THE SIGNS AND DISEASES 
 
 PREGNANCY.
 
 IMPOETANT NEW WOEKS 
 ON THE DISEASES OF WOMEN. 
 
 I. 
 
 A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF WOMEN. By 
 T. Gaillard Thoma's, M.D , Professor of Obstetrics and Diseases of Women and 
 Children in the College of Physicians and Surgeons, New York ; President of the 
 New York Obstetrical Society, &c. In one very handsome octavo volume of 600 pages, 
 ■with about 200 illustrations. (Just Ready.) 
 
 Summary ov Contents. 
 
 Chapter I. History of Uterine Pathology.— II. Etiology of Uterino DiBeases in America. — III. Diag- 
 nosis of Diseases of Female Genital Organs. — IV. Diseases of the Vulva.— V. Diseases of the Vulva 
 (contimied) — VI. Vaginismus.— VII. Vaginitis.— VIII. Atresia Vaginas— IX. Prolapsus Vagina;.— X. 
 Fistulfe of the Female Genital Organs. — XI. Fascal and Simple Vaginal Fistulaj. — XII. General Re- 
 marlis on Inflammation of the Uterus.- XIII. Acute Endo-Afetritis and Acute Metritis.— XIV. Cervi- 
 cal Endo-Metritis.-XV. Chronic Cervical Jletritis. — XVI. Chronic Corporeal Endo-Metritis and Me- 
 tritis — XVII. Ulceration of the Os and Cervix Uteri. — XVIII. General Considerations on Displace- 
 ments of the Uterus. — XIX. Ascent and Descent of the Uterus. — XX. Versions of the Uterus. — XXI. 
 Fle.\ionsof the Uteru.i.— XXII. Inversion of the Uterus.— XXIII. Peri-Uterine Cellulitis.— XXIV. Pel- 
 vic Peritonitis.— XXV. Pelvic Abscess.- XXA' I. Pelvic Hajmatocele.— XXVII. Fibrous Tumors of the 
 Uterus.— XXVIII. Uterine Polypi.— X.KIX. Cancer of the Uterus— XXX. Cancroid Tumors of the 
 Uterus. — XXXI. Epithelial Cancer of the Uterus. — XXXII. Diseases resulting from Pregnancy. — 
 XXXIII. Dysmenorrhoea. — XXXIV. Menorrhagia and Metrorrhagia. — XXXV. Amenorrhoea. — XXXVI. 
 Leucorrhoea.— XXXVII. Sterility.— XXXVIII. Amputation of the Cervi.x Uteri.— XXXIX. Disea.^es of 
 the Ovaries.— XL. Ovarian Tumors.— XLI. Ovariotomy.— XLII. Ovarian Tumors (continued).— Xtlll. 
 Diseases of the Fallopian Tubes. 
 
 II. 
 
 OX DISEASES PECULIAR TO WOMEN: INCLUDING DISPLACEMENTS OF 
 THE UTERUS. By Hugh L. Hodge, M.D., late Professor of Midwifery, &c., in 
 the University of Pennsylvania, &q. With Illustrations on Wood. In one beauti- 
 fully printed octavo volume of about 500 pages. 
 
 Summary of Contents. 
 
 PARTI. Diseases or Irritation. — Chapter I. Nervous Irritation and its consequences. II. Irritable 
 Uterus — Complications. III. Local Symptoms of Irritable Uterus. IV. Local Symptoms of Irritable 
 Uterus. V. General Symptoms of Irritable Diseases. VI. General Symptoms of Irritable Uterus — 
 Reflex Influences of Cerebral and Spinal Irritation. VII. Progress and Terminations of Irritable 
 Uterus. VIII. Causes and Pathology of Irritable Diseases. IX. Treatment (f Irritable Uterus — Re- 
 moval or Palliation of the Cause. X. Treatment of Irritable Uterus — to Diminish or Destroy the 
 Morbid Irritability. XI. Treatment of Irritable Uterus— modified by Menstrual Disorders and In- 
 flammations. XII. Treatment of Irritable Uterus, Complicated with Secondary and Sympathetic 
 Symptoms. 
 
 PART II. Displacements of thi Uterus. — Chapter I. Displacement of the Uterus. II. Causes and 
 Symptoms of Displacement of the Uterus. III. Diagnosis of Displacement of the Uterus. IV. Treat- 
 ment of Displacement of the Uterus. V. Treatment, continued — Internal Supporters. VI. Treat- 
 ment, continued — Lever Pessaries. VII. Treatment, continued. VIII. Treatment of Complications 
 of Displacements. 
 
 PAKT III. Diseases OP Sedation.— Chapter I. General and Local Sedation. II. Sedation of Uterus. 
 III. Diagnosis and treatment. 
 
 III. 
 LECTURES ON THE DISEASES OF AVOMEN. By Charles AVest, M.D., F.R.C.P., 
 Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, &c. Third 
 American, from the Third and Revised English Edition. In one handsome octavo 
 volume of about 550 pages. Extra cloth, $3.75 ; Leather, $4.75. {Now Ready.) 
 
 To a singularly easy and pleasant style. Dr. West adds a lucidity of arrangement without pretence, 
 .and a felicity of expression, which must necessarily make him a favorite with his readers; whilst he 
 exhibits such an avoidance of exaggerated statements, and such a sober care in making deductions, 
 that confidence follows as a matter of course; his investigations of his subject are so detailed, and 
 elaborated with such laudable care, that they demand most respectful attention from all who are 
 called to treat such affections.— iSriY. and For. Med.-Chir. Review. 
 
 As a sound practical treatise, based on the extended experience of a close and accurate observer 
 whose views and aci|uireinent8 are quite au niveau with the present state of medico-obstetrical science, 
 this work is fairly entitled to the highest rank ; and as such, we strongly and heartily commend it to 
 the attention of our professional brethren.- T/ic Dublin Quarterly Journal of Medical Science. 
 
 The manner of the author is excellent, his descriptions graphic and perspicuous, and his treatment 
 up to the level of the time — clear, precise, definite, and marked by strong common sense.— CTiicci^ro Med. 
 Journal. 
 
 HENKY C. LEA, Philadelphia.
 
 ON THE 
 
 SIGNS AND DISEASES 
 
 PREGNANCY. 
 
 THOMAS HAWKES TANNER, M.D., F.L.S., 
 
 Mejmhtr of the Royal College of Physicians, <£c. 
 
 Jrom t^e ^etortb aitb ^nlargcb JTonboit €bttiott. 
 WITH FOUE COLORED PLATES, 
 
 AND 
 ILLUSTRATIONS ON WOOD. 
 
 PHILADELPHIA: 
 
 HENRY C. LEA. 
 
 1868.
 
 Philadelphia : 
 Caxlon Press of Sherman <£ Co.
 
 Iferary 
 
 jtsiiy 
 
 TO 
 
 THE FELLOWS 
 
 OF 
 
 THE OBSTETRICAL SOCIETY OF LONDON, 
 
 ANI, TO THE MEMORY OF THEIR FIRST PRESIDENT, 
 (1859, I860,) 
 
 EDWARD RIGBY, M.D., F.L.S., 
 &c. &c. &c. 
 
 THIS VOLUME 
 
 Is bttb great |Uspect |nstribeb.
 
 PREFACE. 
 
 The first edition of this work was published in 1860. 
 During the seven years which have now elapsed, the sub- 
 jects treated of in the following pages have been con- 
 stantly brought under my notice. It is to be hoped that 
 the experience thus gained will be found serviceable to my 
 readers. 
 
 In preparing this edition for the press, the original plan 
 has been adhered to of enforcing the general principles of 
 the subject by the narration of illustrative cases. Attach- 
 ing great importance to clinical teaching, I have rejDeat- 
 edly ventured to carry the student, in imagination, to 
 the bedside. And if I have there endeavored to act as 
 his guide, and to show him how to recognize and treat 
 the various diseases to which pregnant women are subject, 
 it is hoped that this attempt has always been made in a 
 proper spirit. 
 
 Henrietta Street, Cavendish Square, 
 1st October, 1867.
 
 CONTENTS. 
 
 CHAPTEK I. 
 
 GENEBAL OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 I. The importance of the clinical study of disease — Great advantages of auscultation — 
 Obstacles to the progress of scientific knowledge — Remarks of Sydenham and 
 Mauriceau. — 2. Definition of pregnancy — The varieties — Uterine pregnancy of 
 three kinds. — 3. The limits of the generative faculty in women and men — Exam- 
 ples of premature menstruation — Cases of early pregnancy — Precocious marriages 
 — Cessation of the menstrual flow — Latest time at which parturition has occurred. 
 — 4. An inquiry into the number of children a woman can bear — The fruitfiilness 
 of marriages in difl^erent countries — Marriages of consanguinity — The number of 
 children born out of wedlock in England. — 5. The number of children which a 
 woman can bear at one labor — Hospital statistics — Experience in Edinburgh, 
 Prussia, &c. — ■^. The age at which women are most prolific — A table showing the 
 age of each of 48,929 women, at or just before delivery — The date after marriage 
 at which fecundation generally occurs — Proportion of stillborn to live children 
 — Dangers to the mother in parturition — Mortality in primiparce as compared with 
 multiparge. — 7. Anxiety of men to discover the sex of the fcEtus while it is still in 
 the uterus — Proportion of male to female births under certain conditions. — 8, Rea- 
 sons against placing any reliance upon the statements of the patients themselves 
 in examples of doubtful pregnancy — Instances of feigned parturition — Concealed 
 pregnancy — Women not always aware of their condition — The presence or absence 
 of the hymen no proof of virginity or the contrary — Women may believe themselves 
 to be pregnant when they are not so. — 9. Brief remarks on the function of repro- 
 duction as efiected in the various classes of the animal kingdom — Fissiparous mul- 
 tiplication, .propagation by gemmation, and true generation — Signs of conception. — 
 10. The necessity for showing kindness to pregnant women — Mode in which Cor- 
 sican and Iberian women were treated after parturition — Mortality from childbirth 
 in England and Wales in different years — Means to be adopted to lessen this mor- 
 tality, Page 17-69 
 
 CHAPTER II. 
 
 , THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 Section 1. Classification of the Signs of Pregnancy — The increase in the vital actions 
 of the generative system, which immediately follows conception — The relations of 
 the uterus, as it enlarges, to the neighboring viscera — The constitutional effects 
 which early result from impregnation — A table of the symptoms and signs of preg- 
 nancy.
 
 X CONTENTS. 
 
 Section 2. Suppression of the Menses — The age of nubility — The accession of puberty 
 in the male and female — Menstruation — The catamenial fluid and its source — 
 Anatomy of a Graafian vesicle — The value as a symptom of suppression of the 
 menses — Menstruation during pregnancy — Suppression of the catamenia from other 
 causes than pregnancy — Simulated menstruation. 
 
 Section 3. Nausea, Vomiting, &c. — Symptoms of only slight value — Their occurrence 
 due to sympathetic gastric irritability — The time vrhen they cease — Diarrhosa and 
 salivation sometimes regarded as symptoms of pregnancy. 
 
 Section 4. Mammary Sympathies — Alterations in the areola — Development of the 
 glandular follicles — Silvery streaks — Secretion of milk. 
 
 Section 5. Enlargement of the Abdomen — Position of the uterus at different periods of 
 pregnancy — Changes in the umbilicus — The detection of the position of the foetus 
 by abdominal palpation — The successful way in which some women arrange 
 their clothes to conceal the enlargement. 
 
 Section 6. Movements of the FcEtus — General considerations on the nature of embry- 
 onic life — Quickening and its causes — Description of the motions first experienced 
 — Movements, the effect only of the imagination. 
 
 Section 7. Changes in the Uterus — The form and structure of the virgin organ — 
 Changes which take place in the uterus after conception — No modification in the 
 length of the cervix — Dimensions of the uterus at the chief periods of pregnancy — 
 Fatty degeneration of the uterus after parturition. 
 
 Section 8. Ballottement or Repercussion — Three ways of practising it— Possible falla- 
 cies — Periods of pregnancy when it may be best resorted to. 
 
 Section 9. Signs derived from Auscultation — History of discovery, and modes of prac- 
 tising auscultation — The foital movements— The funic pulsations and funic souffle. 
 The uterine souffle — The foetal heart. 
 
 Section 10. Minor Signs— Kiestein— Contractile power of the gravid uterus — Discolor- 
 ation of the vagina — Examination of the blood — Temperature of the vagina — 
 Peculiar smell of the vaginal mucus — Shape of the os uteri— Vaginal pulse — Occi- 
 pital headache — Certain variable physical and moral changes, . Page 70-143 
 
 CHAPTER III. 
 
 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 1. Spurious Pregnancy— A typical case— Difficulties in the way of diagnosis— Mode in 
 which these cases terminate— Interesting examples of the disease— The nature of 
 the abdominal swelling— Treatment required— The great value of chloroform- 
 Phantom or muscular tumors, their nature, &c. — 2. Ovarian Dropsy — Age at which 
 it is most common— Duration of— Causes of— Diagnosis of small and large ovarian 
 tumors— Sources of error in the diagnosis— Dropsy of the Fallopian tube— Acute 
 inflammation of the ovary ending in suppuration— The coexistence of pregnancy 
 and ovarian dropsy— 3. Ascites— Diagnostic signs of— Differential diagnosis of 
 ovarian dropsy, a.scites, and pregnancy— General symptoms of ascites— The coex- 
 istence of ascites and pregnancy— Dropsy of the amnion— Advanced pregnancy 
 accompanied by great distension of the bladder.— 4. Fibroid Tumors of the uterus 
 — Their structure, situation, and size— Their generally benign and harmless nature— 
 The symptoms and signs— Appearances presented by the breasts in cases of uterine 
 enlargement from any cause— Detection of a souffle in uterine tumors— The coex- 
 istence of pregnancy and fibroid tumors— 5. Enlargements of the Liver, Kidneys,
 
 CONTENTS. XI 
 
 Spleen, &c. — Hypertrophy of the liver — Hepatitis which has gone on to suppu- 
 ration — Malignant disease of liver — Hydatid disease — Malposition of the kidneys 
 — "Horseshoe" kidney — Hydronephrosis — Renal cancer — Enlargement of the 
 spleen — Tuberculated disease of the peritoneum — Facal accumulations — A large 
 ventral omental hernia complicated with ascites, mistaken for extra-uterine preg- 
 nancy — Encysted dropsy of the peritoneum — Cysts in the folds of the omentum, 
 or on the under surface of the liver, or under the posterior part of the peritoneum. — 
 6. Haematometra, Hydrometra, and Pliysometra — Causes and symptoms of retained 
 menstrual blood — An example of this atfection — The pregnant uterus mistaken for 
 a tumor due to retention of the menses — The collection of serous fluid or of pus in 
 the uterus — Its combination with haematometra — The accumulation of gas in the 
 uterus — Symptoms and causes — Explanations of this phenomenon, Page 144-194 
 
 CHAPTER IV. 
 
 THE DURATION OF PREGNAKCY. 
 
 Contradictory views entertained on the subject — Ordinary duration of pregnancy ten 
 lunar months, or forty weeks, or from two hundred and seventy-four to two hundred 
 and eighty days — This period liable to vary within certain limits — The exciting 
 cause of paiturition unknown — Our ignorance of the interval which elapses be- 
 tween intercourse and the actual vivification of the ovule — Tables of cases by Drs. 
 Merriman, Reid, Murphy, and the author — Dates of delivery calculated from the 
 last day of the catamenia — Forty-five cases of conception, the dates being calcu- 
 lated from a single coitus — M. Tessier's researches on cows, mares, &c. — Earl 
 Spencer's observations on the time of gestation in 764 cows — To what extent may 
 pregnancy be prolonged beyond the normal period of gestation? — Protracted par- 
 turition said to be sometimes mistaken for protracted gestation — Very scanty satis- 
 factory evidence that pregnancy, in the human subject, has ever been prolonged 
 beyond ten calendar months — Mode of computing the date of labor from the last 
 day of the last menstrual period — Dr. Clay's opinion that the term of utero-gestation 
 is regulated by the ages of the parents — Table to show that the younger the parties 
 concerned the shorter the term, and vice versd — Popular belief that when the time 
 of gestation is longer than usual, the offspring will be a male, . Page 195-218 
 
 CHAPTER V. 
 
 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 1. Introduction — Definition of the terms abortion, miscarriage, and premature labor — 
 Periods of pregnancy at which abortion is most common — Data by which the age 
 of the embryo can be ascertained after expulsion — The shortest period at which the 
 fcEtus may attain maturity. — 2. Causes of abortion — As they are accidental — As they 
 are due to some deranged state of the maternal health — As they can be traced to 
 some morbid condition of the uterus or its appendages — And as they arise from 
 disease of the embryo or its membranes. — 3. Symptoms — In the early days of ges- 
 tation — At an advanced period of pregnancy — In multiple pregnancies one foetus 
 may die, and either be at once expelled, or be retained until the birth of the other 
 at the full term — The severe consequences of only a portion of the ovum coming 
 away — Inversion of the uterus after an abortion. — 4. Diagnosis — The distinction 
 between the menstrual flow, and the hemorrhage of an early abortion — Women
 
 XII CONTENTS. 
 
 often imagine the ovum has come away, when it has not done so — Abortion some- 
 times feigned. — 5. Prognosis — In the first or second months, the danger sHght — 
 The hemorrhage, the chief source of danger — Retention of a portion of placenta in 
 the uterus, decomposition, and purulent absorption — Hydatidiform degeneration of 
 the placenta. — 6. Treatment — Prophylactic or preventive measures — The treatment 
 when expulsion appears unavoidable. — The after-treatment of a patient who has 
 aborted, Page 219-270 
 
 CHAPTEE VI. 
 
 THE EXAMINATIOK OF SUBSTANCES EXPELLED FROM THE UTERUS, ETC. 
 
 1. An Early Ovum — Mode of examining it — The appearances of the decidual cover- 
 ings — Decidual cotyledons and their office — Death of an embryo, with retention for 
 a time of its membranes. — 2. Moles — The nature of these substances — Three chief 
 varieties — Organized bodies resembling them. — 3. The Vesicular Mole — Its origin 
 in cystic disease of the chorion — General characters of the disease — The nature of 
 the change in the chorion villi which results in the production of vesicles — The 
 causes of the change — Can a portion of placenta left in tlie uterus after labor, ulti- 
 mately form a vesicular mole'? — May true hydatid cysts be formed in utero? — The 
 possibility of their occurrence. — 4. The Menstrual Decidua — Its identity with 
 the true decidual covering of the ovum. — 5. Membranous Formations from the 
 Vagina — Exfoliation of the vaginal epithelium — The effects produced usually 
 slight. &c., Page 271-283 
 
 CHAPTER VII. 
 
 EXTRA-UTERINE GESTATION. 
 
 1. Introduction — The occurrence of extra-uterine pregnancy among animals — Early 
 notices of this abnormality — Changes which occur in the uterus in misplaced ges- 
 tations — The corpus luteum sometimes found in the ovary of the opposite side to 
 that of the tube containing the ovum. — 2. Varieties — Only three divisions or classes 
 positively necessary — The tubo-ovarian, tubal, and interstitial or tnbo-uterine. — 
 3. Symptoms — The catamenia usually suspended — Mammary changes and morn- 
 ing sickness — Enlargement of abdomen not symmetrical — Severe pains in pelvis — 
 A characteristic cry — Signs detected by a vaginal examination — The phenomena 
 which follow rupture of the cyst — Death may occur from the hemorrhage, or from 
 the subsequent peritonitis — When laceration does not take place, labor pains set 
 in spontaneously about the ninth month — Cessation of foetal life, and slow degen- 
 eration of walls of cyst — Suppuration and expulsion of fcEtal debris through walls 
 of abdomen, rectum, vagina, or bladder. — I. Treatment — The precautions needed 
 to prevent or retard rupture of the cyst — The measures which ofler a chance of 
 moderating the hemorrhage after laceration — The steps to be pursued after the ex- 
 tinction of foetal life, Page 284-311 
 
 CHAPTER VIII. 
 
 SUPERFCETATION. — MISSED LABOR. 
 
 1. Superfoetation — Definition — The possibility of its occurrence often denied — Many 
 of the cases brought forward to support it, to be explained on odier grounds — 
 Three varieties of double uteri — Superfoetation may occur where the uterus is not
 
 CONTENTS. Xlll 
 
 bilobed or double — The uterine cavity is not closed until the ovum attains such 
 a size as to force the decidua reflexa into close apposition with the decidua vera. — 
 2. Missed Labor — Definition — Its occurrence in domestic animals — Examples in 
 the human subject — Treatment, Page 312-324 
 
 CHAPTER IX. 
 
 THE DISEASES WHICH MAY COEXIST WITH PREGNANCY, AND THEIR RECIPROCAL 
 
 INFLUENCE. 
 
 1. The State of pregnancy not always a happy one — The fears of the recently-married 
 girl — The anxieties of the poor — The combination of mental disturbance with 
 physical suffering. — 2. The influence of mental disorders — Multiparge more liable 
 than primiparse to attacks of insanity — Melancholia the most frequent form — Par- 
 turition often effects a cure — The tendency of melancholies to commit suicide. — 
 The consequences of pregnancy occurring in a woman already insane — The men- 
 tal affection often aggravated — An analysis of nineteen cases. — 3 Paralytic affec- 
 tions do not hinder conception — Functional paralysis, may arise from pregnancy — 
 Disease of the brain has no effect on the progress of labor — The amount of influ- 
 ence which the three nervous centres exert upon the uterus during parturition. — 
 4. Pregnancy seldom of benefit to epileptics — Marriage only rarely to be recom- 
 mended — Treatment of epilepsy during uterogestation. — 5. Chorea in connection 
 with pregnancy — Primiparous females most frequently affected — Symptoms and 
 progress of the disorder illustrated by cases — The treatment. — 6. The propriety or 
 non-propriety of recommending marriage for young hysterical women — The re- 
 sponsibility of the physician in advising it — The influence of hysteria on pregnancy 
 and delivery. — 7. The occurrence of tetanus after abortion — A case in which it 
 was caused by a retained placenta.— 8. The effect of pregnancy on the progress of 
 phthisis — The belief of many that the disease is retarded— The probability that 
 this opinion is untenable — The effect of pulmonary consumption in hindering con- 
 ception — The puerperal state does not seem to accelerate tuberculization — Phthisis 
 does not materially modify the progress of pregnancy — It lessens the severity and 
 shortens the duration of labor. — 9. The effect of pneumonia on the course of gesta- 
 tion — The frequency of abortion — The condition of the blood in inflammation of 
 the lungs — The fatality of this disease to pregnant women. — 10. The heart nor- 
 mally in a state of hypertrophy during pregnancy — The walls of the left ventricle 
 increased in thickness and firmness — The hypertrophy probably disappears after 
 parturition. — Sympathetic or nervous throbbings of the aorta. — 11. Carcinoma of 
 the labia and cervix uteri no bar to impregnation — Consequences of the pregnancy 
 going on to the full term — The effect of delivery upon the disease — The treat- 
 ment of pregnancy complicated with uterine cancer. — 12. The treatment of syphilis 
 during pregnancy — Precautions to be taken by the accoucheur while delivering a 
 woman with primary sores on her genitals. — 13. The epidemic and infectious 
 maladies which may complicate pregnancy — The severity of acute diseases — Chol- 
 era and its effect in producing abortion — The eruptive fevers, and their great 
 danger — The possibility of pregnancy preventing the development of any symp- 
 toms until after parturition, even though the infection has previously been caught. — 
 14. General observations on the therapeutics of pregnancy — The influence of blood- 
 letting — Cathartics and purgatives — Diaphoretics — Narcotics and sedatives — 
 Counter-irritation — Tonics and stimulants — Remedies to be avoided. 
 
