commands, there were others employed irregularly, or on special duties, which did not remain for any great length of time in any one region or locality, and which, therefore, in a statistical point of view, require to be included under a separate head. These ships were seventy-three in number, and consisted of ships of the line, frigates, and smaller vessels. Their mean force was about 10,000 men. The total number of deaths was 105, or in the ratio of 10.5 to 1000 of mean force. Of these 78 were from diseases, and 27 from accident, the former being in the ratio of 7·8, and the latter of 2.7 per 1000 of mean force. The daily average of men ineffective from wounds and sickness was, for ships of the line, 395; for frigates, 458; and for smaller vessels, 40.2. The total number invalided was 136.

There are, of course, fewer data for general sanitary observations among so scattered a force, than in the case of squadrons employed in particular regions and services; nor do we here find anything relating to the prevalent diseases which need detain us.

Total Force. There is a concluding section thus headed, some of the information contained in which we have anticipated in our notice of particular stations. The total mortality from disease in the navy for the year 1856 amounted to 629, or 71 per cent.; that from accidental injuries, wounds received in action, drowning, and suicide, was 172, or 21 per cent.

The most fatal disease was fever, from which there were 199 deaths, or nearly 25 per cent. of the total mortality: of these deaths 130 were from yellow fever, of which 105 occurred in five small vessels-thus showing how the introduction of a fatal disease into a few vessels, not containing a fiftieth part of the force, may influence the deathrate in the naval service. Next to fever, consumptive diseases were more destructive to life, having been in the ratio of 2.7 per 1000 of mean force. The deaths from all diseases of the respiratory organs were 175, forming 21.9 per cent. of the total mortality. The deaths from disease of the heart and blood-vessels were 4.9 per cent., and those from diseases of the alimentary canal, 13.4 per cent. Of 64 deaths from dysentery 48 occurred in the vessels employed on the coast of China. The total number of men invalided in the navy was 998, or 19.3 per 1000 of mean force.

The mortality from all causes, namely 15.5 per 1000 of mean force, compared with the mortality in civil life in England appears high; but, to make a just comparison, we must strike off at least two-thirds of the accidental deaths in the navy, as well as the deaths from yellow fever, which would reduce the total mortality in the service to about 10 per 1000 annually-showing that the real mortality in the navy from all ordinary causes, is about the same as in the more healthy communities of men living on shore.

The aggregate loss of service from wounds and sickness in the entire navy was in the ratio of 61.7 per 1000, which exceeds the loss in the metropolitan and city police by a little more than one-third. These, it is assumed, are the only bodies of men beside the navy in which this mode of estimating the extent of sickness has been adopted. When we consider that a large proportion of the naval force is employed within the tropics, in regions highly detrimental to European constitutions, and that the police have much better means than the sailors of guarding against the evils arising from exposure to weather, by drying their wet clothing, and refreshing themselves with warm food and drink, the difference in the ratio of sickness is less than might have been expected. Add to this, that, in the police force, a shilling a day is stopped out of each man's pay as long as he is unfit for duty from ill-health, so that it is the interest of every man to keep off the sick list as long as he can; whereas, in the navy, there is no such regulation, so that indolent men and malingerers remain on it as long as they can impose on the medical officers. The majority of the police also are married men, so that they may be supposed to be less liable to contract venereal diseases than the seamen and marines of the navy.

On the whole, this is a very able and satisfactory Report, defective in very few particulars of any importance, though it is, perhaps, written in a more diffuse and less logical style than might have been desired in a document of this description. Here and there we meet with an ambiguity of expression which renders the exact meaning a little obscure; but this occurs chiefly with respect to minor details, and may arise

from ambiguities in the returns from which the Report is drawn up: in such cases it is certainly better to leave the meaning a little indefinite, than to determine it too precisely in a direction which may happen to be the wrong one.

REVIEW III.

Mémoires de l'Académie Impériale de Médecine. Tome XXI. pp. ccxlvi. et 600; Tome XXII. pp. cl. et 542. 4to. Paris, 1857-58.

THE two volumes of the 'Mémoires' we have here to notice do not contain any papers of commanding interest; but there are some the contents of which may be usefully made known to our readers.

