a systematic, and above all in an indepen

Second Report on the Customs, by J. O. McWilliam, M.D.

dent form, deductions might be drawn, not simply of the broad features of the sanitary question, but of the varied local circumstances which not only occasion preventable mortality, but which tend to impair health and constitution. Till this is done, there will be no real sanitary Individual labours may bring out new facts, and confirm old ones, but they will want much of that minuteness which would make them truly valuable in practical application.

science.

REVIEW II.

1. A Manual of Obstetrics, Theoretical and Practical. By W. TYLER SMITH, M.D., Member of the College of Physicians, PhysicianAccoucheur to, and Lecturer on Midwifery at, St. Mary's Hospital. London, 1858. pp. 628.

2. Lehrbuch der Geburtshilfe. Von Dr. OTTO SPIEGELBERG, Privatdocenten an der Universität zu Göttingen.-Lahr, 1858. pp. 372. Manual of Midwifery. By Dr. OTTO SPIEGELBERG.

3. Illustrations of Difficult Parturition. By JOHN HALL DAVIS, M.D., &c. &c.-London, 1858. pp. 284.

SOME one has called this the "Age of Manuals," and there is so much truth in it, that we have manuals, and good ones tco, upon almost every subject. But in the contemptuous sense in which the term was applied we cannot agree, for the manuals of the present day are in fact treatises of considerable length, retaining only the name of the former brief abstracts to which it was applied. Look, for instance, at the series published by Mr. Churchill they are certainly small in bulk, but that is the result of small, ciose print, and thin paper: any one of them, if printed in the old manner, would make a respectable octavo volume. But the most marked difference between them and their predecessors of the same name is, that they are the productions of the ablest men in the different departments of the profession. Almost every section has its volume, and their sale is the best proof of their popularity with the profession. Hitherto, midwifery has been the solitary exception, but at length this want is worthily supplied.

In Germany, more than one series of manuals, we believe, is in the course of publication. Dr. Spiegelberg's volume is one of a series publishing under the editorship of Dr. Schauenburg, and if the other volumes are of as high a character as the present, the students of Germany will have little cause of complaint.

As most of our readers are probably acquainted with Dr. Tyler Smith's former work 'On Parturition,' in which he so successfully applied Dr. Marshall Hall's discoveries to the elucidation of the physiological problem of pregnancy and parturition, they will no doubt be prepared to welcome another work from the same pen. Nor will this feeling be lessened by the practical character of his recent volume 'On

Leucorrhoea.' He has shown that he possesses not only reasoning powers of a high order, but acute and accurate observation of facts. It will be remembered that the course of lectures delivered by Dr. Tyler Smith appeared in print in the 'Lancet' for 1856, and so favourably were they received, that Mr. Churchill applied to the author to recast them for one of his manuals, in which popular form they are now presented to the profession.

We are inclined to begin our notice by finding a little fault, if Dr. Tyler Smith will excuse us. No doubt classification and division may be carried too far, but a certain amount is a great assistance to the student, and we cannot but think that the studied avoidance of such helps on the part of the author is a defect. To those who look closely, there is certainly an undercurrent of connexion, if we may so speak, between the different subjects, but superficially this does not appear. Of course we have the two great divisions of anatomy and physiology, and practical obstetrics. The execution of the first part is very good, perhaps clearer and more correct than in any of the ordinary works on the subject. The second part is good also, but it is by no means superior, perhaps hardly equal, to some of the other manuals. In order to give the reader a bird's-eye view of the ground occupied, we shall quote the titles of the successive chapters. First, we have the subject of generation treated sufficiently fully, followed by a description of the organs of generation, ovulation, menstruation, conception, and the development of the ovum and its appendages, the signs of pregnancy, disorders of pregnancy, the causes and treatment of abortion, molar pregnancy, super-fœtation, extra-uterine gestation, the nervimotor functions of the uterus, the fœtus in utero, and the duration of pregnancy. We next come to the obstetrical portion of the volume, strictly so called, although no classification is made by the author beyond the separation into chapters. Here we find chapters on the pelvis, the anatomy of the foetal head, the mechanism of labour, the stages of labour, the management of natural labour, and of the puerperal state, face presentations, pelvic presentations, transverse presentations, funis presentations, placenta presentations, deformities of the pelvis, obstructed labour, difficult labour, tardy and precipitate labour, post-partum hæmorrhage, rupture of the uterus, puerperal mania, puerperal convulsions, puerperal fever, phlegmasia dolens, and lastly, the various obstetrical operations, induction of premature labour, version, the forceps, embryotomy, the cæsarian section, and a chapter on chloroform.

This enumeration will sufficiently prove the want of an adequate classification, at the same time that it will enable the reader to estimate the wide range of subjects included in the work.

As the volume is merely an improved reprint of Dr. Tyler Smith's lectures, we do not think it necessary to enter upon an elaborate analysis of the volume, but shall content ourselves with culling an extract here and there which may appear to us interesting, original, or practically important.