 Page 325-368
 
 XIV CONTENTS. 
 
 CHAPTEK X. 
 
 THE SYMPATHETIC DISORDERS OF PREGNAXCY. 
 
 Section 1. Disorders of the Digestive Organs. — 1. Introduction — The three sources 
 from which the disorders chiefly arise — Remarks on diet — The possibility of par- 
 tially arresting the development of the fffitus by starving the mother. — 2. Capri- 
 cious appetite — Disgust for food — Longings for improper articles of diet — Generally 
 due to derangement of the digestive organs. — 3. Toothache — Neuralgic pains in 
 the dental nerves — Caries of the teeth. — 4. Salivation — Condition of the salivary 
 glands and buccal mucous membrane — Amount of saliva secreted. — 5. Nausea 
 and vomiting — Morning sickness not peculiar to pregnancy — It presents itself 
 either during the early weeks of gestation, or through the whole period, or merely 
 for the three latter months — Mild attacks rather beneficial than otherwise — Numer- 
 ous fatal instances on record — Sometimes due to inflammation of the decidua and 
 uterus, or to inflammatory ulceration of cervix uteri, or to congestion and tender- 
 ness of the OS and cervix — The treatment — 6. Cardialgia — Chiefly to be remedied 
 by attention to diet — The use of soda and bismuth. — 7. Hcernatemesis — Sometimes 
 erroneously said to be a species of vicarious menstruation. — 8. Diarrhoea — In some 
 women habitual during pregnancy — Treatment.— ;-9. Constipation — The accumula- 
 tion of fseces. — 10. Jaundice — The danger of abortion if powerful remedies are 
 employed. — Hepatic hypertrophy. — Acute atrophy of the liver — The very alarm- 
 ing symptoms which result. 
 
 Section 2. Disorders of the organs of Respiration and Circulation. — 1. Dyspnosa — The 
 cause and treatment. — 2. Cough — Due to sympathy, or growth of the uterus imped- 
 ing respiration and circulation. — 3. Httmoptysis — The quantity of blood expector- 
 ated may be considerable — Astringents, counter-irritants, and opiates. — 4. Palpita- 
 tion of the heart — Independent of any organic disease — Pulsations of the large 
 arteries. — 5. Fainting — Sensations which precede syncope — Mode of prevention. — 
 6. Enlargement of the thyroid gland. — 7. Morbid conditions of the spleen. — 8. 
 Varices — Hemorrhoids — Thrombus, or sanguineous tumor from the rupture of the 
 enlarged vaginal veins, &c. 
 
 Section .3. Disorders of the Nervous System. — 1. Cephalalgia — The two chief varie- 
 ties — Character of the pain — Hemicrania — Clavus hystericus. — 2. Sleeplessness 
 — Causes of — Measures to be adopted to secure sound repose — Frightful dreams. — 
 3. Hypochondriasis — Sad forebodings often not altogether groundless — The physical 
 and moral management of such cases. — 4. Nervous afiections of the ears and eyes 
 — Amaurosis. — 5. Mastodynia — 6. Pain of the right side — The cause of the acute 
 suffering — The diseases for which it may be mistaken — The immediate and sub- 
 sequent treatment — Myalgia, Page 369-424 
 
 CHAPTER XI. 
 
 THE DISEASES OF THE URINARY AND GENERATIVE ORGANS. 
 
 Section 1. Diseases of the Urinary Organs. — 1. Incontinence of urine — Its causes — 
 Treatment — Frequent micturition sometimes a symptom of calculus of the bladder. 
 — 2. Retention of urine — Generally due to the pressure of the uterus on the neck 
 of the bladder — Anteversion and retroversion of uterus affect the bladder. — 3. 
 Urrr-mic eclampsia — The connection of puerperal convulsions with anasarca and 
 albuminuria — Explanation of the term uraemia — Three forms of ursemic poisoning
 
 CONTENTS. XV 
 
 — The frequency and causes of albuminuria — Uraemic convulsions due to the urea 
 retained in the blood being converted into carbonate of ammonia — The diagnosis 
 and prognosis of ursemic eclampsia — The indications for treatment — The value of 
 benzoic acid, lemon-juice, purgatives, and chloroform, &c. 
 Section 2. Diseases of the Generative Organs. — 1. Pruritus of the vulva — The suffer- 
 ing it gives rise to — Its numerous causes — The ulcerations which may arise from 
 scratching — Local remedies and formulae — 2. (Edema of the labia — To be distin- 
 guished from general dropsical effusion — Simply due to the pressure of the uterus 
 upon the pelvic vessels — Often to be relieved by rest in the recumbent posture. — 3. 
 Vaginal leucorrhosa — Its nature, and the parts concerned in its production — Treat- 
 ment by rest, hip-baths, careful diet, injections, and ferruginous tonics. — 4. Discharge 
 of watery fluid from the uterus — The quantity and mode of its escape — The source 
 of the flow — Reasons for believing that the fluid is the liquor amnii — The treat- 
 ment by quiet and sedatives. — 5. Dropsy of the amnion — The remarkable volume 
 which the uterus may acquire from this cause — The quantity of liquor amnii which 
 may be secreted — The symptoms of this condition, and the effects upon the foetus — 
 The treatment — 6. Rheumatism of the uterus — Causes and symptoms — Cures by 
 opium, bicarbonate of potash, &c. — 7. Inflammation of the uterus — Rarity of this 
 disease — Its seat and causes — The constitutional and local symptoms — The differ- 
 ent modes in which the inflammation may terminate — The treatment by salines 
 and diluents, leeches to the cervix uteri, anodyne fomentations, opiates, &c. — 8. 
 Uterine hemorrhage — Its occasional origin in disease of the cervix — Chronic inflam- 
 matory ulceration — Polypus of the uterus — Cancer uteri — Epithelioma, and corroding 
 ulcer — Hemorrhage as the precursor of abortion — Concealed accidental hemorrhage 
 — Flooding from placenta previa, &c., ..... Page 425-463 
 
 CHAPTER XII. 
 
 THE DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 1. Prolapsus of the Uterus — Either partial or complete — Prolapsus or procidentia may 
 come on gradually or suddenly — Symptoms and treatment — Cautions as to sitting 
 up after delivery. — 2. Anteversion of the Uterus — Of rare occurrence — The causes 
 and signs of this displacement — Means by which reduction of an anteverted uterus 
 may be effected — Anteflexion of the uterus — Its nature — An illustrative case. — 3. 
 Retroversion of the uterus: William Hunter's lecture on this subject in 1754 — Its 
 causes — Retention of urine the prominent symptom — The danger of rupture of the 
 bladder, or of blood-poisoning from decomposition of the urine in this viscus — The 
 diagnosis, prognosis, and treatment — The possibility of the full term of gestation 
 being reached with a retroverted womb — Retroflexion of the uterus — A typical 
 case — Retroflexion of the gravid uterus during labor at term. — 4. Hernia of the 
 uterus — Not to be confounded with eventration of the uterus — Hernia of the unim- 
 pregnated organ with two examples — Hernia of the ovary, and of the Fallopian 
 tube — Hernia of the gravid uterus — Two cases where it has happened at the um- 
 bilicus — One instance of its occurrence at the inguinal ring. . Page 464-482
 
 Wate 1 
 
 ■/^\ 
 
 W% 

 
 Plate II 
 
 /i P4,r.lp^'in the pixtli nalerdar montK 
 
 I. Sine lairs ktri, PKala
 
 r.a:e IE
 
 THE 
 
 SIGNS AND DISEASES OF PREGNANCY. 
 
 CHAPTER I. 
 
 GENERAL OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 1. Introductory remarks — The clinical study op disease — Importance of auscul- 
 tation IN detecting pregnancy. — 2. Definition of pregnancy — The varieties. 
 —3. The limits of the generative faculty in women and men— Exajiples of 
 precocious menstruation, early pregnancy, etc. — 4. An inquiry into the number 
 OF children a woman can bear. — 5. Multiple births — Fabulous tales — Statis- 
 tical facts. — 6. Age at which women are most prolific. — 7. Anxiety of men 
 TO discover the sex op the foetus while it is still in the uterus. — 8. State- 
 ments OP patients in doubtful cases — Simulated pregnancy and labor — Con- 
 cealed PREGNANCY — WOMEN NOT ALWAYS AWARE OP THEIR CONDITION.— 9. BriEP 
 REMARKS ON THE FUNCTION OP REPRODUCTION AS IT IS EFFECTED IN THE VARIOUS 
 CLASSES OP THE ANIMAL KINGDOM. — 10. MoDE IN WHICH PREGNANT WOMEN SHOULD 
 BE TREATED — MORTALITY FROM CHILDBIRTH — MeANS TO BE ADOPTED TO LESSEN THE 
 DANGERS OF PARTURITION. 
 
 1. An elaborate argument is quite unnecessary to prove tliat 
 few subjects connected with obstetric medicine can be of much 
 greater interest or importance than the consideration of the 
 signs and symptoms indicative of pregnancy. During the early 
 months, when the development of the uterus is inconsiderable, 
 the difficulty of forming a correct opinion as to the existence of 
 a fecundated ovum in the uterine cavity is acknowledged to be 
 great. But the delicacy of the question only renders its study 
 the more imperative. The physician, in giving his opinion on 
 any doubtful case of pregnancy, can seldom do so without in- 
 curring a serious responsibility ; for very disastrous results to 
 the mental and physical well-doing of the patient may follow 
 from an erroneous diagnosis. Hence, great caution is always 
 
 2
 
 18 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 to be exercised; while it is imperative that the practitioner 
 make himself well acquainted with those general rules which 
 ought to guide him in drawing his conclusions. To advise that 
 frequent opportunities should be sought for verifying the state- 
 ments contained in the following pages might be deemed im- 
 pertinent by those who I trust will try to glean information from 
 this volume, since every tyro in midwifery is aware that knowl- 
 edge derived from reading is of little value by itself. The re- 
 mark of Dryden, that books are to be regarded as spectacles 
 with which to read Nature, applies peculiarly to medical writ- 
 ings. Indeed no one will be found to deny, that he who would 
 become skilful in the diagnosis of disease, in the present day, 
 must combine the study of the literature of our profession with 
 the personal observation of the sick. For although a certain 
 delicacy of the senses, with the capability of distinguishing be- 
 tween various slight impressions, can be acquired by practice 
 alone, j'et the tactus eruditus, or faculty of properly interpreting 
 these differences, demands a knowledge and consideration of the 
 subject in all its bearings. 
 
 It was long since well said by D'Alembert, that the physician 
 is not — as is the vulgar opinion — he who cursorily and without 
 discrimination accumulates facts in the course of a large practice; 
 but rather the man who exercises great scrutiny and penetration 
 in making his investigations, and joins to what he has himself 
 observed an acquaintance with the far greater number of observa- 
 tions that have been made in all ages by men animated with the 
 same healthy impulse. Such knowledge constitutes the true ex- 
 perience of the physician. Believing implicitly in the truth of 
 this remark, I need hardly say that it has been my endeavor to 
 act up to its spirit. The attempt has been generally made on my 
 own part to render each case met with in practice a study in itself; 
 to compare it not merely with like examples previously under 
 treatment, but also with recorded instances in any way bearing 
 upon it; as well as to note minutely the effects of the different 
 remedies employed. In pursuing this plan, the greatest assist- 
 ance has been derived from reading the writings of those masters 
 of our profession who have published the well-considered results 
 of their experience ; and liaving had greater opportunities for 
 practically studying the diseases to which women are liable 
 during pregnancy than fall to the lot of many, I have felt that a
 
 INTRODUCTORY REMARKS. 19 
 
 debt has been incurred by me. How far I have been successful 
 in partly repaying this obligation, my readers must judge for 
 themselves while perusing this volume. 
 
 The author of the imperishable treatise De V Auscultation Medi- 
 ate, ou Traite du Diagnostic des 3Ialadies des Poumons et du Coeur, 
 has not only claims upon our gratitude for the light which his 
 genius has thrown upon the diseases of the chest, but also for 
 the results which have flowed from his discoveries, in enabling 
 us materially to simplify the diagnosis of pregnancy. In the 
 middle of the nineteenth century, such an impostor as Joanna 
 Southcott would be detected immediately ; and no woman could 
 now — as this " chosen vessel" succeeded in doing in 1814 — lead 
 medical men to state that a distended urinary bladder, or a flatu- 
 lent colon, was an impregnated uterus at the sixth or seventh 
 month of gestation. The charlatan and plausible quack will still 
 find followers and admirers, it is true ; for without a doubt gross 
 credulity and superstition even yet reign supreme over many im- 
 perfectly educated or weak minds. But it is probably less injuri- 
 ous in a moral point of view to put faith in table-turning, clair- 
 voyance, spirit manifestations, and infinitesimal doses of drugs, 
 ■ than to believe — as many thousands did — that a silly old woman 
 has been impregnated by supernatural influence, and that she is 
 about to be delivered of the Holy Ghost personified ! 
 
 The advantages to be derived from the practice of auscultation, 
 not only in detecting pregnancy but also in deciding upon the 
 life or death of the foetus, are now so manifest, that it is surpris- 
 ing they were not at once appreciated. Yet, just as Laennec was 
 laughed at for using the stethoscope in the years 1818 and 1819, 
 at the Parisian Hospital Necker, so attempts to hear the pulsa- 
 tions of the foetal heart were deemed useless and ridiculous; and 
 many years elapsed before the authors of systematic works on mid- 
 wifery thought proper to speak of the practice of auscultation. 
 In looking back to the history of science and art, it is curious to 
 ^. obsei've with what pains some men step aside from their accus- 
 / tomed duties to .oppose the progress of knowledge ; and yet in 
 spite of their industry, and often of their great — though mis- 
 directed — abilities, how ultimately futile are their eftbrts. Any 
 one who attempts to benefit his fellow-men by the promulgation 
 of some novel fact, must make up his mind to meet with antago- 
 nism ; and happy will he be, if — his private character escaping
 
 20 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 abuse — he have to submit to no farther opposition than is im- 
 plied in the assertion that his discovery is either useless or obso- 
 lete. 
 
 The following opinion of Dr. Lyall, on a subject of which he 
 confesses himself to have been ignorant, now merely excites our 
 contempt or laughter, though doubtless it had some little weight 
 when written. He observes : " Of the utility or uselessness of 
 auscultation, in discovering pregnancy, we have had no experi- 
 ence. It is said that the operation may be performed, either by 
 applying the ear to different parts of 'the abdomen, or by using 
 the stethoscope of Laennec. Reasoning a jsn'oH we anticipate 
 little advantage from such an examination."' Jn u^tiM ^ 
 
 ,): More extraordinary, because promulgated ten years subse- 
 «r,J^queutly, was the view taken by Dr. James Hamilton, the Pro- 
 ^ fessor of Midwifery in the University of Edinburgh, wdio gives 
 some curious reasons for not investigating the subject of obstetric 
 auscultation. The chief are, that he never adopted new modes 
 of practice when experience had taught him that the old ones 
 were successful ; that, — " in the better ranks, no prudent practi- 
 tioner would have recourse to means calculated to excite alarm 
 in the patient, and surely the ceremony of applying the stetho- 
 scope must be very formidable to susceptible females;" that he 
 believed there "must be some fallacy in the observations of those 
 who have supposed that the stethoscope can detect the pulsations 
 of the foetal heart;" and lastly, admitting that the placental 
 souffle and foetal heart can be heard by the stethoscope, "he is 
 convinced that few cases can occur in actual practice where this 
 test can be required, or can be applied."^ But if these remarks 
 of Lyall and Hamilton call forth our wonder, what will be the 
 feeling raised by a perusal of the doubts entertained by Dr. Fran- 
 cis Adams, in the year 1859, on the question of foetal ausculta- 
 tion. This gentleman — the learned translator of the works of 
 Paulus ^gineta — believed that success in detecting the sounds 
 of the foetal heart depends in a great measure upon the circum- 
 stance whether or not the auscultator considers that he ou^ht to 
 
 1 The Medical Evidence relative to the Duration of Human Pregnancy, as given in 
 the Gardner Peerage Cause before the Committee of the Hou^e of Lords in lb-25-6. 
 With Remarks and Notes by Robert Lyall, M.D., &c. Introduction, p. 20. London, 
 1826. 
 
 2 Practical Observations on Various Subjects relating to Midwifery. Part I, pp. 154, 
 158, and 166. Edinburgh, 1836,
 
 AUSCULTATION DURING PREGNANCY. 21 
 
 detect them; and he asserted — "that the whole system of foetal 
 auscuUation originated soon after the dawn of general ausculta- 
 tion, when men's minds were excited hy the love of novelty, and 
 warped by many erroneous impressions and mistaken modes of 
 thinking; and has since been mainl}' upheld by authority."^ 
 
 Whether Dr. Adams died before his mistake was made clear to 
 him, I do not know ; but he published no other papers on this 
 subject than these referred to. It is, however, much to be re- 
 gretted that because this excellent scholar could not hear the 
 sounds of the foetal heart in one particular instance, he should 
 therefore have jumped to the conclusion that physicians more 
 skilful than himself were merel}' the victims of their imagina- 
 tions; and I cannot but think his papers would never have been 
 written had he only taken the trouble to visit the wards of one 
 of our lying-in hospitals before sitting down to his desk. Much 
 in the same unhealthy antagonistic spirit as that manifested by 
 these gentlemen, a portion of the British public — and not an un_ 
 influential section either — met together one evening in the month 
 of March, 1808, to discuss the question : " Which has proved a 
 more striking instance of the public credulity, the gas liglits of 
 Mr. Winsor, or the cow-pox inoculation ?" The orators of course 
 proved conclusively that both gas-lights and vaccination should 
 be regarded with contempt and ridicule as gross absurdities. Let 
 us learn from all this not to put our trust in mere a priori argu- 
 ments, nor allow ourselves to be swayed by that aversion to all 
 innovation w^hieh seems so peculiarly to afflict the medical mind 
 -''^^fter the age of forty; but rather, without encouraging a weak 
 gullibility, to carefully weigh and practically test the opinions of 
 other men. "There are some," says Sydenham, "who, adding 
 nothing to medicine of their own, are angry at the most trifling 
 addition of another." If any such there be in the present day, 
 let them think upon the advice of old Mauriceau to his readers, 
 which may be as advantageously acted upon now, as when it 
 was written : " Since in the age we live we see most people gov- 
 erned rather by opinion than judgment, I desire (if you mean to 
 profit by my book) you will read and examine it without Critical 
 Envy, free from all preoccupation that may obscure your judg- 
 ment, and hinder your acknowledging the truth of what I pro- 
 
 1 Medical Times and Gazette, p. 402. London, 22d October, 1S59: p. 61-5, 17th 
 December, 1859: and p. 66, 21st July, 1860.
 
 22 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 fess to teacli. Therefore, follow not such as condemn a conception 
 X when thej understand it not, and believe \i false because it is nnv ; 
 neither imitate those who seeking only to carp at words, neglect 
 the sense of the discourse."^ 
 
 2. Pregnancy may be defined as the condition of a woman who 
 has conceived, and bears within her body "the product of concep- 
 tion. It extends from tlie moment of conceiving until the expul- 
 sion of the ovum or foetus; whether this take place prematurely, 
 or at the proper period when the nine'calendar months of gesta- 
 tion have elapsed. There are two kinds of pregnancy, viz., 
 uterine and extra-uterine ; in other words, the ovum may be 
 developed within the uterine cavity, or outside the womb.-* /< 
 Uterine pregnancy is conveniently divided by French authors') 
 into three kinds : The simple, where there exists but one foetus ; 
 the compound, where there are two or more cliildren ; and the 
 complicated, where, together with a foetus, there coexists some 
 pelvic or abdominal tumor, or some structural disease of the 
 uterus, rendering the diagnosis difficult. The term pseudo-jjreg- 
 naney is also sometimes applied to diseases which simulate preg- 
 nancy; and though such an expression should hardly have a place 
 
 in any scientific nosology, yet we shall subsequently find that it 
 is very difiicult to propose a good substitute. 
 
 3. The limits of the generative faculty in women are those of 
 the function of menstruation ; i. e., from about the fourteenth or 
 fifteenth to the forty-fifth or forty- eighth j^ear. Some few girls, 
 however, menstruate as early as the eleventh, twelfth, or thir- 
 teenth year; and about a dozen extraordinary cases are to be 
 found scattered through medical literature in which children 
 have had the catamenia appear when only two, three, and five 
 years of age. The most recently recorded cases of this kind 
 with which I am acquainted are the two following. The chief 
 facts in the history of the first example are these : 
 
 Mary Deane was born at Manchester on the 7th January, 1853. In May, 
 1858, when exainitied by Mr. 11. B. Smart, she was three feet seven inches 
 high, and her weight — in her clothes — was fifty-two pounds and a half. Her 
 
 1 The Di-SPRses of Women with Child, and in Child-bed. Translated from the French 
 of Francis; Mauriceau by Hugh Chamberlen, M.D. 7th edition. Introduction, p. vii. 
 London, 1736.
 