I. The Pathological Anatomy of Cysts. By L. BAUCHET.-After passing in review the different classifications of cysts that have been proposed, M. Bauchet prefers that one derived from the nature of the matters or substances which constitute the contents of these bodies. It allows of the establishment of clear and precise divisions of the subject; while the nature of its contents being known, the structure of the cyst itself can almost always be predicated. In this way he constitutes ten varieties of cysts: 1. synovial; 2. serous; 3. mucous; 4. sebaceous; 5. milky; 6. hæmatic; 7. purulent; 8. parasitic; 9. fœtal; and 10. pilous cysts. Of some of these subdivisions are made. Of course we have not space to go through the catalogue, and will confine ourselves to what the author states respecting synovial cysts. These he divides into articular, tendinous, and submuscular.

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1. Articular Synovial Cysts.-These, again, constitute three varieties, accordingly as they are formed at the expense of the synovial membrane, outside of this, or by the synoviparous follicles. The first of these varieties is the only one that has been described even in our most recent works. A fold of synovial membrane protrudes through an aperture in the protective fibrous covering, and its communication with the synovial cavity is obliterated, a pedicle only remaining. The second variety, the author does not admit as of independent origin, but believes it originally constituted a hernia of the synovial membrane as above described. The third variety is the most interesting and curious, the true nature of its origin having been first established by M. Gosselin. There exist in joints culs-de sac or follicles in a greater or less number, to which gave the name of synoviparous follicles. By the examination of numerous joints, and especially the carpal, we are able to trace the evolution of this form of synovial cysts. Just as with regard to the sebaceous or mucous follicles, we may observe the membrane thrown into relief by little transparent elevations, varying in size from a pin's head to a pea or nut, and having at some part of their parietes a little black point, which cannot be better compared than to the lachrymal point. These are synoviparous follicles having their ducts obstructed and more or less filled with thickened synovia. The little cyst increases more or less in size, according to the region it is placed in and the amount of pressure it is submitted to. These, in fact, constitute the cysts usually met with— those due to hernia of the synovial membrane being rare. The contents of these articular cysts usually resemble synovia, but when the more fluid parts have been absorbed it may assume the consistency of apple or quince jelly. It is rarely of a serous or serosanguinolent consistency. Epithelial cells are sometimes found floating in the liquid, or forming little vegetations projecting from the internal wall. In true articular cysts hordeiform bodies have not been met with. The sac is of the same structure as the articular synovial membrane, excepting that the fibrous investment is often more dense. 2. Tendinous Synovial Cysts.-These vary accordingly as they are confined to one or more tendinous sheaths, and do or do not communicate with this. Cysts of con

siderable extent, occupying a sheath common to several tendons, are usually of a chronic nature, and almost always contain the hordeiform bodies. These are not usually met with in the common variety of cysts which implicates only one sheath. This is generally more acute in its progress, and frequently exhibits sanguineous, pseudo-membranous, or purulent contents. The hordeiform bodies have been considered by some to have arisen from hydatids, and by others to be minute sanguineous coagula; but their true nature seems to be that of vegetations springing from the inner wall of the cyst. They consist in fibrous or cartilaginous tissue, and their pedicle easily giving way, they become free in the cavity of the sheath, deriving a polish from rubbing against each other. They impart a peculiar consistency to the cyst, and give to the examining finger a rubbing sensation, such as may be produced by introducing beans into a vessel full of water-a sensation difficult to describe, but never forgotten when once felt. The absence or presence of these bodies is of importance with respect to prognosis and treatment. Detached and free in the cavity of the sheath, they have no tendency to become absorbed, and present an obstacle to the radical cure of the disease by internal and external resolvents.

3. Submuscular Synovial Cysts.-Under this appellation M. Bauchet describes the enlargement of the submuscular bursæ, when these do not communicate with the articulations.

II. On Bloodletting in Pregnancy. By M. SILBERT.-This is one of the Academical Prize Essays. The author believes that as a consequence of the reaction against the abuse of bleeding in pregnancy, practitioners in our own times are too sparing in its employment. There is, in fact, a tendency to the same exaggeration with respect to the chloro-anæmia of pregnant women which formerly prevailed with regard to plethora.

"That great consideration should be paid to chloro-anæmia in the pathology of pregnancy is right enough, but only on the condition also of not overlooking plethora, a state of complete reality, and which did not exist merely in the imagination of our predecessors. It is only by studying pregnancy under this double point of view, and taking into account at the same time the 'nervous condition' and albuminuria, which also play their part in the production of the accidents with which it is accompanied, that we can embrace the entire truth. This is not to be done by sacrificing one point of view to the other. The determination of the relative frequency of these different conditions as causes of the diseases of pregnancy, would be of very great importance as regards the general indications for bleeding; but this point of medical statistics is far from being elucidated, and it is not in a restricted circle like Paris that the elements of a very exact appreciation are likely to be obtained. For the practitioners of great cities, whose observations are for the most part made on women etiolated by misery in the hospitals, or relaxed by all the delicacies of luxury in private practice, chloro-anæmia and the 'nervous condition' predominate in the pathology of pregnant women. But the country practitioner attributes to the richness and exuberance of the blood most of the accidents which accompany gestation." (tome xxi. p. 117.)

