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the distension follow after the nerves have reflected their abnormal impressions on the muscular apparatus of the organ. There is much in this view that commends itself to the practical experience of the physician, but we prefer to leave it, as Dr. Brinton does, without further development.
In all that the author says upon Acute Gastritis we cordially concur. He adopts the statement of Abercrombie, that acute inflammation of the gastric mucous membrane hardly occurs, except as a consequence of irritant poisoning; and he treats the idiopathic acute gastritis of nosologists as a practically non-existent disease. We are disposed to go beyond our author in this point, and to assert very nearly the same thing of sub-acute and even chronic inflammation, for we have never seen anything coming distinctly within the range of inflammation at all in the gastric mucous membrane generally, which was not to be accounted for on the supposition of mechanical or chemical irritation. In general terms we would say that according to our pathological experience, the gastric mucous membrane, considering the number and variety of the stimuli to which it is constantly subjected, enjoys the most remarkable immunity which it is possible to conceive from serious inflammatory disease, and has the most marvellous power of recovery after even serious injury. And in no point is the stomach more wronged than in the facility with which dyspeptic and feverish symptoms are set down as the result of "chronic gastritis." That the exposed stomach of Alexis St. Martin, tortured from day to day by the direct application of unmasticated food, habitually irritated by curious physiologists in search of gastric juice, and occasionally by strong alcoholic drinks, should only now and then have resented this treatment so far as to cease to give forth gastric juice, and to undergo a temporary congestion and partial extravasation of blood, seems certainly to us rather to disprove than the contrary the asserted liability of the organ to "chronic inflammation." Consider that there is not a trace of evidence that pus was ever formed on this mucous membrane so irritated, and then consider the facility with which this product is evolved under the slightest forms of external irritation on all other mucous membranes excepting those of the alimentary canal, and it will be apparent, we think, how small a share is taken by general inflammation in the diseases of the stomach. The utmost that we can admit as at all common is the existence of transient congestions, resulting perhaps in an excess of mucous secretion and a temporary arrest of the proper digestive process. We agree with Dr. Brinton in doubting even the existence (considered as a disease) of the so-called "chronic catarrh of the stomach," but if it be really a disease, it is quite clear to our convictions that it bears no resemblance to inflammation.
It is more difficult to speak with confidence of the partial affections of the mucous membrane. Beyond all doubt the stomach is subject to disorganizing processes, limited to particular spots of the mucous surface, and the pathological character of these may reasonably be supposed to be inflammatory. Such are the simple perforating ulcer
and the hæmorrhagic erosion. But the relation of these to the ulcerations of other mucous membranes is not a little obscure. The chronic simple ulcer of the stomach is an isolated fact in pathology. Nothing in its history, in its antecedents, in its consequences or accompaniments, throws the least light upon it; and except that the entirely normal character of the general mucous membrane, and the absence of all inflammatory products on the surface of the ulcer itself, seem to belie the supposition, we might as reasonably refer it to inflammation as to anything else. But the destruction of an accurately limited space of mucous membrane, bearing no relation to any special glandular structure, and this without sloughing or suppuration having ever been observed at any stage of the process, is a fact too anomalous to remain securely under this all-comprehensive pathological denomination. It is wiser, surely, to admit ignorance than to speculate in such vague fashion as this. And here again we find ourselves at one with Dr. Brinton, who declines to pronounce on the causes or mode of origin of the gastric ulcer.
We refrain from observations on the rest of this book, which is, notwithstanding, its major part. We have been chiefly anxious to bring before our readers such portions of the author's labours as have not been known to them from our own pages. It is unnecessary to enlarge here upon the exhaustive and admirable manner in which Dr. Brinton has treated of the Chronic Ulcer and on Cancer of the Stomach. The results of both these inquiries are given in this book as fully as is necessary for the busy practitioner, and in a form better adapted, perhaps, for his perusal than the original papers. The same conscientious care for truth has guided the author through every part of his researches, as is apparent in the ground we have now gone over; and indeed not one sentence or phrase from beginning to end of this work will bear the construction that it is written at random, or without the most serious reflection. We sometimes differ from the conclusions adopted; but we are obliged to do so with the respect which is due to well-considered opinions. The practical man will miss some of those vague and dashing generalizations to which he is accustomed in works of this kind. But he will miss them greatly to his advantage if he imbibes in any degree the author's earnest and sober spirit of inquiry.