 PRECOCIOUS MENSTRUATION. 23 
 
 general appearance was wonderfully like that of an adult female, of short 
 stature. The menses appeared every month as regularly as in their normal 
 jLanifestations, and had done so since she was three years and six months old. 
 The bust was full and womanly, the breasts larger and more protuberant than 
 in most girls who have recently attained puberty, while the nipples were well- 
 developed. The pubes was sprinkled over with light-brown hair about an 
 inch in length ; the mons veneris being prominent, the labia externa and 
 nymphss large, and the vagina capacious, with a fringe-shaped hyn)en. It 
 need hardly be added that the intellectual and moral faculties exhibited no 
 signs of precocity at all commensurate with the forward development of the 
 body. For six months prior to the appearance of the catamenia the child 
 seemed ailing, she had a leucorrhoeal discharge, and complained of headache 
 and drowsiness, with pains in the back and groins; but since the first men- 
 strual flow she had gained in flesh, and been hearty and well. The cata- 
 menia generally lasted four days, and were natural in quantity.^ 
 
 The second instance is still more remarkable. As tlie child 
 died, it is much to be regretted that no examination of the body 
 was allowed after death, for the condition of the uterus or ovaries 
 might have thrown some light on the cause of the phenomena. 
 The principal points in the case, as recorded by Dr. T. C. All- 
 butt, are as follows : 
 
 M. A. W. was seen in the summer of 1865, and was reported to have men- 
 struated within the last few days. Her age was one year and six mont^hs. 
 She was then suffering from emaciation, weakness, quick pulse, and other 
 indications of hectic fever. These symptoms passed ofi" in a few days, and 
 she partially recovered her health. On examination the anal and genital 
 regions were found free from discharge, and quite healthy in appearance. 
 On the following month the discharge again appeared, and after it had passed 
 away Dr. Allbutt found her as before — in a state of hectic, and still present- 
 ing a perfectly healthy appearance about the anus and pudenda. He was 
 unfortunately unable, being absent from home for a while, to see her during 
 the continuance of the flow. In about a fortnight, some degree of health 
 had been again recovered. On many occasions the child was carefully ex- 
 amined for disease in other organs, but nothing could be found of any im- 
 portance. At the third monthly period. Dr. Allbutt actually saw the child 
 in a menstruating state. The flow appeared with curious accuracy at the 
 month, and lasted about two days and a half. The discharge was sanguine- 
 ous, and in every way resembled that of a girl at puberty; except that it was 
 more scanty in quantity. 
 
 A return of the hectic fever followed, and the child's life was endangered. 
 She recovered, but only to be again prostrated by a fourth appearance; while 
 after a fifth she died, wasted and exhausted, without any efi'ort to rally. 
 There were no other signs of premature puberty. A post-mortem examina- 
 tion could not be obtained.^ 
 
 But, it may be said, cases like these are mere violations of the 
 
 ' Medico-Chirurgical Transactions, vol. xli, p. 4-5.5. London, 1858. 
 2 Medico-Chirurgical Transactions, vol. xlix, p. 161. London, 1866.
 
 24 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 usual law, and ought not to be taken into consideration when 
 treating of the subject of menstruation generally. This is no 
 doubt true. They are analogous to the nondescript cases of very 
 early puberty in male children, instances of which have been 
 transmitted to us since the days of Pliny, whose Historia Natu- 
 ralis is preserved to us.' And moreover, in the second girl there 
 may have existed some ovarian disease, though not sufficiently 
 advanced to allow of detection during life. Thus, a cliild under 
 my own care had a discharge of blood from the vagina when a 
 little more than nine years of age ; this discharge being regarded 
 by the mother as an ordinary monthly period. At this time the 
 young girl appeared in good health, although shortly afterwards 
 symptoms of ovarian cancer set in, and ultimately proved fatal. 
 Putting aside, therefore, these deviations from the natural course, 
 it can be shown that the majority of young women have their 
 menses for the first time between the fourteenth and sixteenth 
 years. An examination of numerous English, French, and Ger- 
 man tables leads me to infer, that if the histories of 5000 women 
 were taken, it would be found that the catamenia first appeared 
 in these at the following ages : 
 
 Between the tenth and eleventh year, in 50 
 
 Between the elevemh and twelfth year, " 200 
 
 Between the twelfth and thirteenth year, " 350 
 
 Between the thirteenth and fourteenth year, .... " 600 
 
 Between the fourteenth and fifteenth year, .... '■ 900 
 
 Between the fifteenth and sixteenth year, " 1000 
 
 Between the sixteenth and seventeenth year, ... "715 
 
 Between the seventeenth and eighteenth year, ..." 500 
 
 Between the eighteenth and nineteenth year, ..." 350 
 
 Between the nineteenth and twentieth year, ..." 170 
 
 Between the twentieth and twenty first year, ..." 100 
 
 Between the twenty-first and twenty-second year, . . " 40 
 
 Between the twenty-second and twenty third year, . " 12 
 
 Between the twenty-third and twenty-fourth year, . " 8 
 
 Between the twenty-fourth and twenty-fifth year, . . " 4 
 
 Between the twenty-fifth and twenty-sixth year, . . " 1 
 
 5000 
 
 Cases in which conception takes place before the age of four- 
 teen 3'ears are certainly very rare. A few remarkable examples 
 of early maternity are, however, on record. According to Paris 
 and Fonblanque, some girls were admitted, during the year 1816, 
 into the Maternity at Paris, as young as thirteen years ; while 
 
 1 A remarkable case of premature puberty in a boy two-and-ahalf years of age, with 
 references to similar histories, will be found in the Medico-Chirurgical Transactions, vol. 
 i, p. 278. London, IbO'J.
 
 E A R L Y M A T E R N I T Y. 25 
 
 during the Revolution one or two examples occurred of females 
 at eleven, and even below that age, being received in a pregnant 
 state into that hospital. Schurigius states the case of a Flemish 
 girl, who was delivered of a son at the age of nine years; and in 
 the notes to Metzger several instances are related where concep- 
 tion had occurred under the age of ten.* The most precocious 
 instance of pregnancy with which Dr. Montgomery was ac- 
 quainted, was that of a young lady who brought forth twins be- 
 fore she had completed her fifteenth j^ear.^ The earliest age at 
 which Dr. Goodeve, Professor of Midwifery at Calcutta, has 
 known a Hindoo woman bear a child is ten years ; but this 
 gentleman says that he had heard of one at nine. A large por- 
 tion of Hindoo women bear children before they are fifteen years 
 old. The ordinary age at which, in Bengal, women commence 
 menstruation is twelve years. ^ Dr, Josiah Curtis has related the 
 history of a girl aged ten years and eight months, who was de- 
 livered of a healthy child at the full term of pregnancy. The 
 chief particulars of this case were obtained from Mr. Presbury, one 
 of the overseers ot the poor, in the town of Taunton, United 
 States ; and from Dr. Alfred Baylies, of Taunton. The facts 
 are as follows : 
 
 Mr. P. says (15th November, 1858): Elizabeth Drayton was born at the 
 Almshouse in this town, 24th May, 1847. So says the record in the old 
 family Bible belonp;ing to that establishment, and so also says Dr. Alfred 
 Baylies, who was with the mother when Elizabeth was born. The entry in 
 his boob also corresponds with the time and circumstance. Dr. Baylies was 
 also with Elizabeth on the first day of February last, when this male child 
 was born, a nice, full-iirown, plump baby, weighing eight pounds, good weight. 
 These are facts, against which there does not exist the shadow of a doubt. 
 
 The reputed father of this child is a lad said to be about IG years old, who 
 belongs to the State of Maine. There are some circumstances in this case 
 which go to prove that this precocious girl was pregnant twenty-four days 
 before she was 10 years old. On the first day of May, 1857, they were de- 
 tected in their illicit pleasures by his aunt, who lives in Norton, with whom 
 she had lived two years or more, and to whose house he had come to make a 
 visit of two or three weeks. Immediately after they were caught together, 
 the boy was sent home forthwith to his father, who resides in Bangor, Me. 
 The child was born the first day of February, 1858, leaving a space of just 
 nine months. He is a fine little fellow, of a very handsome model, hair 
 
 1 Meilical Jurisprudence. By J. A. Paris, M.D., and J. S. M. Fonblanqiie, Barrister- 
 at-Law, vol. i, p. 257. London, 18-23. 
 
 ^ An Exposition of the Signs and Symptoms of Pregnancy. Second edition, p. 314. 
 London, 18-56. 
 
 ^ Essays and Notes on the Physiology and Diseases of Women, and on Practical Mid- 
 wifery. By John Roberton. P. 118. London, 1851.
 
 26 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 curls a little, hns a bright blue eye, and to all human appearance he has the 
 essential elements in him to make a great man. His growth thus far cor- 
 responds with his age. The mother is a fleshy, healthy girl, and rather 
 larger than girls of her age. 
 
 Dr. B. (2()th Decen)ber, 1859) gives the same dates as Mr. P. for the 
 birth of the mother and her child, and says : They are of pure Yankee 
 blood, and in fine health. The mother menstruated once or twice before 
 conception, was of good size for her age, and was tolerably healthy during 
 gestation, but had a rather lingering time at her confinement, which lasted 
 two or three days, though perfectly natural. The child weighed at birth 8 
 pounds, and to-day he weighs 37 2 pounds. The child was nursed by his 
 mother until last March, at which time he was weaned; though from paucity 
 of nourishment he was fed somewhat after three months. The reputed father 
 of this child was, at the time of conception, between 16 and 17 years of age. 
 The warden of our Almshouse, both he and his wife, Mr. and Mrs. Bassett, 
 think the little boy uncommonly smart, and in appearance he beats all the 
 boys of his age that I have seen. He appears well formed, and of great 
 muscular strength.' 
 
 The earliest age at which I have known a patient to be deliv- 
 ered is between the thirteenth and fourteenth year, the lady being 
 a native of Hayti married to an English gentleman. In the prep- 
 aration of a table of the births in Glasgow, during the year 1865, 
 it was found tliat five of the mothers were in their sixteenth year. 
 One mother, only eighteen years old, had 4 children; and another 
 woman, twenty-two years old, had 7 children. One of the moth- 
 ers, who had borne 13 children, was only in the thirty-fiftli 3'ear 
 of her life; and the youngest mother of 14 children was only 
 thirty-four years of age.^ In England, in one instance at least, 
 pregnancy is positively knowni to have occurred at eleven years. 
 The case is recorded by Mr. Roberton, of Manchester : 
 
 A girl who worked in a cotton factory became pregnant in her eleventh 
 year. When in labor she was seized with convulsions ; but was delivered of 
 a full-grown still born child without unusual difficulty, and she recovered 
 favorably. Mr. Thorpe, who attended the girl, was at the trouble of examin- 
 ing the registers of her birth and christening; and he satisfied himself that 
 she had conceived in the eleventh year of her age, and that at the time of 
 her delivery she was only a few months advanced in her twelfth year. Her 
 figure was that of a well-grown young woman ; her mamnise were fully de- 
 veloped ; and it was proved that she had menstruated before she became 
 pregnant.'' 
 
 ^ The Boston Medical and Surgical Journal, vol. Ixviii, No. 3, p. 49. 19tli February, 
 1863. 
 
 2 Second Detailed Annual Report of the Registrar-General in Scotland. P. 18. Edin- 
 burgh, 1861. 
 
 ' Essays and Notes on the Physiology an'l Diseases of Women, and on Practical Mid- 
 wifery. By John Roberton. P. 3U Loudon, 1S51.
 
 EARLY MATERNITY. 27 
 
 The following is a second example of early pregnancy, the 
 mother being twelve years and seven months old at the time of 
 her labor : 
 
 At t.he Coventry assizes of August, 1848, Julia Sprayson preferred a charge 
 of rape against her uncle, who was convicted of the assault, and sentenced 
 to two years' imprisonment. This girl began to njenstruate when (en years 
 and six weeks old; and it was distinctly ascertained that there had been a 
 regular return of the catamenial discharge, in somewhat profuse quantity, up 
 to the period at which conception took place. The criminal inteicourse first 
 occurred about the middle of November, 1847, and was repeated on four 
 occasions, at weekly intervals ; but as the catanienia had appeared during the 
 last week of that month, and did not recur in the Christmas week, she dated 
 conception from the latter period. She was delivered of a healthy but 
 rather small child on the 16th September, 1848, after a short and favorable 
 labor. Mr. John Smith, who attended her, took the trouble of consulting 
 the registers both of birth and baptism ; and he found the former to bear the 
 date of loth February, 1836, while the latter was the 7th March of the 
 same year.^ 
 
 Dr. Macdowall, of Helensburgh, ]^. B., delivered a girl thir- 
 teen years and six months old, of a full-grown female infant. 
 Conception must, therefore, have occurred at the age of twelve 
 years and nine months. The particulars of this case are as 
 follows : 
 
 "On the 17th November, 1860, I was called," says Dr. Macdowall, "to 
 visit J. W., a girl aged 13 years on the 4th of July last (according to the 
 record of the family Bible), in consequence of some abdominal enlargement. 
 I soon satisfied myself that the enlargement of the abdomen was due to preg- 
 nancy, and intimated my opinion accordingly to the relatives, who received 
 the intelligence with much amazement and doubt. I watched the case from 
 time to tinie; and as pregnancy is very uncommon at such an early age, I 
 requested my friend Dr. J. G. Wilson, of Glasgow, to see the patient with 
 me, who at once confirmed my diagnosis. On inquiry, I ascertained that 
 the catamenia appeared for the first time in January, and that she menstruated 
 regularly till the end of April. The patient appeared quite ignorant of her 
 condition, and made no complaint. 
 
 " On 11th January, 1861, I received an urgent call to visit the girl, and 
 on my arrival I found she had shortly before given birth to a full-grown 
 female child. She could not have been more than three hours in actual 
 labor. I should infer, from the way I found the infant lying in bed, that 
 the presentation was natural. I at once detached the child and removed the 
 placenta. The patient made an excellent recovery. The breasts (which had 
 been suppurating previously) healed up, but without any appearance of milk. 
 The lochial discharge was quite natural as to quantity, character, and dura- 
 tion. Four weeks after delivery the mother and child were transferred to a 
 
 1 London Medical Gazette, p. 751. 3d November, 1848.
 
 28 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 neighboring county, and shortly afterwards the child died, I presume from 
 bad nursing. The age of the lad who acknowledges the paternity is 19 years. "^ 
 
 The early marriages of the more precocious natives of tropical 
 climates have long attracted the attention of the physiologist, as 
 have also the marriages of mere children in the Arctic regions. 
 Amongst the Es'quimaux, young couples have been seen living 
 together as man and wife, where the latter could not have been 
 above twelve or thirteen years old. But it is not as generally 
 known, that in former days marriage often took place in Scotland 
 at a very early age. David Calderwood notices an Act of Assem- 
 bly passed in 1600, — " to correct divers and great inconveniences 
 arising by the untimeous marriage of young and tender persons;" 
 and ordaining "that no minister presume to join in matrimony 
 any persons in time coming, except the man be fourteen j^ears of 
 age, and the woman twelve complete."^ Mr. Robert Chambers 
 also, quotes from the Chronicles of Perth, under the date of 29th 
 August, 1618, the following: " Mr. John Guthrie, minister of 
 Perth, on ane Sunday after the afternoon's sermon, married the 
 Master of Sanquhar with Sir Robert Swift's daughter, ane Eng- 
 lish knight, in Yorkshire. Neither of the parties exceeded thir- 
 teen years of age."^ In the same work, the following instance 
 also occurs, — 9th February, A. D, 1659, the Countess of Buc- 
 cleugh, a child eleven years of age, was married to Walter Scott, 
 a 3^oath of fourteen. 
 
 About 2200 years have elapsed since Aristotle taught, that 
 premature wedlock is peculiarly dangerous to women; inasmuch 
 as many of them suffer greatly in childbirth and several die. The 
 truth of this observation has frequently been confirmed. It was 
 shown, for example, by Burns that when a girl early becomes a 
 mother, the imperfect shape of the pelvis alone may occasion a 
 painful and tedious labor. The result to the offspring in these 
 precocious unions is also apt to be unfavorable, either as regards 
 duration of life, or the physical and mental development. Prob- 
 ably, therefore, it is a safe assertion to make, that no woman 
 under twenty years of age should be allowed to marry. And yet 
 it is a remarkable fact, that according to the present laws of 
 
 ' Edinhnrirli Mi'ilical Journal, p. 332. October, ISGl. 
 
 ■■* True History of the Cliiirch of Scotland, frotn tlie beginning of the Reformation unto 
 the end of the Reign of James VI, vol. vi, p. '21. EdiidKUgli, Wodrow Society, 1^42-'J. 
 
 •'' Domestic! Annals of Scotland, from the Reformation to tlie Revolution. Second 
 edition, vol. i, p. 5U5. Edinburgli and London. ISoO.
 
 PREGNANCY AT A LATE AGE. 29 
 
 England, a girl may marry at the age of twelve, and a boy at that 
 of fourteen, provided the consent of the parents and guardians 
 be obtained. Of course it is not supposed that unions at these 
 very early years do take place. But still it is a matter without 
 doubt, that in the year 1864, there were married in England, 
 11,934 men and 36,235 women, all of whom were "under age," — 
 that is to say, they had not attained the full term of twenty-one 
 years. 
 
 When the menstrual flow has once fairly ceased at any age 
 between forty and fifty, it does not necessarily follow that it has 
 permanently stopped. Dr. Tilt mentions the instance of a lady in 
 whom menstruation ceased at forty-five, was absent for two years, 
 then returned with regularity, and was followed by pregnancy at 
 fifty. The same author refers to a case cited by Capuron, where 
 the menses are said to have returned at sixty-five, after being 
 absent for several years ; the patient becoming pregnant, and 
 aborting three months afterwards of a well-formed foetus.^ I think 
 Haller states that he delivered one woman in her sixty-third and 
 another in her seventieth year. Such instances as these are almost 
 incredible. But it is as well to bear them in mind ; and still more 
 not to infer in any given case that pregnancy does not exist, 
 simply because " the change of life " has previously taken place, 
 or for the reason that the patient's age is above fifty. The latest 
 period at which parturition, at the full term of gestation, is satis- 
 factorily known to have taken place is probably fifty-four; al- 
 though in Glasgow, in 1855, one mother was registered as having 
 given birth to a cliild in the fifty-seventh year of her age.^ 
 
 Dr. Carpenter, of Durham, says that he has attended several 
 women in their confinements whose ages were fifty. He remarks : 
 " I well remember a case occurring in my father's practice, in 
 1839, where a woman became a widow at 49 years of age. Shortly 
 afterwards she married her second husband, and within twelve 
 months of this time gave birth to her first child. These cases 
 belong to the working classes. But I know of two others, where 
 
 1 The Change of Life in Health and Disease. By Edward John Tilt, M.D. Second 
 edition, p. IS. London, 1857. 
 
 ^ In the same city, during the same year, of the women who bore children, four were 
 between 47 and 48 years old; five were between 48 and 49; two were between 49 
 and 50; two were between 51 and 52 ; and four were between 52 and 53 years of age. 
 Second Detailed Annual Report of Registrar-General in Scotland. P. 18. Edin- 
 burgh, 1861.
 
 30 OBSERVATIONS OX THE STATE OF PREGNANCY. 
 
 gentlewomen became mothers at 50; one with her first child, 
 the other with her eighth. I can saj nothing of how they men- 
 struated; but I know of a virgin in whom the catamenia ap- 
 peared regidarly and undiminished up to and at the age of 60."^ 
 Mr. Henry Bloxam, of Portsmouth, has favored me with the 
 particulars of a case, in which he delivered a patient of her first 
 child, when she was 52 years of age. This lady had been mar- 
 ried since her eighteenth year. The child was a fine healthy male, 
 above the average size, and was suckled by his mother for the 
 usual time. The labor lasted for sixteen hours, and was not at- 
 tended with more tliau ordinary suffering. 
 
 In our Court of Chancery, the succession to a large property 
 depended entirely on the question whether a woman might have 
 a child at sixty years of age. The Attorney- General, Sir William 
 Home, stated that there was no such case satisfactorily recorded, 
 and he ofi:ered to give up his client's title if any credible evidence 
 could be produced in support of an instance; but as none was 
 brought forward, he was deemed to have succeeded in proving 
 his claim.^ 
 
 The case is very different with the male sex, who may retain 
 the generative power to a great age. As Lord Erskine asserted 
 in his speech on the Banbury peerage trial, — "there is no statute 
 of limitations on the powers and faculties of man ;" and he quoted 
 the instance of Sir Stephen Fox, who married at sevent3^-seven, 
 and was the father of four children by the day he was eighty-one. 
 Many other analogous cases might be quoted, but the following 
 are the only two sufficiently interesting to merit notice : (1) In 
 the Edinburgh Courant for 3d May, 1776, there is this paragraph : 
 " Wednesday last, the lady of Sir AVilliam Nicholson, of Glen- 
 bervy, was safely delivered of a daughter. What is very singular, 
 Sir William is at present ninety-two years of age, and has a 
 daughter alive of his first marriage, aged sixty-six. He married 
 his present lady when he was eighty-two, by whom he has now 
 had six children." (2) Old TliomasParr is said to have died on 
 the 14th November, 1635, at the age of one hundred and fifty-two 
 years and nine months. His body was examined two days sub- 
 sequently by the illustrious Harvey, who reports that, — " the 
 organs of generation were healthy, the penis neither retracted 
 
 1 British Medical Journal, p. 55'2. London, 21st November, 1S63. 
 
 * London Medical and Surgical Journal, vol. iii, p. 6S7. 29th June, 1833.
 
 WOMEN BEARING MANY CHILDREN. 31 
 
 nor extenuated, nor the scrotum filled with any serous infiltra- 
 tion, as happens so commonly among the decrepit. The testes, 
 too, were sound and large ; so that it seemed not improhahle that 
 the common report was true, viz., that he did public penance 
 under a conviction for incontinence after he had passed his hun- 
 dredth year; and his wife, whom he had married as a widow in 
 liis hundred and twentieth year, did not deny that he had inter- 
 course with her after the manner of other husbands with their 
 wives, nor until about twelve years back had he ceased to em- 
 brace her frequently," This account was first published by Dr. 
 Bett, who received the manuscript from Harvey's ne^^hew. The 
 entire report deserves perusal.^ 
 
 4. The inquiry is sometimes made, — How many children can a 
 woman bear ? Dr. Szukits, in replying to this question, says that 
 he has himself observed two women, each of whom had borne 
 twenty-four children. Osiander refers to one woman who during 
 her married life bore forty-four children ; and to another who had 
 fifty-three. Burdach mentions that the wife of a countryman in 
 the Moscow district had given birth to sixty-nine children in 
 twenty-seven confinements: viz., four times, four at one birth; 
 seven times, three; and sixteen times, twins. In the Ilarleian 
 MSS., Nos. 980-87, is the following extraordinary case, which is 
 generally regarded as true : 
 
 " A weaver in Scotland had by one woman 62 children, all living till they 
 wer baptized, of which ther wer but fower daughters onely, who lived till 
 they wer women, and fourty-six sonns, all attaining to man's estate. During 
 the time of this fruitf'ulness in the woman, her husband at her importunity 
 absented himself from her for the space of 5 years together, serving as a 
 soldier under the command of Captain Selby, in the Low Countries. After 
 his return home, his wife was again delivered of three children at a birth, 
 and so in her due time continued in such births till through bearing she be- 
 came impotent. The certainty of this relation I had from Joh. Delavall, of 
 Northumb' Esqr. who, anno 1630, rid about 30 miles beyond Pjdinburrough 
 to see this fruitful couple, who wer both then living. Her stature and features 
 he described to me then more fully. Ther was not any of the children then 
 abiding with ther parents, Sir John Bowes and three other men of qualitie 
 having taken at severall times ten of ther children a peece from them and 
 brought them up. The rest were disposed of by other English and Scottish 
 gent, amongst which three or four of them are now alive, and abiding at 
 Newcastle, 1630."^ 
 
 1 De Ortu et Natura Sanguinis. Joanne Betto, M.D. Editio secunda, p. 320. Lon- 
 dini, 1692. 
 
 * Quoted from the History and Antiquities of Newcastle-upon-Tyne. By John Brand, 
 M.A. Vol. ii, p. 4.54. London, 1789.
 