Having premised thus much, M. Silbert divides his subject into three parts; in the first he treats of its history, in the second he considers the general indications for bleeding in pregnancy, and in the third he passes in review the particular cases which may call for its administration. We pass over the historical part, and proceed to the next. General Considerations on Bleeding in Pregnancy.-The modifications which pregnancy produces in the system are of two kinds; first anatomical and functional, which are constant and essential to pregnancy, having their seat in the uterus itself; and secondly, sympathetic, which are eminently variable. The accidents which are due to the mere physical development or acquired functions of the uterus are admitted at all hands to be best allayed by antiphlogistic treatment. The sympathetic modifications, which are of great importance in the pathology of pregnancy, are referrible to three heads: (1), to disturbances of the nervous system; (2), to notable changes in the composition and quantity of the blood; and (3), to the presence of albumen in the urine. These three conditions have then to be considered in relation to the question of bloodletting.

(1) Disturbances of the Nervous System.-To this condition must we attribute not

only the extreme moral irritability which some pregnant women exhibit, but also a good share of those functional disorders which are so common, so intense, and so obstinate, and which have been too frequently attributed to plethora, as vertigo, loss or perversion of the senses, and disturbances of the circulatory, respiratory, or digestive functions, as shown by palpitations, syncope, vomiting, &c. These generally disappear or become diminished with the progress of pregnancy in women whose nervous system has only become disturbed by the fact of the pregnancy itself; but it is otherwise with those in whom the pregnancy finds this condition of the nervous system already acquired. This “ nervous condition" has been laid down by Sandras as a formal contra-indication to bleeding, when it is unconnected with cerebral plethora, and the prohibition is justified by the close relationship which usually prevails between impoverishment of the blood and the production of nervous disorders. But in pregnancy the diminution of the globular element of the blood will not explain most of these nervous disturbances, inasmuch as these in general disappear before the blood has undergone any notable improvement in this respect. The sympathetic excitement is in many cases the direct consequence of the irritable state of the uterus, and capable of relief by small general or by local bleeding. Moreover, the "nervous condition" is an unequivocal cause of uterine plethora. The women who menstruate most are not the strong and plethoric, but the nervous and delicate. Great care is indeed required in employing bloodletting in the nervous affections of pregnancy, especially towards the end of this, but when the state of the strength permits it, the contra-indication must not be regarded as absolute.

(2) Modifications in the Composition and Quantity of the Blood.-Modern researches have shown that,-1st. The globules diminish from the commencement to the end of pregnancy, their proportion rapidly decreasing from the seventh month. 2nd. The fibrine, slightly diminished during the early months, is then increased somewhat to the seventh, becoming much augmented during the two last months. 3rd. The albumen diminishes progressively, though only to a slight degree, throughout the whole of the pregnancy. Although these modifications cannot be called pathological, yet is the relation which such blood bears to chloro-anæmia so strong as to lead to the same pathogenic character being attributed to the latter as formerly attached to plethora. M. Cazeau's views concerning the agency of chloro-anæmia are certainly too exclusive. The condition of the blood in pregnancy is, in fact, quite peculiar and special. In some exceptional cases, true chloro-anæmia may prevail, but it is rather as a coincidence and an exaggeration of a condition already present, than a consequence of the sympathetic reaction of the uterus. But true plethora may also prevail in women notably predisposed, or it may do so temporarily and at different stages of the pregnancy in those in whom it is only a result of the increased vitality dependent on pregnancy. And depletion requires to be used with more caution when plethora is a temporary, accidental condition, than when it is a habitual state, aggravated by pregnancy. Even in serous plethora, in which, with a diminution of globules, there may be a proportionate increase of serum, and in which ferruginous preparations may be called for, the mass of the blood being also augmented, careful depletion is not the less indicated. Mere mechanical plethora, determined by the pressure of the uterus during the latter months, may also call for palliative bleeding.