On the subject of the "behaviour" of the uterine mucous membrane

during menstruation, the author has carried still further the views of those who regard that membrane as excrementitious under certain circumstances. After describing accurately and carefully the phenomena of menstruation, the character and quantity of the discharge, and the condition of the ovaries and uterus, he observes :

"It appears to me in accordance with what I have observed on uteri examined during a menstrual period, the facts connected with membranous dysmenorrhoea, and the detachment of the decidua in abortion and parturition, to suppose that the mucous membrane is in great part or entirely broken up, and its débris discharged during each menstruation. The blood is probably exuded during the breaking up of the mucous structure, and the duration of the menstrual period represents the time occupied in the periodical decadence and renewal of the mucous membrane of the body of the uterus. The new membrane becomes converted into decidua in the impregnated female." "According to the view I have stated, a new mucous membrane is formed as a part of the process of preparation for the reception of a fœcundated ovum ; not that the aptitude for the reception and implantation of the ovum belongs only to the newly-formed mucous membrane, though it is probably greater at this time than at others. The mucous membrane may become the seat of the change consequent upon impregnation just before a menstrual period, and in cases where menstruation is suspended. According to the view now stated, the mucous membrane of the uterus becomes excrementitious every month, and is discharged from the cavity of the uterus in a state of disintegration. The uterus appears to gain a new mucous membrane by a process similar to the reproduction of lost parts." (p. 62.)

This is ingenious, no doubt, but we think the facts hitherto observed are far from sufficient to establish it. Nor is it at present reconcileable with known facts, for if the exfoliation is an essential part of the regular monthly process, and necessary for the reception of the ovum, what proof have we that it occurs in those cases when conception takes place before a menstrual epoch, or how explain the occurrence of impregnation during the menstrual flow, as in the cases related by Raciborski? In truth, the condition and changes of the interior of the uterus during menstruation, gestation, and after parturition, require more careful and detailed observation.

The chapters on conception, and the development of the ovum and its appendages, are clearly and carefully written, but without any original observations. The different signs of pregnancy are detailed in a condensed and able manner. The description of the sounds of the fœtal heart is somewhat imperfect: nothing is said of the peculiar rhythm which differs so much from the healthy adult heart, but which is occasionally simulated in typhus fever.

The variations in the actions of the kidneys is very well told, and the treatment of albuminuria very sound. A variety of the renal secretion is noticed by Dr. Tyler Smith, as he believes, for the first time, and we shall quote his own words :—

"I am not aware that the matter has been observed by obstetrical authors, but in some pregnant women, the urine, without being albuminous, contains habitually a large quantity of triple phosphates, is of a high specific gravity, and has an alkaline reaction during the greater part of pregnancy. The nervous and vascular erethism attendant upon, or produced by, the state of pregnancy,

is followed by the same results as other and more marked causes of exhaustion. I have known this phosphatic diathesis to exist in cases in which fatty degeneration of the placenta has occurred in successive pregnancies.” "The treatment in such cases should be that employed in the phosphatic diathesis occurring under other circumstances than pregnancy, namely, the mineral acids, opiates, rest, and a nutritious regimen. Such patients also require, either during or after the completion of pregnancy, preparations of steel, as a marked degree of anemia is produced by the persistence of the disorder.” (p. 121.)

When treating of retroversion of the impregnated uterus, under the head of disorders of pregnancy, Dr. Tyler Smith mentions M. Gariel's proposal to introduce his india-rubber pessary, and then inflate it as a means of raising the fundus uteri, but he adds, that he is not aware of its having been tried. We had an opportunity of testing its value recently, and we are happy to say that it succeeded perfectly, and in a few minutes, without the least pain; but then it is only fair to state that the patient was only about three months pregnant, the uterus by no means tightly filling the pelvis. The idea of thus replacing the uterus, however, is due to Dr. Halpin, of Cavan, who many years ago reported a case thus treated successfully to the Dublin Obstetrical Society.

The chapter on abortion and its treatment is very good as far as it goes, but scanty information is given upon one or two points which are most puzzling to beginners, and even sometimes to those of riper age. Suppose an abortion of two or three months, the fœtus being expelled, but the shell of the ovum retained. We are to restrain hæmorrhage of course, and to procure the expulsion of the retained portion by ergot, &c., if we can. But suppose we fail, and that we can neither expel nor extract it, what is to be done? Dr. Tyler Smith has not provided for such cases, and yet they are very common.

The cause of the ordinary position of the foetus in utero, i.e., with its head downwards, whether it be the result of gravitation or instinctive and voluntary motions or reflex movements, is yet a subject of controversy. Probably no one of these theories affords an adequate explanation, and this seems to be Dr. Tyler Smith's opinion. His own views are thus given :

"In the early development of the embryo the limbs are deficient in muscular power, and do not assume any definite form. The nervous system has hardly commenced its control over the, as yet, feeble muscles. The quantity of liquor amnii is very large in proportion to the size of the uterus, and the uterus is circular rather than ovoid in shape. We have to consider these elements as slowly altering from day to day in an almost inappreciable manner, during the middle and later months of pregnancy, and while the foetus is gradually taking up its ultimate position. The limbs of the foetus enlarge, becoming subject. to the vis nervosa, and under the influence of tone; the arms and legs, particularly the latter, become contracted so as to form the foetal ovoid. During this time, the relative quantity of the liquor amnii diminishes, so that at the full time the liquor amnii scarcely does more than fill up the interstices left between the foetus and the uterus. Synchronously with these events, the uterus itself, by the development of the cervix, changes from the circular to the pyriform or ovoid shape. With this change of shape the uterus acquires