 32 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 A Vienna newspaper, in the year 1809, contained the following 
 announcement : 
 
 Maria Ann Helm, the wife of a poor linen-weaver, in Neulerchenfeld, has 
 been married twenty years, and has borne, in eleven labors, thirty-two chil- 
 dren. Of these, twenty-eight are living and four are dead : twenty-six are 
 males, and six females; and all were begotten by one man, and nursed by 
 herself. She had at her last confinement three children; one living and two 
 dead. Her husband was a twin, she herself one of four; her mother gave 
 birth to thirty-eight children, and died during a labor with twins. 
 
 Among the family portraits in the Palazzo Frescobaldi, at 
 Florence, there is a full-length painting of a good-looking lady, 
 witli this inscription beneath it: "Dianora Salviati, moglie di 
 Bartolomeo Frescobaldi, fece cinquantadue figli, mai meno che 
 tre per parto." (Dianora Salviati, the Avife of Bartolomeo Fres- 
 cobaldi, gave birth to fifty-two sons, and never had less than 
 three at a labor.) 
 
 The following histories are interesting, as examples of the fe- 
 cundity of women in the present day : 
 
 Mrs. W., now a nurse in the London Hospital, was married in 1839, at 
 the age of 21 years. In nineteen years (/. e. by 1858) she had borne twenty 
 children, viz., eight ainijh births, three times hvins, and triplets twice. 
 
 Elizabeth D., of Old Montague Street, Brick Lane, was attended by one 
 of the maternity pupils (Mr. Dyte), in her twenty-sixth labor. She had 
 previously borne twenty-five children, all of them at full time, or near it.^ 
 
 In the year 1857, I was consulted by a poor woman, the wife 
 of a shoemaker, who stated that she had been pregnant twenty- 
 five times in thirty-three years, *and that she had given birth to 
 nineteen living children. None of these, moreover, had been 
 plural births. It is perhaps fortunate, that cases such as the fore- 
 going are very exceptional ; or otherwise some corrective to the 
 redundance of mankind would be needed. The result even of 
 giving birth to sixteen children may be very remarkable ; as the 
 following inscription on the tomb of a Robert Thompson, in 
 Lenham Church, Essex, serves to show. This epitaph states that 
 " He was grandchild to Mary Iloneywood of Charing, who had 
 at her decease 367 children lawfully descended from her: 16 of 
 her own body, 114 grandchildren, 228 in the third generation, 
 and 9 in the fourth." The third quarterly return of the Wycombe 
 
 1 Clinical Lecture.'? and Reports, by the Medical and Surgical Staff of the London 
 Hospital. Vol. i, p. 2US. London, 18G4.
 
 FRUITFULNESS OF MARRIAGES. 33 
 
 Registrar for 1863, records the death at Wendover of a woman 
 94 years old, who left a husband also 94; as well as 7 children, 
 46 grandchildren, 77 greatgrandchildren, and 3 great great grand- 
 children — 133 descendants, who with herself formed five genera- 
 tions. She had lived in marriage over 74 years. Upwards ^of 
 60 of her relatives are said to have followed her to the grave. 
 
 The fruitfulness of marriages in different countries is liable to 
 some variations. According to Burdach,the proportion of chil- 
 dren born to each marriage in England is five to seven ; in 
 Germany, six to eight ; in France, four to five ; and in Spain and 
 Portugal only two to three. With regard to England and France, 
 I believe these numbers are now too high ; the average in our 
 own country being slightly above four children for each marriage, 
 and in France only about three. The same physiologist likewise 
 says that one marriage out of fifty is unfruitful ; that there is one 
 birth on an average for every twenty-five of the population of a 
 place; and that, taking the whole population of the world at six 
 hundred and thirty-three millions, about fifty-one children are 
 born every second. Great difliculty is experienced in obtaining 
 any accurate returns of the proportion of unproductive to pro- 
 ductive marriages ; but with regard to Great Britain it will pos- 
 sibly be nearly correct to say that one marriage in every ten is 
 without issue. 
 
 In 1864 there was one child born alive, in England, to every 
 28 persons living; the birth-rate in this year being the highest 
 experienced since the commencement of registration. The total 
 number of births registered, amounted to 740,275; the males 
 being in the proportion of 104.2 to every 100 females. The 
 natural increase of the population in England, during this year, 
 by the excess of births over deatlis, was 244,744, or at the rate of 
 669 daily. 
 
 At the first blush it might be supposed that the greater the 
 facilities for bringing up children, the greater would be their rate 
 of increase ; and that the rich consequently would be more prolific 
 than the poor. Hippocrates did not leave unnoticed the fact, 
 however, that the labor and privation of the lowest sphere of life 
 were just as favorable to fertility, as the indolence and affiuence 
 of the highest were adverse to it; and it still remains true that the 
 poorest and most industrious part of mankind are the most fruit- 
 ful. Among the British peers, in 1833, there were 503 existing 
 
 3
 
 34 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 marriages, of which no fewer than 102 had no issiie.^ What is 
 the exphmation of this remarkable fact? Is it true, as Adam 
 Smith following the doctrine of Hippocrates suggests, that luxury, 
 while it probably increases the passion for enjoyment, seems al- 
 ways to weaken, and frequently to destroy altogether, the powers 
 of generation ? Dr. Short certainly entertained this view, for he 
 went so far as to attribute the great prolificness of the Israelites 
 in Egypt, as a secondary cause, to their bondage and affliction ; 
 and he even attempted to prove that in his day the most laborious 
 and toilsome months of the year were the most fruitful in con- 
 ceptions. A more enlightened and comprehensive consideration 
 of the subject, however, shows us that these explanations will 
 not entirely suffice. The true reason, it has been suggested, is in 
 all probability this, — that a large proportion of the upper classes 
 possess unhealthy or feeble constitutions, which are unfavorable 
 to increase ; and it is this circumstance which explains why so 
 many of our old families have died out. Throughout the higher 
 ranks of society most of the children are reared. Among the 
 lower classes more than one-half perish before the fifteenth year 
 is attained; while in numerous unhealthy towns, one-half of all 
 who are born to the lower orders are cut off before they reach 
 their fifth year. The natural physiological consequence of this 
 is, that among the adults of the liigher classes there exists a much 
 larger proportion of individuals of feeble frames than among the 
 lower classes. It has also been shown that throughout the whole 
 of Europe, marriages are less prolific in large than small towns, 
 and less again in these than in the rural districts. 
 
 There is a very prevalent opinion that marriages between near 
 relations are undesirable, so that the remark is proverbial — "The 
 marriage of first cousins proves either healthless, wealthless, or 
 childless." Certainly, recent observations seem to show that such 
 unions are relatively more completely sterile, or lead to more 
 frequent abortions, than is the case in mixed marriages ; or, if 
 these intermarriages are prolific, that the offspring will more than 
 ordinarily be the subjects of some arrest of development, or will 
 exhibit a physical and intellectual feebleness. Hence, the children 
 born from these intermarriages are more liable to early death, or 
 to strumous affections, malformations, blindness, and deaf-mutism, 
 
 ^ Journal of the Statistical Society. Vol. xiv, p. 79. London, 1851.
 
 PLURALITY OF CHILDREN. 35 
 
 than infants begot by individuals not related by blood to each 
 other. And even if the first generation be spared, the injurious 
 influence of consanguinity may show itself subsequently; while 
 when these unions are continued for several generations, the 
 family often steadily degenerates until it finally becomes extinct. 
 The number of children born out of wedlock in England is 
 rather more than six per cent, of the total number of births. Ac- 
 cording to the Registrar-General, of 1000 children whose births 
 are registered in England 65 are illegitimate ; while of the same 
 number registered in Scotand 89 are illegitimate (1856-60).' 
 Parent-Duchatelet states that in a thousand prostitutes there will 
 scarcely be six deliveries in the course of a year; but Marc asserts 
 that not more than two or three mature children are born from 
 two thousand prostitutes in the same space of time. Illegitimate 
 children are also said to be more frequently malformed than the 
 legitimate. 
 
 5. The various fictions which have been published as to the 
 number of children which a woman can bear at one labor, at 
 least afibrd evidence of the great inventive powers of authors. 
 From an early period men seem to have taken a pleasure in pub- 
 lishing these tales, as the few following show. Pliny tells us, in 
 the third chapter of the seventh book of his l!^atural History, that 
 in Egypt as many as seven children were occasionally produced 
 at one birth; and Seneca says it is an acknowledged fact, that 
 the waters of the Nile possess the property of promoting fecundity. 
 Albucasis mentions that not only may four, five, six, seven, or ten 
 children be formed in the womb ; but that in one case of abor- 
 tion he has known of seven foetuses being expelled, and in an- 
 other of fifteen, all well formed ^ Petrus Borellus records that a 
 lady, the wife of the noble J). Darre, produced at one birth, in 
 the year 1650, eight perfect children.^ Parfe, " a man of much 
 experience, some erudition, and not a little credulity," relates 
 that in his time there was the lady of a nobleman called Malde- 
 meure, residing near Chambellay, who produced twins the first 
 
 1 Twenty-seventh Annual Report of tlie Registrar-General of Births, Deaths, and 
 Marriages in England. P. 22. London, 1866. 
 
 ^ Gynfeciorum sive de Mulierum turn eommunibns, turn gravidarum, parientium et 
 puerperarum aftectibus et morbis, libri veterum et recentium. Israel Spachius. P. 444. 
 ArgentinsB, 1597. 
 
 ^ Petri Borelli, Medici Regii Castrensis. Centuria 2. Observatio xliv, p. 143. Paris, 
 1656.
 
 86 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 year of her marriage ; triplets the second ; quadruplets the third; 
 quintuplets the fourth ; and sextuplets the fifth year, of which 
 numher only one survived. The mother died after this deliver}'.^ 
 Muuriceau's opinion of the following history will hardly be dis- 
 puted : " But I esteem it either a miracle or a fable, what is re- 
 lated in the history of the Lady Margaret, Countess of Holland, 
 who in the year 1713 was brought to bed of 365 children at one 
 and the same time ; which happened to her (as they say) by a 
 poor woman's imprecation, who asking an alms, related to her 
 the great misery she was in by reason of those children she had 
 with her. To which the lady answered, Site might be content with 
 the ineonvenieyice, since she had had the pleasure of getting them."^ 
 Pare, referring to this case, completes the history, and states that 
 182 of the children were said to be males, as many females, and 
 the odd one an hermaphrodite. The infants were baptized in 
 two brazen dishes, by Don "William, Suft'ragan Bishop of Treves ; 
 the males having the name of John bestowed on them, and the 
 females that of Elizabeth. It might be thought that the force of 
 imagination could hardly produce anything more remarkable 
 than the foregoing ; but these cases are insignificant compared 
 to that of the estimable Bishop Otho, who solemnly asserts that 
 he baptized one thousand five hundred and fourteen children, 
 the miraculous offspring of his niece at one birth. It was, and 
 perhaps is still, a doctrine of the Church of Rome, that the ovum 
 becomes a fit subject for baptism as early as the fortieth day after 
 conception ; and hence it may be surmised that the simple prel- 
 ate performed the sacred rite on a large bunch of vesicular hy- 
 datids which he mistook for aborted ova. 
 
 At Wishford Magna there is a very old monument in memory 
 of one Thomas Bonham, lord of the manor, who died in 1473. 
 lieport says that he was the father of " seven children, born at 
 one birth, and all brought to church in a sieve to be baptized."^ 
 The story goes, that Thomas Bonham and his wife Edith, find- 
 ing a family coming on rather too rapidly for their means, agreed 
 to separate for seven years; with the understanding, that if 
 neither party was seen or heard of in that interval, either was to 
 
 1 The Works of that Famous Chirurgion Ambrose Paroy. Translated from the French 
 by Thos Joiinson. Liber xxv, p 648. London, 1665. 
 
 2 Diseases of Women witli Child, ike, 7th Edition, p. 40. London, 1736. 
 
 3 The Modern History of Soifh Wiltshire. By t>ir Richard Colt Hoare, Bart. Vol. 
 ii, p. 48. London, 18'25.
 
 PLURALITY OF CHILDREN. 37 
 
 be at liberty to many again. Tbomas tben went abroad ; but at 
 the instigation of "a witch" returned seven years afterwards, just 
 in time to prevent his wife from contracting a new marriage. 
 This lady, at her next labor, Avas delivered of seven children. 
 
 Although we cannot say with certainty what are the limits of 
 human fertility, yet it is generally allowed in the present day that 
 six children is the largest number which has ever been produced 
 at one birth. I must, however, confess my inability to refer the 
 student to any very authentic instance where this number has 
 been borne. It is true that the following announcement is con- 
 tained in a newspaper published in 1806 ; but it is not improb- 
 able that some ingenious contributor furnished it to fill up a 
 column, just as marvellous stories are fabricated in our own time. 
 The paragraph runs thus : 
 
 At Ohlau, in Silesia, the wife of a chimney-sweeper was delivered of six 
 children on the 10th December, 1805. They were all boys, and were all 
 dead. The woman, who had been twice married, had altogether given birth 
 to forty-four children. During her first marriage, which lasted twenty-two 
 years, she bore twenty-seven boys and three girls. In her second marriage, 
 which had lasted but three years, she had borne fourteen children ; viz., 
 three at the first labor, five at the second, and now six at the third confine- 
 ment. 
 
 A second example which I have found recorded is more recent, 
 and is possibly true. The report is to the following effect: 
 
 On the 30th December, 1831, the wife of a peasant named Dernian Plo- 
 sou, residing in the village of Dropin, in Bessarabia, was delivered of six 
 daughters, all living. They were only a little smaller than the usual size of 
 children at birth ; with the exception of the one that was born last, which 
 seems to have been very dintinutive. The mother was not quite twenty years 
 of age. She was of a strong constitution. All the sis children lived long 
 enough to be baptized, but died in the evening of the day of their birth. The 
 mother suffered from a severe indisposition afterwards, but subsequently got 
 quite well.' 
 
 A third and still more recent instance is that of an Irishwoman 
 at Port Philip, who, in 1841, was delivered of six children, after 
 a labor of sixteen hours. The infants were all females. The first 
 was stillborn, two died directly after birth, and three were thriv- 
 ing six or seven weeks after the labor.^ 
 
 But to leave the region of romance and descend to actual facts, 
 
 ^ The American Journal of the Medical Sciences, vol. xii, p 218. Philadelphia, 1833. 
 2 The Port Philip Gazette, 28th August, 1841.
 
 88 OBSERVATIONS ON THE STATE OF PREGNANCY, 
 
 it may be observed, that some five or six cases at least are re- 
 corded where women have been delivered of five children at once. 
 Many years ago, Dr. Garthshore communicated to the Royal 
 Society the particulars of a poor woman who rapidly recovered 
 her health, after being delivered at the twentieth week of gesta- 
 tion of five children. They were all females. Two were born 
 alive, and sur\ived for a short time ; two were putrid ; and one 
 was dead, but not decomposed. The whole proceeding was 
 accomplished in fift}^ minutes. Each child presented naturally, 
 was preceded by a separate bu^rst of water, and was delivered by 
 the natural pains only : there was only one extraordinarily large 
 placenta.^ The same author also refers to two instances pub- 
 lished in the Gentleman's Magazine, a journal which is gener- 
 ally regarded as a trustworthy record of the times. In the first, 
 a woman was delivered on the 5th October, 1786, at a milk-cellar 
 in the Strand, of three boys and two girls at one birth. In the 
 second example, a woman at Wells, in Somersetshire, was put to 
 bed in March, 173 ), of four sons and a daughter; all of whom, a 
 few hours afterwards, were alive, all christened, and all seeming 
 likely to live.^ 
 
 Scattered through the various volumes of the periodical just 
 alluded to are at least some half-dozen instances of four infants at 
 a birth, and several more may be found in other journals.^ One 
 of the most curious of the cases in the Gentleman's Magazine is 
 the following : 
 
 On the 4th March, 1814, the wife of Mr. James Pickworth, grazier, of 
 Senipringhain in Lincolnshire, was delivered of two boys; after which she 
 was so much composed that she got up the next day, and was able to go 
 about until the Gth, when she gave birth to two more buys. 
 
 1 Philosophical Transactions, vol. Ixxvii, p. -344. London, 1787. The five foetuses 
 are preserved in the Mus(?nni of the Royal Colie;ie of Surgeons. See The Descriptive 
 and Illustrated Catalogue of the Physiological Series of Comparative Anatomy contained 
 in the Museum of the Royal College of Surgeons in London, vol. v. Products of Genera- 
 tion, p. 177. London, 1810. 
 
 2 The notes of a case of quintuple birth of livins; children will also be found in the 
 British and Foreign Medico-Chiruigical Review, vol. vii, p. 547. London, 1851. And 
 another is quoted from a Russian journal in the Medical Gazette, vol. ii, p. 93. London, 
 1828. 
 
 * In 1674 a pamphlet was published in London with the following title-page: "The 
 Fruitful Wonder, or a strange relation from Kingston-upon-Thames, of a woman who, 
 upon Thursday and Friday, the fifth and sixtii days of this instant March, lfi7.'?-74, was 
 delivered of four children at one birth, viz., three sons and one daughter, all born alive, 
 lusty children, and perfect in every part, which lived twenty-four hours, and then died, 
 all mucli about the same time ; with several other examples of numerous births from 
 credible historians, with the physical and astrological reasons for the same. By J. P., 
 Student in Physic."
 
 PLURALITY OF CHILDREN. 39 
 
 Dr. Hamilton reported the case of a woman, near Edinburgh, 
 who was delivered of four children when she was advanced to 
 the middle of the last month of gestation: some of the children 
 lived two or three years. The same writer says that he attended 
 a patient in Edinburgh, who gave birth at the seventh month to 
 four infants, all perfect and well-developed: one was born dead, 
 and the others died the next day. Dr. Hamilton adds that these 
 are the only examples of quadruplets, or any larger number, he 
 had ever heard of as born in Scotland, within his memory. 
 
 Mr. Black, a surgeon at Anstruther in Fifeshire, has published 
 a case of quadruple birth, where the infants were all alive: 
 
 The patient was 82 years of age, and had previously been delivered of six 
 children in the same number of labors. On the 30th January, 1845, when 
 about nine months pregnant, she was delivered at half-past seven in the morn- 
 ing of two male children ; and at two in the afternoon, of two female infants. 
 Three of the placentae formed but one mass : the fourth was distinct but con- 
 nected with the others by a portion of the membranes. The first male pre- 
 sented the breech : it weighed 41bs. 6oz. avoirdupois, and its length was 18 
 inches. The second male presented a foot: its weight was 41bs. 5Joz , and 
 its length nearly the same as its brother. The first female presented a foot: 
 it weighed 41bs. 7Joz., and its length was 18 inches. The second female 
 presented the breech : it weighed 41bs. 3oz., and measured 17 inches in 
 length The patient for some weeks before labor was of an enormous size, 
 and suffered much from dyspnoea. Her husband was phthisical. Their diet 
 consisted chiefly of fish.^ 
 
 The history of another case, the particulars of which have been 
 kindly communicated to me, is as follows: 
 
 On the 22d March, 1864, a Mrs. Kennaby, set. 24, was delivered by Dr. 
 Simpson, of the City Road, London, of four mature female children. Three 
 or four days afterwards the mother and infants were all doing well ; but the 
 latter then died. Dr. Simpson informs me that there were four separate 
 placentae, as well as a rough fibrous mass having the appearance of a false 
 conception. The whole delivery only occupied forty-five minutes. It was 
 the mother's second pregnancy; at her fir.st labor she had only one child. 
 
 In the following example, the children were born prematurely; 
 but the case, as related to the Fellows of the Obstetrical Society 
 of London, in October, 1860, by Mr. Henry G. Times, is deserv- 
 ing of further record : 
 
 The patient, aged thirty-three, was pregnant for the fifth time. She was 
 taken in labor on the morning of the 28d September, 1860. At eight p. M., 
 
 1 The Northern Journal of Medicine, vol. ii, p. 2G5. Edinburgh, 1S45.
 
 40 OBSERVATIONS ON THE STATE OF PR Eft NANCY. 
 
 a feiiiiile child was delivered by the midwife in attendance; ten n)inutes after, 
 a second child ; and twenty minutes afterwards, a third was born. Then 
 followed a very large placenta; when the midwife, finding there still was left 
 another child, sent for Mr. Times. The placenta had drawn down the abd(nnen 
 of the remaining child. After a little manipulation the feet were reached, and 
 delivery of this, the fourth child, effected. The first three were alive and 
 crying ; the last never breathed. There was little hemorrhage. The previ- 
 ous pregnancy terminated at eight months, in December, 1859. The last 
 catamenial period was during the first week in March, but the discharge was 
 so scanty that she considered herself to be then pregnant. Hence the quad- 
 ruplets were probably between six and seven months old. The children were 
 all well formed, all upwards of twelve, and Dne thirteen, inches in length. 
 The first lived seven hours ; the next two, three hours. The placenta was 
 single, but each funis had a distinct attachment. There was no lobulation 
 of the placenta. The patient recovered well. 
 
 The most recent case of quadruplets, in this country, with which 
 I am acquainted, is the following : 
 
 On the 16th March, 1866, Mr. James Wilson, of Cullen, was called to see 
 
 Mrs. M , aet. 38, who had just been delivered by a midwife of two live 
 
 full-grown male children. On examination, Mr. Wilson removed two pla- 
 centae united. He then discovered a third child presenting. It was born 
 alive, was a female, and the placenta soon followed. Two hours afterwards a 
 fourth child was born, a female; it showed symptoms of vitality, but the 
 feeble powers of life could not be resuscitated. Shortly afterwards, the fourth 
 placenta was removed. The children were all mature, about the average size 
 of twins, well-formed, and healthy-looking. The mother speedily recovered.* 
 
 Haller conjectured that quadruplets happened once in about 
 20,0(.0 births ; but had he said once in 200,000 the remark would 
 have been nearer the truth. In the reports of the Dublin Lying- 
 in Hospital, only one case of quadruplets is recorded out of nearly 
 170,000 deliveries. Again, in England, during the year 1846, of 
 married women who bore children, only 1 in 588,690 had quad- 
 ruplets. 
 