There is an introductory chapter, to which we have not alluded, on the Anatomy and Physiology of the Stomach. It is of the same character as the rest of the work, but does not aim at putting forward any new views or observations on the subject.
In the preceding remarks, it is to be observed, we have not attempted anything like complete analysis. Were we to have done so, we should have been obliged to re-write the book, which is, especially in the parts on which we have touched, far too condensed in expression to admit of further reduction of its argument. Indeed, we are sensible at some points of having even expanded the author's ideas in referring to them. We trust we have done them no injustice in thus handling them, and in venturing to indicate further points on which
we would willingly see the author engaged. The enlargement of this volume by a chapter or two in a future edition would, we think, make it still more serviceable to the public and to the reputation of Dr. Brinton.
Practical Midwifery: comprising an Account of 13,748 Deliveries which occurred in the Dublin Lying-in Hospital during a period of Seven Years, commencing November, 1847. By EDWARD B. SINCLAIR, A.B.F.K. and Q.C.P., &c. &c., Ex-Assistant-Physician to the Dublin Lying-in Hospital; and GEORGE JOHNSTON, M.D., L.K., and Q.C.P., &c. &c., Ex-Assistant-Physician to the Dublin Lying-in Hospital.-Dublin, 1858. 8vo, pp. 574.
THE above volume, although purporting to be a treatise on practical midwifery, is essentially a statistical record of the deliveries which occurred in the Dublin Lying-in Hospital during the seven years' mastership of Dr. Shekleton, interspersed with some general observations on practice. We say essentially statistical, for there is scarcely a fact or an incident recorded in the volume which is not given in a statistical form; and it is curious to observe in how many ways the same fact may be numerically stated. As a mass of statistics, therefore, we regard the work as a valuable contribution to obstetrical literature, and those who attach more importance to such data than ourselves will doubtless accord to it a high tribute of praise. For ourselves, however, we cannot help thinking that throughout the work the practical has been too much sacrificed to the statistical-that an immensity of labour has been expended in stating facts numerically which are of little clinical importance, and that a too servile deference has been paid to the arbitrary rules of an artificial nosology. Thus, instead of the history of Face Presentations being given in a consecutive series, we find them scattered among different chapters of the book, in deference to nosological formula; so also is it with Puerperal Fever and many other of the subjects treated of. We concede that a large array of facts and figures gives an imposing character to a work, and that where upwards of 13,000 deliveries are recorded, there exist ample materials for such a purpose; but we nevertheless think that the volume would have been more generally useful and available if less encumbered with figures and calculations, and as we do not think we could interest our readers by a merely statistical abstract, we shall rather endeavour to enucleate from its pages the spirit or principles which would appear to have guided the practice in the Dublin Lying-in Hospital during the period over which its history extends.
Let us, however, premise a few generalities culled from the introductory observations. The report as already stated contains an account of the cases which occurred in the hospital during the seven years' mastership of Dr. Shekleton, which commenced in November, 1847, and terminated in November, 1854. During this period, 13,748
women were delivered, and gave birth to 13,933 children. Of these children, 7177 were males and 6756 females, whilst the still-boru, including those born putrid, amounted to 968. Of the 13,748 women delivered, 4535, or one-third, were primiparous, 233 had twins, 1 had triplets, and 163 died in childbirth from puerperal and other causes. From these latter, however, it is right to deduct 17 who were admitted into the hospital in a dying state, leaving a balance of 146 deaths from all causes, or 1 in 94. But of these it would appear that 70 deaths were due to puerperal epidemic disease, which subtracted, would reduce the mortality to 76, or 1 in 180, and of these it is further to be observed that 40 died of other than puerperal diseases, such as apoplexy, bronchitis, pneumonia, phthisis, &c., leaving a total of 36 deaths only which originated in labour, or 1 in every 381 of those delivered.