(3) Albuminuria.-Although pregnancy may run through its course quite uninterfered with when albuminuria is present, at other times it becomes a most grave complication, signally favouring the production of sanguineous or serous congestions, which in a great number of cases are the point of departure of alarming accidents. Bleeding may often be advantageously resorted to in order to ward off such consequences, when albuminous nephritis coincides with pregnancy, and when the condition of the urine, analogous to that observed in the anasarca consecutive to scarlatina, implies renal congestion. Albuminuria, considered in itself, is most often connected with asthenia, and therefore bleeding is contra-indicated; but the peculiar conditions observed in the pregnant woman often compel practitioners to depart from this rule, no one hesitating, when uterine or cerebro-spinal congestions become menacing, to have recourse to this

means.

In the sections on the inconveniences and dangers of bleeding in pregnancy, the author makes several quotations, in order to show that injudicious depletion during pregnancy, by impoverishing the blood, may give rise to abortion, and predispose to disease, especially to puerperal fever.

We pass on to the third part of the work, treating of the particular circumstances which may call for bleeding.

1. Bleeding in the Diseases proper to Pregnancy.-As long as the exaggerated ideas concerning the plethora of pregnancy prevailed, bleeding was performed without any reserve in all the diseases of pregnancy, and although any such excess would now be unjustifiable, yet does bleeding still constitute our principal mode of treating such affections. This arises from the fact that whenever they reach a certain point, the usual result is the production of congestion. The causes of the diseases of pregnancy are (a) the anatomical and functional changes in the uterine system, and the fluxion of which the pelvis is necessarily the seat during gestation; (b) the mechanical obstacle which the development of the uterus opposes to the free play of the organs: (c) the sympathetic reaction excited by the uterus in certain organs; and (d) the influence which the general modifications of the nervous system, the changed conditions of the blood, and the existence of albuminuria, exert upon the economy. Any of these four causes may act in an isolated manner, but usually more than one act together, and concur in the production of the accidents. It would be difficult, therefore, to consider the diseases of pregnancy by distinguishing them according to the causes which give rise to them; and the author prefers dividing them into idiopathic and sympathetic diseases. The former have their seat in the uterus and pelvic organs, and are the result of anatomical and functional changes; and the others interest distant organs, being due to the reaction which the condition of the uterus exerts upon the entire economy.

(1) Idiopathic Affections-(a) Uterine Plethora or Congestion.-This may be sometimes dependent upon a state of general plethora, but it is oftener found in nervous, albuminuric, and hydropolyæmic subjects. Not only does uterine plethora exert a great influence on the production of uterine hæmorrhage and premature contractions, but it determines almost the entire pathology of the ovum, placental congestion and apoplexy being, in fact, intimately dependent on it. Although it may appear at any period, it is yet during the first half of pregnancy that it is most commonly met with. Bleeding is the treatment indicated, the amount of this being regulated by the nature of the cause giving rise to the plethora. (b) Hæmorrhage is commonly a consequence of uterine plethora, and it should be treated by bleeding, when there is evidence of the permanent operation of an active cause, and especially during the first six months. At a later period greater circumspection is required. (c) Premature contraction is a frequent consequence of congestion, and especially of hæmorrhage, and bleeding is a powerful means of arresting it. (d) Among other pathological conditions, dropsy of the amnios and hydrorrhoea admit only of bleeding when signs of congestion and plethora are present. (e) Uterine neuralgia is sometimes dependent on plethora. (ƒ) Uterine rheumatism is usually best treated by depletion.

Passing on to the affections of other organs than the uterus, which arise from the physiological fluxion taking place towards the pelvis, we have congestion of the broad ligaments, which, although a rare affection, must still be borne in mind. The hæmorrhagic molimen of the veins of the rectum, giving rise to hæmorrhoids, may become an active cause of abortion. When connected with a state of plethora bleeding should be resorted to, while when the hæmorrhoids are inflamed and painful, leeches may be safely applied, although they are often but of little use. Cystitis is not a rare occurrence in pregnancy, and the softening of the pelvic ligaments, which is so constant an occurrence, may go on to a true inflammation.

(2) Sympathetic Affections.-The great benefit derivable from blood-letting in the idiopathic affections of pregnancy is not obtained in the management of the sympathetic affections. (a) Affections of the Breast.-Although it is rare for the changes which take place in this organ to assume a morbid character, yet in some instances a true phlegmasia may be developed, and depletion be called for. (b) Disturbance of the digestive organs.-The stomach is the organ which, of all others, is most readily and most