 The most extraordinary history of a woman being several times 
 delivered of triplets which I have met with, is that related by the 
 Abbe Menage. He says : 
 
 " M. D. told me, the day before yesterday, that the wife of a petty shop- 
 keeper in his neighborhood had borne twenty-one children in .seven successive 
 childbcarings. These triplet children had not only been baptized, but had 
 lived, sonie several days, others several months; twelve of the most robust 
 being alive and grown up. He added, that as doubts might be entertained 
 whether the husband or the wife contributed the most to produce this kind 
 
 1 The Lancet, p. 558. London, 2Gth May, 1866.
 
 PLURALITY OF CHILDREN. 41 
 
 of prodiey, the man made a further experiment by seducing the servant girl 
 who lived with them. At the end of nine months she likewise was delivered 
 of three male children, who, notwithstanding their mother's youth and deli- 
 cate health, lived a fortnight or three weeks. "^ 
 
 A remarkable example of the delivery of triplets without any 
 help, and of the murder of the three infants directly afterwards, 
 occurred at Leominster in 1864. The report states : 
 
 For some six month.s past a young woman named Emma Smith, about 17 
 or 18 years of age, has been living in the service of a Mr. Wilkes, at the 
 Leystors, near Leominster. About half-past twelve o'clock on Monday last, 
 Mrs. Wilkes had occasion to go upstairs, when she saw the girl Smith in one 
 of the bedrooms with a large slop-pail lull of water. Mrs. Wilkes said she 
 would carry it downstairs for the girl. To this Smith made strong objec- 
 tions. The suspicions of Mrs. Wilkes became aroused : she insisted upon 
 taking the pail away with her, and eventually carried it downstairs. Mr. 
 Wilkes was communicated with, and he examined the contents of the pail 
 with a stick He first brought up to the top of the water the arm of a child, 
 then the body of a fine grown infant; he next brought up the leg and after- 
 wards the body of a second child ; and at last discovered a third. The three 
 children were all, of course, dead. The girl Sujith had delivered herself of 
 the three children at a birth, and provided herself with the slup-pail full of 
 water, into which she had plunged them immediately they were born. The 
 girl had always borne a good character, and was believed to be a hard-work- 
 ing and industrious servant.^ 
 
 Mr. Creswick Jackson has reported the history of one of his 
 patients who Avas delivered of seven children within the space 
 of two years and a half. The lady was about 30 years of age, 
 was married in 1859, and did not give birth to her first infant 
 until after more than two years. Then, in INlay, 1862, she was 
 confined with twins ; in July, 1863, with triplets ; and on 2d 
 I^ovember, 1864, with twins. The children were all born alive.^ 
 
 The Dublin Lying-in Hospital was established in the year 1757, 
 from which time until the end of ISTovember, 1854, there were 
 delivered within its walls 169,848 women. These patients gave 
 birth to 172,468 children. Of the women so delivered, 2599 had 
 twins ; 34 triplets ; and only 1 quadruplets. As regards the sex, 
 it may prove instructive to add, that 89,491 were males, and. 
 82,977 females. — jf^gain, of 18,300 women delivered at the British 
 Lying-in Hospital in London, the proportion of twins was one in 
 ninety-one births; while there was not a single case of triplets. — 
 
 1 Menasiana. Tom. i, p. .332. Amsterdam, 1713 
 
 ^ The Times. London, 29th December, 1864. 
 
 3 The Lancet, p. 589. London, 19th November, 1864.
 
 42 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 Dr. Hamilton, of Edinburgh, said that he had seen triplets born 
 there five or six times in less than twenty-five years; but it is not 
 improbable that these births are more common in the north than 
 far south of the Tweed. This opinion is confirmed by the fact, 
 that of 1475 women delivered under the superintendence of the 
 officers of the Eduiburgh Maternity Hospital, between May, 1844, 
 and the same month of 1^46, 3i had twins and 3 brought forth 
 triplets ; whereas in England, during 1846, the proportion of 
 married women who bore tri[)lets was only 1 in 19,581. — During 
 the year 1856, the births registered in Scotland amounted to 
 101,821. Of these, 1267, or 1 in every 84, were twin births; and 
 12 or only a fraction more than 1 in every 10,000, were cases of 
 triplets. — If the student should wish for more extended tables, 
 he will find them in the statistical accounts of Prussia, given by 
 Hoffman. From these it appears, that between the years 1826- 
 34 there occurred in Prussia 4,467,031 single births, 52,3s4 twin 
 births, 659 triplets, and 11 quadruplets. One woman bore twins 
 five times. In the same country, in the year 1840, there were 
 574,293 single births ; 6381 twin births, or 1 in 90 ; 72 triplets, 
 or 1 in 7976 ; and only 1 quadruplet. 
 
 Professor Spaeth, of Vienna, states that among 14,880 births 
 at his clinic, twin births have been observed 185 times (1 in 80), 
 viz., 135 times in pluriparte, and 50 times in priraiparse. In 176 
 of the cases the infants were born alive, and in 62 examples at 
 full term. In 108, the children were viable but not mature : in 
 6, they were not viable. In most instances the children were of 
 unequal size : measurements taken in 65, gave only a like result 
 in 3. In only 3 of the cases was the placenta of the first child 
 expelled prior to the birth of the second. The placenta w^as 
 carefully examined in 126 instances. In 49 there were separate 
 organs with 2 chorions and 2 amnions; in 46, united placentae 
 with 2 chorions and 2 amnions ; in 28, united placentae with 1 
 chorion and 2 amnions ; in 2, united placentse with 1 chorion 
 and 1 amnion ; and 1 case was doubtful, as the textures were 
 torn. As regards the children, the sexes were similar in more 
 than double the number of instances in which they were different ; 
 for of the 185 cases, the twins were only of different sex in 56. 
 Comparing this statement wHth the 126 examinations of the 
 placenta it appears, that of the 49 instances with separate pla- 
 centt^, 32 of the infants were of the same and 16 of different
 
 AGE OF GREATEST PROLIFICNESS. 43 
 
 sex. Among the 46 cases of united placentae and double cho- 
 rions, there were 26 of the same and 20 of different sex. The 
 31 cases with a single chorion all had twins of the same sex.' 
 
 6. Attempts have been made to learn at what age woman is 
 most prolific. The investigation cannot be carried out very satis- 
 factorily, as the facts illustrative of it are comparatively few. N^o 
 data on which an opinion can be founded are supplied by the 
 Registrar-General for England ; while but few authorities appear 
 to have paid any attention to the subject. 
 
 Dr. Bland, the first appointed physician-accoucheur to the West- 
 minster General Dispensary, communicated the results of his 
 practice to the Royal Society in 1781. From his register, care- 
 fully kept, it would seem that more women between the age of 
 twenty-six and thirty years bear children than at any other periods. 
 Thus, of 2102 pregnant women, 85 were from fifteen to twenty 
 years old ; 578, from twenty-one to twenty-five ; 69D, from twenty- 
 six to thirty ; 407, from thirty-one to thirty-five ; 291, from thirty- 
 six to forty; 36, from forty-one to forty -five ; while 6 were between 
 forty-six and forty-nine.^ By extending the examination we shall 
 obtain a confirmation of Dr. Bland's views. 
 
 The following table has been compiled from the reports of Dr. 
 Collins and Dr. Granville, as well as from that of the Registrar- 
 General of Scotland for 1855, as given by Dr. Matthews Duncan. 
 The arrangement is such as to exhibit the ages of each of 48,929 
 women at or shortly before delivery. This number is made up 
 of 16,385 women delivered in the Dublin Lying-in-IIospital, 
 during the period of seven years, commencing November, 1826;^ 
 of 16,243 pregnant women who applied for admission either to 
 the Westminster General Dispensary or to the Benevolent Lying- 
 in Hospital, between December, 1817, and December, 1836 ;^ and 
 of 16,301 women delivered in Edinburgh and Glasgow during 
 the year 1855.^ 
 
 1 Zeitschrift der Gesellschaft der Aerzte zu Wien. Pp. 225, 241. April, I860. 
 
 2 Philosophical Transactions of the Royal Society, abridged with notes, &c. Vol. xv, 
 (from 17^'l-b5), p. 120. London, 1809. 
 
 '■^ A Practical Treatise on Midwifery, containing the result of 16,654 births in the 
 Dublin Lyint;-in Hospital. P. 27. London, 1836. 
 
 * Transactions of the Obstetrical Society of London. Vol. ii, p. 177. London, 1861. 
 
 * Fecundity, Fertility, Sterility, and allied Topics. P. 9. Edinburgh, 1866.
 
 44 
 
 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 A Table showing the Age of each of 48,929 Women at, or 
 
 VERY SHORTLY BEFORE, DELIVERY. 
 
 At the age of 15 there were 12 women. 
 
 ir, 
 
 " 
 
 52 
 
 17 
 
 ■' 
 
 144 
 
 IS 
 
 " 
 
 481 
 
 19 
 
 " 
 
 898 
 
 •2U 
 
 " 
 
 1788 
 
 21 
 
 " 
 
 1828 
 
 22 
 
 " 
 
 2778 
 
 2.'] 
 
 " 
 
 2736 
 
 24 
 
 a 
 
 2975 
 
 25 
 
 u 
 
 3258 
 
 20 
 
 " 
 
 3319 
 
 27 
 
 " 
 
 2836 
 
 28 
 
 " 
 
 3533 
 
 29 
 
 u 
 
 2127 
 
 3(J 
 
 a 
 
 5253 
 
 31 
 
 " 
 
 1282 
 
 32 
 
 " 
 
 2140 
 
 33 
 
 u 
 
 1686 
 
 34 
 
 " 
 
 15it3 
 
 35 
 
 " 
 
 1730 
 
 3t) 
 
 " 
 
 1512 
 
 37 
 
 " 
 
 944 
 
 38 
 
 " 
 
 1048 
 
 39 
 
 " 
 
 666 
 
 40 
 
 '• 
 
 1088 
 
 41 
 
 " 
 
 290 
 
 42 
 
 '• 
 
 345 
 
 43 
 
 " 
 
 200 
 
 44 
 
 (1 
 
 151 
 
 45 
 
 " 
 
 107 
 
 46 
 
 " 
 
 53 
 
 47 
 
 " 
 
 21 
 
 48 
 
 " 
 
 15 
 
 49 
 
 u 
 
 13 
 
 50 
 
 " 
 
 13 
 
 51 
 
 " 
 
 2 
 
 52 
 
 " 
 
 7 
 
 53 
 
 u 
 
 1 
 
 55 
 
 " 
 
 3? 
 
 57 
 
 u 
 
 1 ? 
 
 3375 
 
 j- 13,' 75 
 
 17,068 
 
 8431 
 
 5258 
 
 1093 
 
 115 
 
 An inspection of this table shows that more women at the age 
 of thirty bear chikh-en than at any other time. Taking each 
 quintuple period, the increase up to the third is well-marked; as 
 is the suliseqnont decrease of the numbers in the fourth and fifth 
 and sixth similar periods. Hence we may infer, that the aptitude 
 for childbearing gradually increases up to the age of thirty ; 
 after which year it as steadily declines until altogether lost. 
 
 For a woman to become pregnant in consequence of a single 
 intercourse is comparatively rare. In the greater number of cases.
 
 PKOPORTIONOFSTILLBIRTIIS. 45 
 
 fecundation does not take place until the second or third month 
 after marriage. Taking, for example, the population tables of 
 Sweden for twenty years, they clearly show that the month of 
 October is that in which the greatest number of marriages are 
 celebrated, but the cue in which the smallest number of concep- 
 tions occur; while the greater number of conceptions are proved 
 to happen in the month of December.^ Statistical tables prove, 
 that when a mother suckles her children the ordinary interval 
 between successive births is from twenty to twenty-four months. 
 
 According to M. Quetelet, the mean proportion of stillborn 
 children in the chief cities of Europe, is one in every twenty -two 
 births ; the number being three times greater among illegitimate 
 than among legitimate children.^ Throughout the whole of 
 France, in 1850, the stillborn to the living births were as 1 to 
 rather above 37; whilst in Paris alone they were as 1 to about 
 12J. Probably in Great Britain nearly the same discrepancy ex- 
 ists between the numbers of those infants born dead in the rural 
 districts as compared with those of large manufacturing towns. 
 It is generally allowed that in the United Kingdom 1 child out 
 of every 20 is stillborn ; but in the Dublin Lying-in Hospital the 
 proportion has been rather more than 1 in 17. Thus it has been 
 already shown, that during nearly one hundred years, 172,468 
 children were born in this institution. Now of this number 
 10,259 were dead. Owing to the larger size of the head, males 
 are much more frequently stillborn than females; the proportion 
 being about 140 of the former to every 100 of the latter. 
 
 The dangers of parturition being greater to male than female 
 children, it will at once be inferred that labors with the former 
 are more frequently attended with difficulties and accidents than 
 with the latter; and this inference is corroborated by statistical 
 facts. From these two propositions a third follows, viz., that of 
 the mothers who perish during parturition, or shortly afterwards 
 from its effects, a much greater proportion have been in labor 
 with male than with female children ; the ratio probably being 
 rather more than two to one. 
 
 ' Traite de Physiologie. Par C. F. Biirdach. Traduit de I'Allemand sur la deuxieine 
 Edition, par A. J. L. Joiirdan. Tome v, p. 74. Paris, 1^39. 
 
 '^ Sur THomme, et le Developpement de ses Facultes, ou Essai de Physique Sociaie. 
 Tome i, p. 121. Paris, 1835.
 
 46 
 
 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 Before leaving this topic I would briefly direct attention to the 
 fact, that the mortality in first labors is about double that of all 
 the subsequent deliveries classed together. This point is well 
 shown in the following table of the deliveries which occurred in 
 the Dublin Lying-in Hospital during Dr. Shekleton's mastership, 
 from November, 1847, until the same month in 1854. The data 
 from which the table has been constructed, have been derived 
 from the report of Drs. Sinclair and Johnstone. 
 
 A Table of 13,748 Deliveries, showing the Mortality in 
 MultiparjE and Primipar^. 
 
 Months. 
 
 Total 
 DeHvei'ie.o. 
 
 Multiparre 
 
 Primiparw. 
 
 Deaths in 
 Multipara;. 
 
 Deaths in 
 Frimiparre. 
 
 January, 
 February, 
 March, . 
 April, 
 May, . . 
 June, . . 
 July, . . 
 August, . 
 September, 
 October, . 
 November, 
 December, 
 
 
 
 1042 
 1087 
 1255 
 1232 
 1293 
 12.34 
 1170 
 1143 
 1072 
 1067 
 1077 
 1076 
 
 693 
 759 
 857 
 853 
 879 
 806 
 810 
 779 
 691 
 713 
 691 
 681 
 
 349 
 328 
 398 
 379 
 414 
 428 
 360 
 364 
 381 
 354 
 386 
 395 
 
 8 
 
 7 
 5 
 2 
 3 
 9 
 7 
 8 
 3 
 8 
 14 
 
 6 
 12 
 
 7 
 11 
 5 
 5 
 8 
 6 
 1 
 7 
 6 
 9 
 
 Total, . . 
 
 13,748 
 
 9212 
 
 4536 
 
 80 
 
 83 
 
 An examination of this table shows that while the mortality in 
 multipara is only 1 in 115, in primiparse it is about 1 in 55. The 
 month of May is seen to be that in which the largest number 
 of deliveries occurred, while it exhibits the smallest mortality. 
 Contrasted with December, the latter appears in a veiy unfavor- 
 able light. 
 
 After the eighth labor certain conditions concur to gradually 
 increase the dangers of each subsequent delivery. The chief 
 risks are from flooding, placenta previa, and puerperal fever; 
 while from advance in age, combined with the efl'ects of the wear 
 and tear of a probably anxious life, the system is less able than 
 in earlier years to bear up against pain and sickness. 
 
 7. From all time men have been curious to learn the sex of the 
 foetus contained in the uterus. And consequently, just as some 
 farmers' wives pretend to be able to say whether an egg is fecun-
 
 PREDICTING THE SEX OF THE FCETUS. 47 
 
 dated or not, and whether it will produce a male or female bird, 
 so a Solomon can often be found to satisfy the curiosity of his 
 brother sages with regard to the human female. Two aphorisms, 
 attributed to Hippocrates, have especially been the cause of much 
 criticism and useless speculation.^ That physicians and astrolo- 
 gers in former days should not have deemed it a foolish waste 
 of labor to treat of this subject, is by no means astonishing; and 
 we can readily believe that such rules as those contained in The 
 BirtJie of 3Iankinde, and similar works, were thought by the vulgar 
 to be the fruit of great learning.^ But it is certainly remarkable 
 to find, that even as late as the year 1834 an esteemed professor 
 of midwifery, in a German university, did not consider it un- 
 scientific to discuss at some length the various theories which 
 have been broached respecting the signs by which the sex of the 
 child may be foretold; as well as the means which may be taken 
 by the parents for securing the production of male or female chil- 
 dren at pleasure. It seems almost incredible that any educated 
 gentleman out of Bedlam could promulgate the doctrine that in 
 order to obtain sons, the generative act is to be performed when 
 the wind is northerly; yet this is one of M. Venette's seven chief 
 rules on the art of procreating the sexes at will, and his writings 
 were formerly much read in France. Almost equally ridiculous 
 is the idea that the Graafian follicles of the right ovary discharge 
 male ovules, while those of the left produce female; and no less 
 so the advice which flows from this view, that in order to procure 
 
 1 "A woman with child, if it be a male, has a good color; but if a female, she has a 
 bad color." Aphorism 42, section 5. 
 
 " The male foetus is usually seated in the right, and the female in the left side." Aph- 
 orism 48, section 5. The Genuine Works of Hippocrates. Sydenham Society's Edition, 
 vol. ii, pp. 745, 746. London, 1849. 
 
 The first of these aphorisms is still acted upon by midwives in the East. Dr. Paul 
 Eram says (Quelques Considerations Pratiques sur les Accouchements en Orient, Paris, 
 1860), that the first thing the midwife has to do on arriving at her patient's house, is to 
 declare the sex of the child. This she does without hesitation. If the woman's face be 
 highly flushed and her eyes brilliant, the child will be a boy. If, on the contrary, the 
 expcictant mother looks pale and sad, and her eyes are dim, the midwife declares that 
 a girl will be born. 
 
 ^ " But if ye be desirous to know whether the conception be man or woman, then 
 let a drop of her milke or twaine be milked on a smooth glasse, or a bright knife. 
 Other els on the naile of one of her fingers, and if the milke spread abrode upon it by 
 and by, then it is a woman child; but if the drop of milke continue to stand still upon 
 that the which it is milked on, then is it a signe of a man child. 
 
 "Item, if it be a male, then shall the woman with child be well colored, and light in 
 going, her belly round, bigger towards the right side than the left (for commonly the 
 man childe lyeth in the right side, the woman in tlie left side), and in the time of her 
 bearing she shall better digest and like her meate." — The Birthe of Mankinde, other- 
 wise named the Woman's Booke, p, 193. London, 1604.
 
 48 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 fecundation of the former the woman must lie on her rio-ht side 
 during coitus, and on her left to impregnate the latter. For my 
 own part I should scarcely have alluded to the matter, had I not 
 reason to believe that erroneous views still prevail on this sub- 
 ject. Medical doctrines, no matter how absurd they may be, are 
 very tenacious of life. Like some of the Rotifera, they appear 
 dry and dead enough ; when all at once an active and credulous 
 student supplies them with moisture, and off they are started to 
 run another career with as much vitality as ever. It is, however, 
 to be hoped that there is no chance of all the old, ridiculous, and 
 perhaps disgusting notions of the ancients being revived in the 
 present day. To discard much of such nonsense, it is only ne- 
 cessary to remember two facts. First — that a man who has had 
 one testicle removed by a surgical operation has afterwards been 
 the father of both male and female children ; and consequently 
 the ancient opinion that boys were begot by the secretion of the 
 right testicle, and girls by that of the left, can hardly be true. 
 Secondly — that several years ago a poor woman died in the 
 Maison d'Accouchement in Paris, who had had twelve or thir- 
 teen children of both sexes. On examining her body after death, 
 it was found that the uterus ^^'as imperfectly formed; the left half 
 of this organ and the left ovary and Fallopian tube being absent.^ 
 In the year 18G3, M. Zepulder, of Vienna, was in the habit of 
 counting the beats of the foetal heart to ascertain the sex. If the 
 pulsations were 144, the birth of a male was predicted; if 150, a 
 female. M. Zepulder stated, that of sixty cases, he was only five 
 times in error; these mistakes arising from various circumstances 
 independent of the soundness of his theory. Farther on it will 
 appear that Dr. Frankenhauser had previously promulgated 
 somewhat similar views, and it will be seen how little reliance 
 can be placed upon them. Moreover, independently of the ex- 
 periment related in the section on the sounds produced by the 
 foetal heart, I have examined the pulse in a considerable num- 
 ber of infants within one hour of birth, but have not found the 
 difference in the sexes sufficient to allow of any rule being de- 
 duced. As might be expected, the frequency of the beats is less 
 in the strong and large children than in the Aveakly and averaged 
 size ; while as most large children are of the male sex, this fact 
 
 1 Dictioiinaire tie Medecine. Deiixieine Edition. Tome xiv, p. 369, Paris, 1836,
 
 PRODUCTION OF EITHER SEX AT WILL. 49 
 
 might seem to corroborate M. Zepulder's opinions. But taking 
 an ordinary run of cases for some few weeks, it can be shown 
 that the pulse is on an average the same in both sexes. Hence I 
 advise, that if any physician, in fear of being deemed ignorant, 
 should still desire to be thought clairvoyant, it will be wise for 
 him to adopt the practice advocated by an ancient author, and 
 predict the opposite to the patient's desires : "Because if it happen 
 to be true (although by chance), what was foretold, they will 
 then conclude me to be knowing, and to have said well ; if other- 
 wise (which may be once in twice), the woman and her husband 
 obtaining what they desired, will not take so much notice of it, 
 because one always receives with a good welcome what they de- 
 sire, though unhoped for." 
 