From the same source we learn that the greatest number of monthly deliveries was respectively in the following order :-May, March, June, April, July, August, February, November, December, September, October, and January, whilst inversely as regards mortality, the fewest deaths occurred during the month of May, and the greatest during December, the May series for the seven years presenting the least amount of mortality and the greatest number of deliveries, whilst the December gave the smallest number of deliveries and the greatest amount of mortality. Taking the series of months during the seven years in the order of their salubrity, commencing with the most healthy and terminating with the most fatal, we find them to run thus:-May, June, September, October, August, March, January, November, April, July, February, and December.
It is worthy of remark that the general fact thus indicated as to the salubrity of different seasons in regard to parturient females accords very strikingly with that which has been observed elsewhere, and the reader will find an interesting exemplification of it in a note published in the appendix to Dr. Ferguson's essay on Puerperal Fever. From it we learn that the most injurious months in Paris are respectively, November, October, and February; in Geneva, January, March, and November; in Aberdeen, October, December, and November; in Edinburgh, November, December, January; and in London, January, March, February, December, and May. As a general rule, the cold months are the most fatal, and it is surmised that this increased mortality is partly due to the want of ventilation. Nothing, it is remarked, will induce the patients in winter to allow a window or door to be opened; hence the whole ward is hot and close; while in the month of July every door and window admits fresh air day and night.
We shall next proceed to give an outline of the practice pursued in the 13,748 deliveries recorded and tabulated in the work, premising that the arrangement of labour into four classes-Natural, Preternatural, Difficult, and Anomalous, as proposed by Denman, has been adopted throughout, each, however, having certain subdivisions, to which we shall refer in the progress of our analysis.
I. NATURAL LABOUR.-This is understood to signify labour where the head presents and the delivery is completed within twenty-four hours. It is divided into purely natural labour and varieties of natural labour, the latter being subdivided into face, face to pubes, and armwith-head cases.
Commencing, then, with purely natural labour, we have to express our approval of the careful manner in which the duties to be discharged in the management of these cases are laid down; the necessity of investigating the state of the os uteri, that of the membranes, the presentation and its relative position, the condition of the pelvic strait, that of the soft parts in the pelvis, their surfaces and secretions, the state of the bladder and rectum, the existence of morbid growths and tumours, are successively indicated as points for careful investigation. Upon this subject, however, we have no time to enlarge, and passing over the management of the first and second stages of natural labour with the single observation that we object altogether to the practice of puncturing the membranes in the first stage, as recommended by our authors in certain exceptional cases, we proceed to the consideration of the treatment recommended in the third or placental stage of labour.
We believe, notwithstanding the difference of opinion which exists, that the practice recommended by our authors is essentially the best viz., the fundus uteri having been steadily compressed manually, and thus followed down during the descent and birth of the child, and the charge of maintaining its contraction having been intrusted to the midwife, whilst the necessary attentions are paid to the child on its birth, the medical attendant resumes the charge of maintaining uterine contraction until after the expulsion of the placenta. We believe this practice is better than the ordinary plan of applying the binder immediately after the birth of the child. We concur with our authors in thinking, that by this means the liability to hæmorrhage is lessened, the state of the uterus as to flaccidity, distension, or contraction, is more certainly determined; the detention of clots within the uterus prevented, and the abdominal parietes generally better supported. As compared, moreover, with the immediate application of the binder, we conceive that it has the advantage that it obviates the chance of overlooking insidious or internal hæmorrhage, and that it thus does away with the necessity and consequent delay of having to undo the bandage, and seek for and restore the contraction of the uterus in cases in which internal hæmorrhage has occurred.
For after pains, opium is recommended, but we should prefer giving a full dose of castor oil, either with or without turpentine, when they are troublesome. We believe, however, that when care has been taken to maintain the contraction of the uterus in the manner described, they will seldom be severe, and when they do occur under such circumstances they will generally be found to be occasioned by a clot which is expelled under the action of the purgative. We hold that the employment of opium, after labour, should be as much restricted as possible, tending, as it frequently does, to constipate the bowels,