 M. Thury, of Geneva, has propounded the doctrine that in 
 animals the male sex is always produced when fecundation is 
 accomplished upon ova of complete maturity, while females re- 
 sult when ova of a less advanced maturity are acted upon. Thus, 
 by serving the cow with the bull at the commencement of the 
 rut, females can always be produced ; while by serving her at 
 the middle and terminating periods of the rut, she will give 
 birth to males. In proof of this it has been said to be a fact, 
 that queen bees lay female eggs first and male eggs afterwards. 
 The theory can also be tested in the common fowl ; in which 
 bird several eggs fecundated at the same time by a single im- 
 pregnation arrive only successively, and in the order in which 
 they are placed, at maturation. But in an experiment by M. 
 Coste, a fowl, separated from the cock at the commencement of 
 her laying, produced five eggs within the space of eight chxys, 
 and the sexes resulting were as follows — male, male, female, 
 male, female. This test, as far as it goes, certainly seems to 
 offer a radical objection to the theory. I believe also that much 
 stronger evidence could be adduced against the soundness of the 
 doctrine, that conception in the human female, in the first half 
 of the time between the menstrual periods, produces females: in 
 the latter half, males. 
 
 It is not improbable, although nothing very positive is known, 
 that a difference in the ages of the parents has some infiuence in 
 regulating the proportion of the sexes of their children. The 
 following table may be taken as indicating the proportion of 
 
 4
 
 50 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 male births to females, under the conditions mentioned in the 
 first column :' 
 
 Father younger than mother, 1000 males to 1156 females. 
 
 Father and mother of equal aife, 1000 " 1055 " 
 
 Father oldpr by 1 to 6 years, lOnO " 9fi4 " 
 
 " 6 to 11 " 1000 " 789 " 
 
 " 11 to 16 " 1000 " 625 " 
 
 " 16 to 21 " 1000 " 625 
 
 " 21 and upwards, 1000 " 600 " 
 
 In a record of 2000 births by Hofacker, the following were the 
 respective ages of the parents, and the proportion of the sexes 
 produced : Of 568 children engendered by fathers who were 
 younger than their wives, 298 females and 270 males were pro- 
 created ; of 145, from fathers and mothers of equal ages, there 
 were 75 females and 70 males; of 353, by fathers from one to 
 three years older than their wives, there were 163 females and 
 190 males; of 466, by fathers from three to six years older than 
 their wives, there were 229 females and 237 males; of 191, by 
 fathers from six to nine years older than their wives, there were 
 85 females and 106 males ; and of 277, by fathers from nine to 
 twelve years older than their wives, there were 113 females and 
 164 males.'^ 
 
 Thus it seems from these observations that the advanced age 
 of the father possibly has a decided influence in occasioning a 
 preponderance of male children. This view also tallies with 
 what we know to be the case ; for, as a rule, in England, the 
 husband is rather older than the wife, and the proportion of live 
 births is about 104.7 males to 100 females. It may perhaps also 
 account for the circumstance, that amongst illegitimate children 
 the number of males born to females is higher than it is amongst 
 the legitimate, being as 106.3 to 100. The Messrs. Campbell 
 state that in all countries, except among Europeans at the Cape 
 of Good Hope, the male progeny predominate. At the Cape, 
 from 1813 to 1820, there were born of European parents, 6789 
 females and 6604 males ; while among the slave population the 
 returns were 2826 females and 2936 males. 
 
 The proportion between the sexes in England, at the time of 
 
 1 The Law of Population. By Michael Thomas Sadler, MP., vol. ii, p. 343. Lon- 
 don, 1830. 
 
 - Introduction to the Study and Practice of Midwifery. By William and Alexander 
 J). Campbell. Second edition, p. 76. Edinburgh, 1843.
 
 FEIGNED PREGNANCY. 51 
 
 puberty, is rendered more equal than a consideration of the birth- 
 rate alone would lead us to expect, owing to the fact that the 
 deaths of boys in each year average 103 to 100 deaths of girls. 
 After puberty the females predominate, in consequence of the 
 large number of youths drafted into the army and navy and 
 merchant marine for foreign service, the immense drain by emi- 
 gration, and the greater mortality among males in consequence 
 of their more hazardous occupations. In the year 18G6, the 
 population of the United Kingdom, including the islands, was 
 estimated at 14,775,810 males, and 15,553,397 females. 
 
 8. The examination of cases of doubtful pregnancy must al- 
 ways be conducted with considerable deliberation and delicacy. 
 It is of course to be regretted that very little reliance can usually 
 be placed upon the statements of the patients themselves, espe- 
 cially if any motives exist for their resorting to deception. The 
 fact is well known that women occasionally feign pregnancy, and 
 even labor, either for the purpose of extorting money, or com- 
 pelling marriage, or to gratify the expectations of a husband, or 
 in order to be fashionable or patriotic. On the authority of Madame 
 de Crequy it may be mentioned, that after the first French Revo- 
 lution there was a great cry about patriotism, and the need of 
 children for the Republic. Hence, those Parisian ladies who were 
 fortunately enceinte^ made the greatest possible display of their 
 condition ; while such as were less happily situated, invented a 
 style of dress which should at least give them the reputation of 
 being as they vainly desired to be. 
 
 More than 2000 years ago, Terence, in " The Woman of Ah- 
 dros," ridiculed the imposition attempted by Glycerium with the 
 aid of Lesbia, the midwife, and showed how it failed. Davus 
 thus explains the state of afiairs to Simo : 
 
 Multa concurrunt simul, 
 Qui conjecturam banc nunc facio: jam primum hsec se e Pamphilo 
 Gravidam dixit esse: invetitum est falsum : nunc, postquam videt 
 Niiptias domi apparari, missa est ancilla illico 
 Obstetricem arcessitum ad earn, et puerum ut afferret simul.i 
 
 Frauds like the foregoing are still practised, and often require 
 much care for their detection, since the skill of a cunning and 
 
 ^ Andria. Actus iii, scena 2.
 
 52 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 unscrupulous woman is considerable. But the practitioner who is 
 properly impressed with the responsibility attached to his calling, 
 and who considers how readily negligence on his part may be the 
 origin of private pain and public scandal, will not fail to be scru- 
 pulous and watchful. Sometimes the impostors are caught by 
 their own devices, as is shown in the following curious case re- 
 ported by Capuron : 
 
 A young person, about 25 years of age, had been seduced under a promise 
 of marriage. The promise not being fulfilled, she thought to hasten it by 
 counterfeiting pregnancy. She arranged her dress, so as to make her abdo- 
 men appear to be gradually increasing in size; at the same time her friends 
 were informed of her supposed condition. At the proper time, preparations 
 were made to counterfeit a confinement. She obtained two or three pounds 
 of bullock's blood, with which her bed and linen were soiled. A confidential 
 friend procured a nurse. After remaining in bed for nine or ten days, a 
 fortnight was devoted to a convalescence. Then, reappearing in public, the 
 patient asserted that she had been delivered, and had placed the infant out 
 to nurse. The lover still refused, however, to marry the woman, though he 
 did not deny that he was the father of the supposed child. A year or two 
 passed, and the father then claimed the infant. The woman refused to give 
 it up; and hence proceedings were taken against her before the criminal 
 tribunal of the Departement de lu Seine.' She was then obliged to confess to 
 the fraud she had practised, and she defied any one to find a trace of her 
 having had a labor on her person. Capuron, with two other physicians, was 
 deputed to examine her; and she was discharged from custody upon their 
 declaration that they could discover uo trace of delivery either recent or 
 otherwise.' 
 
 In a remarkable case [Gredney v. Smith, Eolls Court, November, 
 1864), the imposition succeeded for nearly ten years, and indeed 
 would not have been detected then save for the confession of the 
 fictitious mother just before her death. The chief features of the 
 trial, abbreviated from the reports published at the time, are the 
 following : 
 
 The plaintiiT claimed to be the only child of Mr. and Mrs. Gedney, and 
 to be entitled to property under a marriage settlement. The supposed parents 
 were married in May, 1851: from that time to 1854 there was no issue, 
 though it was said there had been several miscarriages. Mrs. Gedney, al- 
 leging she was pregnant in 1853, came to London into lodgings in the early 
 part of 1854. On the 10th February, she had labor pains, and sent for a 
 man named Goss. This person, it was said, delivered her of a female child — 
 the plaintiiF. Mr. Gedney came up to town in a day or two, dismissed Goss 
 from further attendance, and called in Dr. Arthur Farre. This gentleman 
 
 1 La M6decine Legale, relative a I'Art des Accouchemens. Par J. Capuron. P. 110. 
 Paris, 1821.
 
 FEIGNED DELIVERY. 53 
 
 testified at the trial, that he first saw Mrs. Gedney on the Tuesday, as she 
 was said to have heen delivered on the previous Friday ; that he attended 
 her from the 14th February until the 7th March ; that it was an ordinary 
 case; that he put his hand on the uterus, abdomen, &c. ; and that it was 
 impossible, in his opinion, the lady covhl not hare heen confined at all. The 
 reputed father had registered the child and always treated it as his own until 
 his wife's death. 
 
 On the part of the defendant, it was alleged that Mrs. Gedney had not 
 been delivered of a child. Her physician, who examined the body after 
 death, deposed to this effect; while another practitioner, who attended her 
 for venereal disease in September, 1^53, stated his belief that she was not at 
 that time pregnant. It was further proved that Go.ss and his wife — the lat- 
 ter with a bundle under her cloak — called at the lodging-house on the day 
 Mrs. Gedney was said to be confined, and remained with her for some hours. 
 No nurse was procured ; no noise of a child was heard ; and the landlady, in 
 the evening, was shown a baby, which had no redness of the skin about it 
 like new-born children. There were marks of blood about the fireplace, and 
 Goss said he had burnt the afterbirth. It was also shown that on the 4th 
 February, as Mrs. Gedney was alleged to have been confined on the 10th. a 
 poor woman named Fletcher was delivered at the York Road Lying-in Hos- 
 pital ; and that on the 7th February, a man and woman — afterwards identi- 
 fied as Goss and his wife — called at the hospital and induced Fletcher to give 
 her child to them, in order that it might be adopted by a lady. In addition 
 to other evidence, a clersyraan was examined, who swore that Mrs. Gedney 
 voluntarily communicated to him that the plaintiff was a supposititious child, 
 which she had adopted in order to recover the affections of her husband by 
 appearing to have become a mother. The secret had also been confided to 
 her maid by Mrs. Gedney; and, on her death-bed, to her father. The jury 
 returned a verdict for the defendant ; thus denying the fact of the plaintiff 
 being the child of Mr. and Mrs. Gedney. 
 
 This extraordinary investigation may serve to prove, that when 
 a medical man is called in, for the first time, to a case of so-called 
 recent delivery, where the surrounding circumstances are in the 
 slightest degree suspicious, he is bound to make a careful exami- 
 nation of the infant and the patient. No statements should, per 
 se, be taken on trust ; any more than a physician ought to rely 
 only on the word of one who consults him, as to the existence 
 of some form of structural disease. There is neither difficulty 
 nor impropriety in making the necessary scrutiny. Every accou- 
 cheur, for example, can tell at a glance an infant that has been 
 born only a few hours from one, two, or three days old. So, also, 
 an examination of the umbilicus would enable us to distino-uish 
 between a child of four days and one of ten ; for, in the great 
 majority of cases, the remains of the umbilical cord do not fall 
 off until the fourth or fifth day after birth, while cicatrization of 
 the navel is commonly complete by the tenth or twelfth. And
 
 54 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 then as regards the motlier, or reputed mother, as the case may 
 be, it is useless to trust to the appearances of the breast; inas- 
 much as no great skill is needed to produce a fictitious areola 
 with walnut-juice, or to give prominence to the gland hy irrita- 
 ting it. So, again, any woman can arch her spine forwards, and 
 thus produce a feeling of abdominal fulness very much like that 
 caused by a tumor. But no patient is able to induce artificially 
 that condition of the uterus and its mouth which exists naturally 
 for a few weeks after labor. And hence, by a vaginal examina- 
 tion, the true nature of the case could~be proved incontestably ; 
 so that if there were any attempt at imposition, the fraud would 
 be detected before much harm had been done, or if the patient 
 had been really delivered, she would be protected from unjust 
 suspicions. 
 
 The physician, in the daily practice of his profession, has more 
 frequently to deal with instances of concealed, than of simulated 
 pregnancy. Concealment of pregnancy is not regarded as an 
 oflence by the law of England. But the concealment of delivery, 
 or of the birth of a child which has died before or at or after its 
 birth, is a misdemeanor, punishable by imprisonment for any 
 period not exceeding two years (24 and 25 Vict. c. 100, sect. 60). 
 It should be noticed that the child must be dead; concealment 
 of the birth of a child which is living at the time of the investi- 
 gation not being a crime. ^ 
 
 The dogged and indignant manner in which some women who 
 are pregnant when they ought not to be so, will dispute the pos- 
 sibility of such an occurrence, is often rather startling to a young 
 practitioner. The case of the nun — as mentioned by Fod^re — 
 who sent for a surgeon to cure her of a violent colic, and who 
 continued to disown being with child, until the cries of the infant 
 silenced her, is doubtless no exaggeration. Indeed, it has been 
 said that women have not only unfalteringly denied ever having 
 been pregnant, directly after giving birth to a child ; but have 
 even drawn so extensively on the credulity of their friends as to 
 
 ^ By the law of Scotland, if a woman conceals her pregnancy during the whole period 
 thereof, and if the child of wliich she was prejjnant he found dead, or is missing, she is 
 guilty of an otfence, and is liahle to prosecution. Evidence may be given as to there 
 having been outward ai)pearnnce, indicative of pregnancy; but the main proof of a 
 woman having been pregnant, and that which is relied on for conviction, is clear and 
 distinct evidence of the actual delivery of a child. See The Principles and Practice of 
 Medical Jurisprudence, by Alfred Swaine Taylor, M.D. &c., p. 759. London, 1865.
 
 CONCEALED PREGNANCY. 55 
 
 assert, that the newlj-born infant has been brought to them by 
 the accoucheur in attendance. Hence, in estimating the value 
 to be attached to the remarks of patients, it is necessary to be 
 more skeptical even than the learned Irish bishop ; who, after 
 reading Gulliver's book of travels, hypercritically remarked that 
 the volume contained some things which he could not prevail upon 
 himself to believe. But independently of the notorious fact, that 
 single women who have clandestinely indulged in sexual inter- 
 course, and become impregnated, will resort to every kind of 
 equivocation and falsehood and will make the most obstinate ef- 
 forts to deceive, it not very unfrequently happens that the patient 
 herself is really ignorant of her condition. There is, indeed, no 
 doubt that a woman who has incurred the risk may become 
 pregnant without being aware that she has conceived ; and not 
 only so, but — extraordinary as it may appear — it must be allowed 
 that she may become pregnant in consequence of intercourse 
 without knowing that such intercourse has occurred. Beyond 
 all question, such an event is very rare. But the possibility of a 
 woman, habituated to sexual connection, being impregnated while 
 in deep sleep under the influence of excessive fatigue or of nar- 
 cotics, or of alcoholic drinks, cannot be denied ; since certain 
 indisputable examples of its occurrence are recorded. In inves- 
 tigating cases of this kind, however, the shrewd observation at- 
 tributed to old Valentin must not be forgotten, — Non omnes dor- 
 mivMt, qui dausos et conniventes habent oculos. Somewhat allied 
 to the very exceptional occurrences just referred to, are those in- 
 stances in which women have been delivered during natural sleep, 
 without any knowledge of the circumstance ; illustrations of which 
 are to be found in most works on medical jurisprudence.^ 
 
 Much more marvellous are those cases where virgins are said 
 to have been impregnated without their knowledge. It was 
 formerly the law, that when in a charge of rape pregnancy was 
 
 1 The following well-marked case may be quoted : M, Schultze was called on the 
 25th May, 18-14, to attend tlie wife of an artisan who had reached the full term of her 
 fourth pregnancy. He found her lying in a stale of profound somnolency; so tiiat it 
 was quite impossible to arouse her, either by a violent shaking, or by a[)plying the most 
 powerful stimulants to the nostrils. On the third day of this unnatural sleep, tlie woman 
 without awaking, was delivered of a healtliy, living, well-formed child. On visiting 
 her the following morning, M. Schultze found that she had just previously awakened 
 spontaneously from her sleep ; and as she had no recollection of being delivered, she 
 was of course much astonished to find the child by her siile. — Annales d'Hygieiie Pub- 
 lique et de Medecine Legale. Tome 33, p. 216. Paris, 1845.
 
 56 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 found to have ensued, the occurrence of this state should be 
 deemed as proving that the woman had consented; it being held 
 that fecundation could not take place without the woman sharing 
 in the enjoyment of the man during coition. This opinion, how- 
 ever, was founded on error ; experience and the first principles 
 of phj'siology alike contradicting it. Gooch very truly remarks, 
 that it is not necessary the woman should be sensible at the time 
 of impregnation, and he subjoins the following narrative in proof 
 of his assertion : 
 
 A maid at an inn, who was always thought to be virtuous, and bore a good 
 character, began to enlarge in a way which excited suspicions of pregnancy. 
 She solemnly declared that she had never had connection with any man. At 
 length she was delivered, and was afterwards taken before a magistrate to 
 swear to the father; but she repeated her former declaration. Not long 
 afterwards, a postboy related the following circumstance : He said that one 
 night he came to this inn, put his horses in the stable, and went into the 
 house. He there found that all had gone to bed except this girl, who was 
 lying asleep on the hearth-rug, and without waking her he found means to 
 gratify his desires. 
 
 Mr. Cusack communicated to Dr. Montgomery the following 
 particulars of a somewhat similar case, which occurred under 
 his own observation : 
 
 A female servant at a hotel in Nenagh proving pregnant, solemnly de- 
 clared that she was not conscious of having had intercourse with any man. 
 Suspicion, however, fell upon a hostler in the establishment, who subse- 
 quently acknowledged that he believed himself to be the father of the child. 
 He stated, that having found the woman in a deep sleep from great fatigue, 
 he had connection with her ; and, as he believed, totally without her knowl- 
 edge, as she neither evinced conciousness of the act at the time, nor recol- 
 lection of its occurrence afterwards. The parties were married by mutual 
 consent. 
 
 ITot many years since it was the opinion of physiologists, that 
 the only active portion of the seminal fluid was its volatile odor, 
 the grosser particles being merely of use as a vehicle for this 
 aura seminalis. On this absurd hypothesis, the foregoing cases 
 would have been easily explained; and it is strange that the first 
 one has not been added to the histories of what Gardien terms 
 those "marvellous phenomena," where women are said to have 
 become impregnated by the mere application of the male secre- 
 tion to the external parts of the vaginal labia. 
 
 But allowing that impregnation may occur, under ver}^ peculiar
 
 UNCONSCIOUS PREGNANCY. 57 
 
 circumstances, without a woman's knowledge, is it possible that 
 she can continue ignorant of her pregnancy until the child is 
 brought forth ? Hebenstreit, writing one hundred years ago, 
 answered this question in the affirmative ; for he asserts that a 
 female might be impregnated while intoxicated, could go to the 
 full period without knowing she was pregnant, and might mistake 
 her labor pains for an attack of colic or dysmenorrhoea. Here 
 it will be observed the combination of three most improbable 
 conditions is required, viz., impregnation without consciousness, 
 the imitation of disease by the gradually enlarging gravid uterus, 
 and the mistaking of labor pains for an attack of colic. Surely 
 it must be conceded that if such an occurrence is barely within 
 the bounds of possibilitj^, yet to say the least very strong moral 
 evidence would be requisite to make it credible in any particular 
 instance. 
 
 On the other hand, putting aside the question of unconscious- 
 ness during sexual intercourse, it is quite possible for a woman 
 to become pregnant, and to go to the full term of gestation, with- 
 out knowing that she is in such a condition. She may, indeed, 
 remain for some hours in labor, and yet be ignoraht that slie is 
 about to give birth to a child. The following case, which occurred 
 in my own practice, is a proof of the truth of these remarks : 
 
 I was sent for on Thursday mornino;, 17th April, 1SG2, at nine o'clock, to 
 see Mrs. 6., forty-two years of age, who had been sufFeriiio- great pain in the 
 abdomen since eleven o'clock on the preceding night. This lady had previ- 
 ously .sought my advice on some half-dozen occasions. She had last consulted 
 me at the beginning of March for an attack of indigestion, on which occasion 
 no mention was made of any enlargement of the abdomen, nor was there any 
 swelling perceptible through her dress. Her history is that she has been 
 married rather more than three years (since February, 1859), and that she 
 has never been pregnant. The catamenia were last on some time in June, 
 1861 ; but as they had been very scanty for five or sis months before, this 
 circumstance did not particularly attract her attention. In fact she attributed 
 the cessation to the change of life. 
 
 On my arrival at the patient's house I found her in bed, complaining of 
 great abdominal pain, which had kept her awake the whole night. Her hus- 
 band and mother-in-law were present, as well as a married sister who had 
 borne children. I was told that Mrs G. had not been well for a fortnight, 
 her breath having been short on making any exertion, and her legs having 
 become swollen. On Wednesday night, at eleven o'clock, she suddenly 
 began to suffer from pain in the stomach, for tlie relief of which her friends 
 applied a mustard-poultice. At two o'clock a. M. the sufferings were so great, 
 that a neighboring medical man was sent for. This gentleman was unable to 
 attend, but sent his assistant, who was said to have stated that the illness was 
 due to ■' flatulence and inflammation of the bowels." He gave a bottle of medi-
 
 58 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 cine, tlie second dose of which, however, caused sickness, and failed to afford 
 any relief. 
 
 On exauiinins; the abdomen, I discovered an oval tumor distinctly occupy- 
 in<r the right side, and extendino; fronj the pelvis to some two inches abuve 
 the uiubilicus. It seemed to be about the size of the adult head ; but althoujih 
 the abdominal parietes were thin, the tumor was by no meyns distinct to the 
 sight, though it was readily made out on palpation. On making a vaginal 
 examination I found the os uteri dilated to the size of a crown piece, and the 
 head of a foet-is entering the brim of the pelvis, with the vertex presenting. 
 The membranes were ruptured; but the patient was not conscious of any dis- 
 charge of water having taken place, and there was no appearance of moisture 
 on the bed upon which she had been lying.all night. On inspecting the 
 breasts a narrow brown areola was seen ; but it certainly did not exceed half 
 an in(di in width. When Mrs G. was asked if she had felt any movement 
 in her abdomen, she allowed that she had occasionally experienced curious 
 sensations for some weeks past, but these were attributed to flatulence. 
 During the whole period of pregnancy there had been neither sickness nor 
 any feeling of nausea. The moderate increase in size which was perceptible 
 had been attributed to the natural deposition of fat, for all the members of 
 her family are disposed to be stout. 
 
 As the pains were not violent, and the head did not advance, I left the 
 case at nine o'clock, after explaining its nature; but this explanation was 
 received with incredulity, neither the patient nor her husband having the 
 slightest suspicion that pregnancy existed. The sister, however, took steps 
 for obtaining the loan of some baby-linen, &c. 
 
 At half past one in the afternoon, when I returned, the pains of labor were 
 strong and of fre(|uent occurrence. The head was low down and the parts 
 fully dilated. After waiting an hour the violence of the pains and their 
 slisiht effect upon the foetal head led me to fear that rupture of the uterus 
 might take place, unless relief could be quickly aifordod ; and therefore I 
 applied the short f(irceps, and easily effected delivery. The child, a female, 
 was born with animation suspended ; but, by a persevering use of artificial 
 respinition, it was resuscitated at the end of half an hour. Although small 
 it seemed to be a mature infant. She has since become strong and healthy.^ 
 
 The medico-legal bearings of the foregoing cnrious case are so 
 apparent, that they need but little comment. The history, how- 
 ever, seems to establish the fact that a woman may conceive, may 
 go to the full term of gestation, and may be in labor for ten hours, 
 without having any suspicion that she is pregnant. It ought per- 
 haps to be mentioned that from all I have seen and heard of Mrs. 
 G., no doubt whatever is entertained but thatlier statements may 
 be taken as strictly true. Independently of this circumstance it 
 so liai>i>ens that both parents, though they despaired of ever having 
 a child, were most anxious for one; and the birth of the little 
 girl is, therefore, regarded as the happiest event wliich could 
 befall them. The publication of this case led Dr. J. Shortt, of 
 
 1 Transactions of the Obstetrical Society of London, vol. iv, p. 113. London, 1663.
 
 IMAGINARY PREGNANCY. 59 
 
 Chinglepnt, Madras, to forward the details of a somewhat similar 
 instance to the Obstetrical Society of London. The chief features 
 are as follows : 
 
 A. B., get 40, European. Married in India in 1844, where she has been 
 residing for the last eleven years. Has had two children, the last nine years 
 before. She had been at first actively treated by the speculum and caustic 
 for inflammation of the womb; and had likewise taken much medicine, with 
 the idea of removins; what was considered to be a dropsy of the abdomen. 
 She was in entire ignorance of her pregnant condition. The escape of a 
 watery fluid for two days was considered as evidence of rupture of the ovarian 
 cyst. At the end of the two days severe pains set in, for which she was 
 directed by a surgeon to be placed in a warm hip-bath ; opiates were given. 
 While in the hip-bath, however, delivery of a living mature child occurred, 
 to the great surprise of the patient and her friends. 
 
 The presence or absence of the hymen proves nothing with 
 regard to pregnancy; for it can be ruptured by other causes than 
 sexual intercourse, while it may continue perfect in spite of con- 
 nection, and may even remain intact until labor has set in. 
 Still it must be allowed, that although the presence of this cres- 
 centic reduplication of the vaginal mucous membrane is not a 
 reliable sign of chastity, yet the presence of a delicate and com- 
 plete hymen renders it very probable that the woman in whom 
 it exists is a virgin. When this membrane is found uninjured 
 in a pregnant woman, it will generally, but certainly not always 
 happen, that impregnation has been the result of one coitus ; and 
 hence it is much more frequently met with in girls who are the 
 victims of the seducer than in married women. ^ 
 
 Women sometimes imagine themselves to be with child when 
 they are not so ; such a mistake being most commonly made 
 about the time of "the change of life." Although this subject 
 
 ' The reader should refer to a few notes of cases where the vagina has been found 
 at the time of labor, almost completely closed by the hymen, or by an adventitious 
 membrane, extending between the labia, in A Synopsis of various kinds of Difficidt 
 Parturition, by Samuel Merriman, M.D, third edition, p. 216 to 222. London, 1820. 
 Some remarkable examples of the same kind are also related by Mauriceau, Gardien, 
 Baudelocque, Meigs, and many other authors; and further on, one will be found quoted 
 which hai)pened in the practice of Professor Rossi. In the Medical Times and Gazette 
 (p. 606, 28di May, 1864), there is a remarkable instance, in which pregnancy was de- 
 tected by Scanzoni, although the orifice of the vagina was closed by a firm and tense 
 membrane, in which an aperture only big enough to admit a probe was discovered with 
 much diflRcndty. The same journal cites a case by Dr. Mattel, where instead of the 
 vagina tliere was only a cul-de-sac, in which no opening through which semen could 
 have passed was to be detected. After severe labor for three days, the tissues in front 
 of the head gave way, and delivery was accomplished with the forceps. 
 
 y
 
 60 OBSERVATIONS ON THE STATE OF PREGNANCY, 
 
 will be found more fully treated of in the third chapter of this 
 treatise, 3'et a few remarks in the present section will hardly be 
 deemed out of place. It may be shortly said, then, that in such 
 instances the error is fostered chiefly by the following circum- 
 stances: The catamenia become irregular, or they entirely cease; 
 the breasts enlarge ; there is often nausea and vomiting ; the ab- 
 domen grows full and prominent from the deposition of fat in 
 the integuments and throughout the omentum, as well as from 
 flatulent distension of the intestines ; the appearance of a tumor 
 is produced by some abnormal action of the diaphragm and ab- 
 dominal muscles; while the movements of a fcetus are simulated 
 by the rapid passage of flatus from one portion of the intestine 
 to another. Occasionally the self-deception is carried so far, 
 that at the end of the supposed gestation, spurious pains imita- 
 tive of labor set in. Under such circumstances, the patient is 
 often apt to be both incredulous and indignant when told that 
 she is not pregnant. I remember a case which occurred in my 
 own practice, a few years since, and which may be mentioned as 
 corroborative of these remarks : 
 
 Having been previously engaged to attend a lady forty-two years of age in 
 her second labor, I received a message one evening that my assistance was 
 required immediately, as the pains had commenced. On visiting the patient, 
 I found the nurse busily engaged in airing the infant's clothes, and in assum- 
 ing all the bustling importance of a person in authority ; while the expect- 
 ant mother was walking about the room, and complaining of her suiferings. 
 On making a vaginal examination, however, I found to my great surprise 
 that the uterus was only of the normal size in its unimpregnated state, with 
 a long cervix, and the mouth and lips small and healthy. Pursuing the in- 
 vestigation still further, it became clear that she was not even pregnant; but 
 had been deceived by the natural, though early cessation of the catamenia, 
 by an excessive increase in the adipose tissue of the abdominal walls, and by 
 an abundant secretion of flatus in the intestines. I was, of course, prepared to 
 find my explanations of her condition laughed at as impossible ; for it is not 
 to be expected that when a woman has been dwelling exclusively upon one 
 idea for many weeks, she will cast it aside just at the moment she believes 
 her anticipations are about to be realized. It is due, however, to my patient 
 to add, that she did not maintain her delusion very long; since she listened 
 to a simple statement of the facts, and was apparently convinced of her mis- 
 take by the end of twenty-four hours. 
 
 Ladies are not by any means always as sensible as the one 
 whose history has just been given. Dr. Montgomery states that 
 lie has known them remain perfectly persuaded of their preg- 
 nancy for one, two, and three years; while, in one instance,
 
 VARIETIES OF REPRODUCTION, 61 
 
 both the lady and her physician assured this gentleman that the 
 movements of the child had been distinctly felt for nine years.' 
 
 9. The function of reproduction, as it is effected in the various 
 classes of animals, is one of the most interesting subjects to 
 which the attention of the j)hysiological student can be directed. 
 A superficial examination of the matter shows that there are 
 three modes in which this function is performed : (1) Fissiparous 
 multiplication^ a non-sexual mode of reproduction, in which 
 propagation is effected by the division of the parent body into 
 two symmetrical portions, or into four or six or eight or more 
 irregularly shaped masses, each of which becomes an indepen- 
 dent individual; this process being common amongst the Infu- 
 soria, and in some of the Cestoidea and Annelida. (2) Multipli- 
 cation hy gemmation, also a non- sexual form of reproduction, in 
 which the offspring arise by buds, like the parts of a tree, as is 
 seen in Vorticellse and Polyps. In this variety of reproduction, 
 the buds or sprouts either gradually assume the structure and 
 appearance of the perfect animal while attached to the parent 
 stem, afterwards being separated to enjoy an independent exis- 
 tence ; or the young are produced from small germs or buds de- 
 tached from the parent body, the evolution of the new animal 
 not beginning until after such separation, in a manner analogous 
 to the production of the foetus from the e^g in higher animals.^ 
 And (3) True generation, or sexual reproduction, consisting in 
 the union of the contents of two different cells, called respec- 
 tively the "sperm cell" and the "germ cell." The sperm cell 
 is secreted by the male organs, and the germ cell by the female; 
 and these male and female organs may exist in one individual 
 or in separate individuals. The first condition is known as uni- 
 sexual, and the second as bisexual generation. In some uni- 
 sexual, or hermaphrodite animals, self-impregnation takes place, 
 as is the case in the taenia solium ; while in other instances con- 
 course is necessary, in order that the ovules should be exposed 
 to the action of the sjDermatic fluid, as happens with many of the 
 mollusca like the common snail. In these last instances each 
 hermaphrodite animal impregnates its neighbor ; that is to say, 
 
 ' An Exposition of the Signs and Symptoms of Pregnancy, &c. By W. F. Montgom- 
 ery, M.D. Second Edition, p. 394 London, 1S56. 
 
 2 Animals which propagate by self-splitting or self-dividing, or by budding from 
 without or within, are often spoken of as parthenogenetic individuals. The term is 
 derived from TrapSivo^, a virgin, and yty^c^iAt, to be born.
 
 62 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 the male organ of each fecundates the female of the other. 
 Again, where the situation of the sexual organs on separate 
 individuals leads to the necessity for copulation, the oflspring 
 may be born alive, or they may be hatched from eggs produced 
 by the female. To the viviparous animals, the mammalia belong: 
 to the oviparous, the birds, with most reptiles and osseous fishes. 
 The distinction, however, between these two classes is more ap- 
 parent than real. For in both, fecundation of the ovum — or 
 ovule, as it is better to term it, so as to distinguish it from the 
 fecundated ovum — generally occurs within the body of the 
 female parent ; the egg, so to speak, being hatched after its ex- 
 pulsion from the oviduct. But in the one case, this hatching or 
 incubation takes place within the female body, in a special organ 
 known as the uterus ; while in the other, it occurs out of the body 
 under the influence of warmth and air. The exceptional cases, 
 in which the ovules are not fecundated within the female parent's 
 body, consist of those osseous fishes and batrachian reptiles, in 
 which there is no strict union between the sexes; the ovules or 
 spawn deposited by the female having the seminal fluid or milt 
 difiused over them by the male. Intermediate, as it were, be- 
 tween the viviparous and oviparous, are the ovo'vivijmrous ani- 
 mals ; of which the cartilaginous fishes, with certain snakes and 
 lizards, are examples. In these, the ovule is fecundated before 
 it leaves the ovary or just afterwards: in the oviduct, the ovum 
 inclosed in a vitelline membrane, receives a covering of soft 
 albumen, on which is condensed a thin and tough membrane free 
 from calcareous matter. The eggs are retained within the ovi- 
 duct until the young are able to leave them ; so that the ofispring 
 are born alive. 
 
 Among the placental mammalia the generative organs resem- 
 ble those of the human subject. In the male, we have the bun- 
 dles of seminiferous tubules inclosed in a fibrous capsule, and 
 constituting the testicle, together with the efferent duct ; to 
 which is added the penis and certain accessory glandulary struc- 
 tures. On the part of the female, there is the ovary with its 
 Graafian follicles or ovisacs, in which the ovules are developed 
 and prepared for fecundation ; together with the parovarium or 
 remains of the Wolffian body, the Fallopian tube or oviduct, the 
 uterus, and the vagina. Each ovule is invested with a homo- 
 geneous tissue, called the zona pellucida, or vitelline or yolk-
 
 SPERM CELLS AND GERM CELLS. G3 
 
 membrane, witliin which is the yolk, with its germinal vesicle 
 containing the germinal spot. The ovule is about the j ^^tli, and 
 the germinal spot about the yoVo^^^ of an inch in diameter. The 
 spermatic filament, or spermatozoon, or sperm cell of man is 
 about 5^0^^ of an inch long and about 50^00^^ of an inch wide at 
 the head. It is now regarded in the light of an epithelial cell — 
 or rather as its nucleus — modified in structure, and endowed with 
 peculiar properties. The originally received notion of its animal 
 nature is placed without the bounds of speculation. The move- 
 ments of the spermatozoa continue longer in the interior of the 
 female organs of generation than in any other situation. The 
 researches of Mr. Newport on the ova of the frog, prove that im- 
 pregnation does not take place unless the spermatozoon actually 
 passes through the vitelline membrane, and comes into imme- 
 diate contact with the yolk-s ubsta nce. 
 
 The exact nature of the influence communicated by the sper- 
 matozoa to the ovule is an enigma which has not yet been solved. 
 Philosophers, however, are chary of confessing their fallibility; 
 and hence many and strange are the opinions which have been 
 put forward as a cloak for ignorance. Yet the errors which seem 
 unavoidably to belong to the early stage of almost all scientific 
 investigation may — if rightly studied — serve for something more 
 than mere amusement. Just as the search by the alchj^mists for 
 means whereby they might transmute the baser metals into gold 
 has been productive of some most important and varied chemical 
 facts, so inquiries into the inexplicable ultimate cause of all vital 
 functions has at least increased our knowledge of the various 
 processes of the phenomena of life. Drelincourt, in his Opuscula 
 Medica, published in 1727, prefaced his theory of generation by 
 showing that two hundred and ^xty-two groundless hypotheses 
 had already been proposed ; and as Blumenbach naively remarks, 
 " Nothing is more certain than that Drelincourt's own theory 
 formed the two hundred and sixty-third." Some of these conceits 
 are perhaps sufficiently extraordinary to demand a passing notice. 
 Thus, Pythagoras thought that a vapor descended during coition 
 from the brain and nerves of the male, from which these parts 
 were formed in the embryo ; the grosser tissues being composed 
 of the blood and humors contained in the uterus. He considered 
 also that the foetus was formed in forty days ; but that seven, nine, 
 or ten months were required for its perfection. Empedocles
 
 64 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 imagined that some portions of the embryo were contained in the 
 semen of the male, and others in that of the female ; the child 
 being formed by the union of the two. The opinion of Hippoc- 
 rates also was, that conception took place in the uterus by the 
 mixture of due proportions of the male and female semen, in 
 which the organic principles of the embryo were equally con- 
 tained ; the sex of the offspring depending upon whether the male 
 secretion was more powerful than the female's, or vice versa. 
 Aristotle taught that the material parts of the embryo were formed 
 by the catamenial blood, and that the' male semen imparted the 
 principle of life when the body was formed. Making a long stride 
 over many centuries, we find Descartes and his followers believing 
 that when the male and female seminal fluids were mingled, a 
 fermentation took place and a foetus was fbrmed. The experi- 
 menters in chemistry would have it, that the male secretion being 
 acid, and that of the female alkaline, a double decomposition took 
 place on their mingling, so that a foetus was precipitated. Then, 
 lastly, we have Ludwig Hamm in 16G7, and a few months sub- 
 sequently Leeuwenhoek, asserting that an immense number of 
 animalculae exist in the semen of all male animals, and that they 
 contain the perfect rudiments of a future animal, each of its own 
 kind ; and that these animalcule merely require from the female 
 a proper nidus or habitation, and suitable nourishment. The 
 discovery of the movements of the minute seminal particles 
 seemed to confirm this theory ; while some writers even held that 
 these supposed animalcules were of different sexes, and that they 
 copulated so as to engender male and female offspring. 
 
 Leaving these fancies of a bygone age, I would add a few words 
 upon the immediate signs by which many obstetricians of the 
 present day consider it may be jnferred that a woman has con- 
 ceived. Although undeserving of much attention, the phenomena 
 which have been relied upon for centuries are as follows : A sense 
 of greater voluptuousness, a more general erethism is experienced 
 during the fruitful coition by both parties, but especially by the 
 female ; a slight rigor or spasm or feeling of contraction is ex- 
 cited, followed by an indescribable pleasure, which is again suc- 
 ceeded by a sense of languor and depression ; while the seminal 
 fluid is retained, instead of passing away by the vaginal orifice. 
 Sometimes a sonsatioii like colic is felt in the umbilical region, 
 with pain in the pelvic and lumbar regions ; and a feeling as of
 
 PRIVILEGES OF PREGNANT WOMEN. 65 
 
 congestion and slight weight in the uterus occurs, with a tendency 
 to nausea. In a day or two there may be neuralgic tenderness 
 of the cutaneous surface of the abdomen, with a variable amount 
 of tumefaction ; as well as a general excitement of the vascular 
 sj^stem, with a disposition to feverishness. The eyes become 
 more sunken and languishing, their brightness diminishes, and a 
 bluish circle appears round the orbits ; and there is often a 
 peculiar softness and trifling lividity of the features. One author, 
 M. Mangars, has said that it is a sign of conception when the 
 seminal odor is appreciable to the taste; but some foreign writers 
 seem to take a pleasure in suggesting anything that is grossly 
 extravagant. 
 
 10. When a woman has become pregnant she should be treated 
 with watchful solicitude and tenderness by those immediately 
 around her, and more particularly so the nearer the time of her 
 suffering draws nigh. In all ages the state of utero-gestation has 
 secured certain privileges to the female. Paris and Fonblanque 
 remind us* that the Athenians spared the murderer who took 
 refuge in her dwelling. The ancient kings of Persia presented 
 pieces of gold to every woman in this condition. In Egypt, the 
 woman condemned to die was nevt-r executed till after her de- 
 livery ; while even the Jews relaxed the rigid commandments of 
 the Mosaic law and allowed prohibited viands to the pregnant 
 female, whose fastidious appetite might make them articles of 
 desire. The fact is undeniable that pregnancy increases the 
 general susceptibility and alters the disposition. It may give rise 
 to a weak self-indulgence in wayward and capricious fancies ; 
 whilst the most amiable are often rendered by it extremely irri- 
 table, particularly under any attempt at control or contradiction. 
 In many, also, the anticipation of the pains and dangers of labor 
 is the cause of much mental uneasiness, or even of great des- 
 pondency; the depression rather increasing than diminishing 
 with each gestation. The respectful deference which is commonly 
 shown to women in civilized countries at all times, is now there- 
 fore more especially demanded ; wiiile a little forbearance and 
 gentleness and persuasion will do much more than rudeness or 
 harshness in making the future mother conceal any infirmity of 
 temper, as well as in enabling her to assume a calm and cheerful 
 deportment.
 
 66 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 These remarks will possibly be deemed unnecessary by some of 
 my readers, but it is often far from unprofitable to repeat borne 
 truths. No doubt pregnancy and parturition are perfectly natural 
 conditions; and certainly very many individuals can be found 
 who are able to go through both with almost as much ease as the 
 women of rude and savage nations are supposed to have formerl}^ 
 done. We know that many barbarous customs were prevalent in 
 days long gone by, but we cannot learn to what extent the victims 
 of these habits died. Thus Bruce, in describing the inhabitants 
 of Galla, in Abyssinia, curtly observes: "The w^omen are said 
 to be very fruitful. They do not confine themselves even a day 
 after labor, but wash and return to their work immediately. 
 They plough, sow, and reap."^ Even in the present day, accord- 
 ing to Dr. John Batty Tuke, the process of parturition among 
 the Maori women is not the dreaded ordeal which it is amongst 
 more civilized nations. When the native feels that her time has 
 come, she retires alone to a creek or brook, preferring one that 
 flows through the bush. There she gives birth to her child, per- 
 forming the necessary duties herself. On the coi'jjpletion of 
 labor, she steps into the water, washes herself and infant and 
 clothes ; and then proceeding to her tvJiare or hut, reappears with 
 the babe in the family circle, as if only a matter of slight moment 
 had occurred. Her female friends never interfere unless assist- 
 ance is solicited. "I have seen," says Br. Tuke, "a w^oman 
 quietly leave the house, and reappear within the hour with her 
 baby in her arms, and surrounded by her congratulating rela- 
 tives." The umbilical cord is never tied, merely twisted. The 
 result is, that umbilical hernia is very common. But Dr. Tuke 
 adds that nial-presentations are by no means unknown, and when 
 nature cannot relieve the patient, death necessarily results. The 
 usual treatment under such circumstances consists in scarifying 
 the abdomen, and the employment of charms and incantations. 
 " This practice is, like some in more civilized nations, more war- 
 ranted by antiquity than success."^ Still more extraordinary 
 stories are told by ancient travellers. Diodorus, the Sicilian — the 
 contemporary of Csesar and Augustus, and who ti'avelled over a 
 great part of Europe and Asia before writing his Universal Ilis- 
 
 ^ Travels to Discover the Source of the Nile. By James Bruce. Vol. iv, p. 408. Edin- 
 lHirf.'li, 17U0. 
 
 - Medical Notes on New Zealand. Edinburgh Medical Journal, vol. ix, p. 724. 
 February, 18^4.
 
 DIMINISHED MORTALITY OF CHILDBIRTH. 67 
 
 toiy — speaking of the Corsicans, tells us: "A very strange thing 
 there is among them concerning the birth of their children. 
 When the woman is in labor, no care is taken of her in the time 
 of her travail ; but the husband goes to bed, as if he were sick, 
 and there continues for certain days, as if he were suffering the 
 pains of a woman in travail."^ So also Strabo relates of the 
 Iberian women, that "they till the ground, and after parturition, 
 having put their husbands instead of themselves to bed, they 
 wait upon them."^ And if we are to believe the statement of a 
 former Bishop of !N^orwich, these manners were not quite extinct 
 at the end of the last century ; for Dr. Home remarked that — " In 
 Kardan, a province of Tartary, as soon as a woman is delivered, 
 she rises, washes, and dresses the child. Then the husband, 
 getting into bed with the infant, keeps it there forty days, and 
 receives visits as if he had lain in."^ I have also heard that this 
 practice is still adopted among the Basques of Spain ; and that a 
 like custom prevails with some of the Indians of South America. 
 Now although it may be well supposed that no change of fashion 
 can ever introduce these manners into any part of civilized Eu- 
 rope, yet it is not as certain that we shall not draw false conclu- 
 sions from reasoning upon them. As I before remarked, we have 
 no means of learning what proportion of women formerl}- died 
 in childbirth. But we happily can tell, that as our knowledge of 
 physiology and pathology has increased in modern times, so the 
 mortality of parturition has certainly, in this country at least, 
 lessened. Not to weary the reader with long proofs of this, it 
 will suffice to mention that the annual deaths in childbirth, in 
 London, in the years 1660-79, were 86 for every 100,000 inhabi- 
 tants; whereas in 1859 the numbers were only 17 for the same 
 proportion.'' Moreover, it has been shown again and again, by 
 Dr. William Farr, in letters to the Registrar-General, that the 
 mortality during childbirth in England and Wales is steadily 
 diminishing. For instance, in the year 1847, the birth of every 
 
 1 Diodori Siculi, Bibliothecoe HistoriccE. Liber v, cap. 5, p. 139. Basilese, 1578. 
 
 2 The Geography of Strabo. Book iii, chap. 4. Bohn's Edition, vol. i, p. 2-17. Lon- 
 don, ] 854. 
 
 ^ Memoirs of the Life, Studies, and Writings of Dr. George Home, late Lord Bishop 
 of Norwich, &c , p. 405. London, 1795. 
 
 * The Twenty-second Annual Report of the Registrar-General of Births, Deaths, and 
 Marriages in England, p. 36. London, 1861. The reader may likewise be particularly 
 referred to a table showing the average number of deaths in childbed in London from 
 the year 1660 to 1819, contained in Dr. Merriman's Synopsis of the Various Kinds of 
 Diflicult Parturition, &c. Third edition, p. 3:i3. London, 1820.
 
 68 OBSERVATIONS ON THE STATE OF PREGNANCY. 
 
 10,000 living- children was the death of 60 mothers ; in 1848, of 
 61 ; in 1849, of 58 ; and so gradually downwards, until in 1857 
 only 42 mothers died to every 10,000 live births. Unfortunately 
 the decline has not been progressive. The number of deaths to 
 the same proportion of births, runs thus: 48 in the year 1858; 
 51 in 1859; 46 in 1860; 43 in 1861; 48 in 1862; 49 in 1863; 
 and 54 in 1864, during which year 740,275 children were born 
 alive. That the mortality in childbirth is still so large, should 
 not be allowed to escape the notice of the practitioner of ob- 
 stetric medicine. The number of deaths registered in England 
 during 1864, as due to childbirth, was 2532; this number not 
 including 1484 fatal cases of puerperal fever (metria), nor 460 
 deaths after childbearing from diseases not incidental to parturi- 
 tion, though possibly aggravated by it. How to lessen such a 
 mortality as this for the future, ought to be a subject of serious 
 reflection with us all. For my own part, I cannot but believe 
 that some advance may be made in this direction by discouraging 
 the marriages of young women before their growth is complete, 
 and before their organs are fully developed ; as well as by paying 
 greater attention to the general health during the whole period of 
 pregnancy. Seeing that several zymotic diseases have a somewhat 
 more fatal tendency when they occur during gestation, the greatest 
 care is necessary by sanitary arrangements and measures against 
 contagion to guard the pregnant women from the influence of 
 epidemic disorders. And then, instead of attempting to harden 
 the system, instead of allowing the pregnant woman to toil and 
 endure anxieties and hardships beyond her strength, we should 
 try to soften her lot as much as possible, and to avert as far as 
 may be the law — " in sorrow thou shalt bring forth children." It 
 has sometimes been erroneously thought that because the par- 
 turient process in domesticated animals is easy or diflicult in 
 proportion as tliey are subjected to a life of toil, so a similar law 
 must apply to the human subject. But the experience of every 
 obstetrician who has practised both in St. Giles's and in St. James's 
 will rebut this opinion. The cow in the country farm, living 
 unfettered in the meadow until the day of calving, has in general 
 a safe and easy labor. The poor beast, on the contrary, whicli 
 is kept in a town dairy has a time so incredibly dangerous, that 
 the proprietor generally sells ofi' his stock every year, and re- 
 places it with cows in calf; such cows not being put into the stalls
 
 DIxMINISHED MORTALITY OF CHILDBIRTH. 69 
 
 till within six or eight days of the expected period of parturition. 
 The correct deduction from this is, that an artificial mode of 
 life — a life maintained by improper food, and without a sufiicient 
 supply of pure air, or a due amount of exercise — has a most dele- 
 terious influence upon the process of labor; and not that a toil- 
 some existence, embittered with all the pains and anxieties of 
 poverty, gives comparative immunity from danger in the hour of 
 parturition. 
 
 The only other step that can be recommended, in addition to 
 the measures already advised, to render the time of pregnancy 
 and labor in women less dangerous than it is now, is to lay the 
 foundation of a sound and vigorous constitution in early life. If 
 the present race of mothers can but be taught to rear and educate 
 their girls in accordance with the simple teachings of physiological 
 science and sound common sense, the future mortality in child- 
 birth will be materially lessened. Instead of being so anxious to 
 provide their children with wealth, and to make them worldly- 
 wise or fashionable or even l,earned at any cost, let the parents 
 consider how much more important it is to devote some time and 
 attention to securing for each of them a sound and robust con- 
 stitution. Let them take care to note in time, the truth of those 
 wise words of the son Sirach, that — " Health and good estate of 
 body are above all gold, and a strong body above infinite wealth."
 
 70 THE SIGNS AND SYMPTOiAIS OF PREGNANCY. 
 
 CHAPTER 11. 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 Section 1. The classifications which are usually adopted — A table of the symp- 
 toms AND signs op pregnancy. 
 
 Section 2. Suppression of the catajienia — Puberty and menstruation. 
 
 Section 3. Nausea and vomiting — diarrh(ea and salivation. 
 
 Section 4. Mammary sympathies — The areola, secretion of milk, etc. 
 
 Section 5. Enlargement of the abdomen — Position of the uterus at different 
 periods of pregnancy. 
 
 Section 6. Movements of the fcetus — Quickening and its causes. 
 
 Section 7. Changes in the uterus — Dimensions of this organ at the various 
 months. 
 
 Section 8. Ballottement or 'repercussion. 
 
 Section 9. Signs derived from auscultation — The foetal movements — The funic 
 pulsations and funic souffle — The uterine souffle — The fcetal heart. 
 
 Section 10. Minor signs — Kiestein — Contractile power of the gravid uterus — 
 Discoloration of vagina — Examination of the blood — Vaginal temperature — 
 The vaginal mucus — Shape of the os uteri — Vaginal pulse — Occipital head- 
 ache — Certain physical and moral changes. 
 
 Section 1. — Classification of the Signs of Pregnancy. 
 
 The division of the signs of pregnancy into classes appears to 
 have been a favorite custom with most authors. In France, the 
 almost universal subdivisions which are adopted seem to be into 
 the rational and the sensible signs. The first class includes those 
 characters usually pointed out as existing in the earliest periods, 
 — such as the suppression of the menses, the enlargement of the 
 abdomen, the darkening of the areola, the functional disturb- 
 ances in the digestive organs, the modifications in the urine, and 
 the changes in the general habits as well as in the moral and 
 intellectual faculties ; while in the second category we find those 
 signs which are derived from the practice of the touch, or of aus- 
 cultation. In Germany, some of the most esteemed writers speak 
 first of those signs which are to be detected only by a physical 
 examination ; and secondly, of such as result from the derange- 
 ments of particular functions. The authorities of Great Britain 
 are wanting in unanimity as to a sj'stem of classification, and
 
 CLASSIFICATION OF THE SIUNS. 71 
 
 each teacher strives to put forward a different scheme. Thus, 
 Dr. Evorj Kennedy speaks of — (1) those signs ascertained through 
 the representations of the individual supposed to be pregnant, — 
 such as Uie pelvic and lumbar pains, morning sickness, menstrual 
 suppression, mammary pains, vitiated tastes, &c. : (2) the evi- 
 dences which are tangible to the practitioner, — particularly the 
 state of the hymen, the changes in the os uteri, ballottement, and 
 the condition of the abdomen : (3) the visible evidences, — as the 
 appearance of the areola, the emergence of the umbilicus, the dis- 
 colorations of the skin, the swelling of the limbs, and the vari- 
 cose state of the veins: and (4) the audible evidences, — or those 
 which are detected by mediate or immediate auscultation. Dr. 
 Montgomery classes the signs into three groups, — the presump- 
 tive, the probable, and tlie unequivocal. Many of the sympathies 
 included in the first class may arise from uterine irritation equally 
 with pregnancy, since they consist chiefly of constitutional affec- 
 tions ; in the second class are included the symptoms which are 
 due to the altej;ed Condition of the uterus itself, which, increas- 
 ing in size, ceases to be a pelvic organ, and rises into the abdo- 
 men ; w^hile, under tlie head of unequivocal symptoms, are placed 
 those which are produced by the movements of the foetus, as 
 well as the signs derived from the practice of auscultation. Dr. 
 Rigby considers — (1) the general effects which pregnancy pro- 
 duces upon the system; and (2) the changes and phenomena 
 that are peculiar to this state, and which may therefore be taken 
 as so many means of diagnosis. Dr. Blundell treats of those 
 phenomena which are of ordinary occurrence ; those which are 
 rare or anomalous ; and those which are common to all women, 
 but which can be ascertained solely by means of a careful manual 
 examination. Dr. Churchill groups together the earl}' evidences 
 of pregnancy, and afterwards the indications of more advanced*' 
 gestation. 
 
 Not to push this uninteresting inquiry further, I shall content 
 myself by remarking, that no classification can be proposed with 
 which some fault may not readily be found ; and that even if a 
 perfect subdivision could be laid down, it seems to me that it 
 would be useless. In the dail}^ practice of the obstetrical por- 
 tion of his profession, the physician must have his knowledge so 
 arranged in his mind — so, in every sense of the phrase, at his 
 fingers' ends — that he can immediately apply it to the particular
 
 72 THE SIGNS AXD SYMPTOMS OF PREGNANCY. 
 
 case before him ; and tins will be best accomplished by each one 
 making himself fully acquainted with the subject in all its bear- 
 ings, and then, if he should find it necessary, forming such divi- 
 sions and subdivisions as the bent of his own judgment will 
 readily suggest. 
 
 A very remarkable and progressive increase in the vital actions 
 of the generative system is manifested almost immediately after 
 a woman has conceived. As might be expected, this is shown 
 chiefly in the uterus. But it is also exhibited, though to a lesser 
 extent, in the striking metamorphosis of the Graafian follicle, or 
 ovisac, which has discharged the ovule, into a true corpus luteum ; 
 as well as h\ the congestion and tenderness of the mammjie which 
 ensue. The uterus not only acquires a principle of growth, but 
 its walls are rendered very vascular; the tissue of this organ gets 
 infiltrated with serum, while the mucous membrane becomes 
 greatly thickened ; and the cervix and labia consequently pre- 
 sent a peculiar velvety feel, not unlike that presented by an 
 abraded os. In time, as the womb gradually expands and 
 slowly rises out of the pelvic cavity, it disturbs the relations of 
 the abdominal viscera. The bladder — being supplied, like the 
 uterus, with nerves from the h3q:)ogastric and sacral plexuses — 
 first suffers. This organ becomes irritable, so that a frequent 
 troublesome desire to micturate is manifested ; wdiile in the latter 
 stages of gestation, w^hen the pressure and weight of the womb 
 are considerable, great inconvenience is ordinarily experienced 
 from an inability to retain the urine, wdiich comes away involun- 
 tarily on coughing or laughing or even walking. Moreover, as 
 soon as the uterus has acquired considerable size, it necessarily 
 begins to interfere with the circulation, and particularly ^^'ith 
 that through the veins ; producing more or less anasarca of the 
 feet and legs by its pressure on those venous trunks which re- 
 turn the blood from the lower extremities. In the same way, the 
 foundation is laid for intractable varicose veins and troublesome 
 piles ; though in the production of the latter the pregnancy may 
 have a smaller share than that congestion of the hemorrhoidal 
 veins which results from constipation. So, also, from the pres- 
 sure on tlie pelvic nerves, numbness and cramps are experienced 
 in the thighs and legs ; and occasionally' evert, a temporary form 
 of paralysis results from this cause. By the time the uterus has
 
 EPITOME OF THE SYMPTOMS. 73 
 
 acquired its full growth, it looks as if it occupied almost the whole 
 of the distended abdominal cavity ; while by pressing the liver 
 and stomach against the diaphragm it diminishes the capacity of 
 the chest, impedes the action of the lungs and heart, and occa- 
 sionally produces a considerable amount of dyspnoea. Some- 
 times the uterus, as it expands and stretches the abdominal 
 parietes, causes a separation between the recti muscles, — perhaps 
 to the extent of tw^o or even three inches ; this abnormal chink 
 contracting after delivery, though the sides never come into as 
 close apposition as they were originally. The umbilical ring also 
 is likely to become dilated, leaving a predisposition to hernia at 
 this part. And not uncommonly, pain is complained of on either 
 side, just below the false ribs; this pain, which at times is very 
 acute, being consequent on the dragging of the abdominal mus- 
 cles at their insertions. 
 
 In addition to these mechanical effects, the new action in the 
 uterus induces certain changes which are to be regarded as symp- 
 toms of pregnancy. Prominent amongst these are suppression 
 of the menses, nausea and sickness and other disturbances of the 
 digestive organs, increased irritability of the nervous system, 
 peculiar alterations in the tastes and disposition, and various 
 neuralgic pains. Equally remarkable are the appearances pre- 
 sented by the mammary areolae, the enlargement and extra firm- 
 ness of the breasts, and the secretion of a small quantity of milk ; 
 the alterations in the countenance, resulcing either from an in- 
 crease in the adipose tissue or from absorption of the fat ; and 
 the change in the hue of different parts of the skin, as well as in 
 the deepening of the color of the vaginal mucous membrane. 
 Generally, on making a vaginal examination, strong pulsations 
 can be felt in the arteries of the lower part of the uterus. Any 
 of the foregoing conditions may, however, be present indepen- 
 dently of pregnancy ; though it is certain that if they all coexist, 
 they are very much more likely to be the result of utero-gesta- 
 tion than of any combination of local and constitutional disease. 
 At the same time it must be granted, that the only certain signs 
 of pregnancy are, — the detection of the active movements of the 
 child, positively feeling the presence of the foetus in utero by 
 ballottement, and the discovery of the pulsations of the foetal 
 heart by auscultation. 
 
 Before proceeding to the consideration of the symptoms and
 
 74 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY, 
 
 signs of pregnancy seriatim, it will probably facilitate their study 
 to glance at the chief of them as they are arranged in the follow- 
 ino; tabular form : 
 
 A Table of the Symptoms and Signs of Pregnancy. 
 
 Term of Preonancy. 
 
 W 
 
 ■p 
 
 o 
 
 + 
 + 
 
 + 
 
 ? 
 
 i 
 
 C M 
 'a. C 
 
 p 2 
 
 + 
 
 3 <i 
 
 + 
 + 
 + 
 + 
 + 
 + 
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 a i 
 
 0) o 
 
 a <w 
 
 ^ o 
 
 + 
 + 
 + 
 + 
 + 
 + 
 
 _ o 
 
 si 
 s 
 
 ? 
 
 + 
 + 
 
 o 
 bD . 
 
 a X 
 "a > 
 
 + 
 
 a 
 
 i 
 
 + 
 + 
 + 
 + 
 ? 
 
 |l 
 ■£ o 
 
 ato 
 
 '? 
 
 + 
 + 
 + 
 + 
 
 + 
 + 
 
 1 
 
 + 
 + 
 + 
 
 + 
 + 
 
 O 
 
 3 n 
 ,c .2 
 
 >, 5i 
 .a a 
 
 3 
 
 Q 
 
 ? 
 
 + 
 + 
 + 
 
 + 
 + 
 + 
 
 End of First Month, . . 
 " Spcond " 
 " Third " . . 
 " Fourth " . . 
 " Fifth " . . 
 " Sixth " . . 
 " Seventh " . . 
 " Ei2:hth " . . 
 " Ninth " . . 
 
 This table reads thus : At the end of the third calendar month 
 the symptoms and signs of pregnancy are, morning sickness, sup- 
 pression of the menses, the development of the mammary areola, 
 perhaps enlargement of the abdomen, possibly the uterine souffle, 
 and may-be a dusky hue of the vagina. Again the table shows 
 that, at the end of the eighth month, we may expect to find sup- 
 pression of the menses, increased development of the areola, en- 
 largement of the abdomen, foetal movements, perhaps ballotte- 
 ment, the uterine souffle, the foetal heart, and a dusky hue of the 
 vagina. 
 
 Section 2. — Suppression of the Menses. 
 
 The exact value to be attached, as a symptom of pregnane}^ to 
 the circumstance that the menses have become suppressed, can 
 scarcely be explained without some brief preliminary remarks. 
 Hence, a few observations on the accession of puberty in the 
 male and female will hardly be deemed out of place. It is neces- 
 sary to premise, however, that the time of puberty is not to be 
 confounded with the epoch of the perfect development of the 
 organization, when the stature has ceased to increase and ossifi- 
 cation is completed. This epoch in man is probablj^ not attained 
 until the twenty-fifth year. In woman, the age of nubility — 
 when by the development of her frame and intelligence she is
 
 SUPPRESSION OF THE MENSES. 75 
 
 fitted to bear healthy and vigorous children, and is competent to 
 discharge all the duties of a mother — is reached at a period vary- 
 ing from the nineteenth to the twenty-second year. 
 
 In the male^ puberty occurs about the sixteenth year, and is 
 marked by an increase in the tone of voice, by augmented de- 
 velopment and symmetry of the limbs, by the growth of hair on 
 the face and pubes, by a greater development of the genital or- 
 gans, and by the formation of perfectly formed spermatozoa in 
 the testes. 
 
 In the human female, the accession of puberty at about the 
 fifteenth year is characterized by an exaltation of the mental 
 powers, by an increased development of the body generally, by 
 enlargement of the breasts, by the growth of hair upon the mons 
 veneris, and especially by the appearance of the menses or cata- 
 menia — Kara, according to ; iirf^, a month. The power of procre- 
 ation continues for about thirty or thirty-five years; viz., from 
 the time of puberty until the decline of menstruation — "the 
 change of life," — at about forty-five to forty-eight or fifty years 
 of age. In the intermediate years between puberty and the 
 change of life women suffer from a sanguineous flow — the cata- 
 menia, menses, or courses — every lunar month, except during 
 the periods of lactation and pregnancy ; the menstrual discharge 
 appearing every twenty-eight days, counting from the beginning 
 of one period to the commencement of the next. As each period 
 lasts, on an average, four days, the interval is of course about 
 twenty-four days. This it must be observed is the rule, but it is 
 a rule which has numerous exceptions. Many healthy women 
 have an interval of thirty or thirty-one days between each period ; 
 while others, on the contrary, are unwell every three wrecks. I 
 have sometimes seen such women subjected to very unnecessary 
 medical treatment; the practitioner forgetting that his patient 
 was " regular" so long as her periods recurred at the times to 
 wdiich she was habituated. In tropical climates the menses ap- 
 pear about two years earlier than in this country ; and about one 
 year later in cold northerly latitudes. Puberty, also, in both 
 sexes, is hastened by luxurious and indolent habits, by high 
 living, and perhaps by residence in large tow^ns. It is probable 
 that in at least two cases out of every three, primary menstrua- 
 tion is unattended with any pain. And it is certain, that as a 
 rule, strong and healthy women menstruate more sparingly than
 
 76 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 anaemic or strumous girls ; many females with a tendency to 
 tuberculosis having a copious watery — perhaps almost colorless 
 — catamenial flow for eight or ten days. 
 
 The menstrual fluid consists of pure blood, which becomes 
 mixed with mucous and epithelial cells in its flow through the 
 cervix uteri and vagina. It is of alkaline reaction in the uterus; 
 and if, owing to contraction of the os, it be retained in the uterine 
 cavity, it coagulates, and is expelled in the form of small clots. 
 When it becomes mingled with the secretions of the vagina, 
 however, it is rendered acid ; and it is this acidity which prevents 
 the menstrual blood from coagulating, and not, as was errone- 
 ously supposed, an absence or diminution of fibrine. The 
 quantity of the menstrual discharge at each period varies ; but 
 it may be stated that from four to six ounces is the average.' 
 The source of the flow is chiefly the mucous membrane of the 
 body of the uterus; and perhaps, in a less degree, the lining 
 membrane of the Fallopian tubes. It is still a disputed point 
 whether the discharge is a secretion from the mucous membrane 
 of the uterus and tubes, or simply a mechanical filtration of 
 blood owing to great congestion. The latter view is the one 
 which commends itself to my judgment; but some authorities 
 are of an opposite opinion. On a more important question, how- 
 ever, there is less uncertainty ; for it may now be said to be a 
 recognized fact in physiology, that during menstruation — as 
 during the rut or heat of animals — Graafian vesicles are ruptured 
 and ovules discharged.^ At the same time it must not be over- 
 looked, that a discharge of blood from the uterus is not neces- 
 
 1 A great variety of opinion lias existed upon this point. Hippocrates tlionght that 
 the (jreek women lost twenty ounces at each period. Galen supposed it to be eighteen 
 ounces in the Romans. Haller says it yaries from eight to twelve ounces for German 
 women. Du Hahn fo(md, as the result of many careful experiments, that some women 
 evacuated tliree ounces, others four or Ave, and very few ten ounces, unless the lUerus 
 was diseased. Baudelocque estimates it as three or four ojur^es for the French, though 
 Magendie thinks it is often much greater Fitzgerald regards it as amounting to four- 
 Teen or fifteen ounces in Spanish women. In Holland, according to Gorter. the dis- 
 charge does not exceed six ounces. Dr. Meigs states that lie is confident that many 
 healthy American women lose fully twenty-one ounces as the regular and normal 
 elimination; wiiile in England authorities calculate that it varies from three to tea 
 ounces, tliougli — as stated in the text — from four to six oiuices is probably the average. 
 
 2 Mr. Roberton has pointed out the curious circumstance that the Hindu lawgivers 
 have long since acted upon this notion; for it is enjoined in the Hindu Shastras, that 
 females be given in marriage bef()re their first menstrual discharge, and that should 
 marriage not take place until after this event, then the ceremony is regarded in a sinful 
 light. Moreover, Atri and Kasyapa (Hindu sages) state, "that if an unmarried girl dis- 
 charges tlie menstrual fluid at lier father's house, the father incurs a guilt similar to that 
 of destroying a fuetiis, and the daughter becomes Bfisulee, or degraded in rank."
 
 ANATOMY OF A GRAAFIAN VESICLE. 77 
 
 sarily a menstruation ; for while the latter is a natural and healthy 
 function, the former frequently occurs as the consequence of 
 local or constitutional disease. Neither should it be inferred, 
 that during each menstruation the rupture of a Graafian vesicle 
 necessarily takes place; or, on the other hand, that a vesicle may 
 not rupture without any external flow of blood. It is only by 
 allowing that the ovarian portion of menstruation may occasion- 
 ally occur without the uterine part, that those rare cases can be 
 
 SECTION OF A GRAAFIAN VESICLE FROM THE HUMAN OVARY. (After Valentin.) 
 
 At a is the follicular membrane, which everywhere incloses Ihe vesicle. The greater part of the 
 cavity 6 is filleJ up by a peculiar honiojieneous fluid. A proper tnewlrana granvlufci, c. covers almost 
 all the inner .surface ot the follicuhir membrane. The highest part of the fullicular cavity is occupied 
 by the very minute ovule/j/ /i ; which is everywhere surrounded by a ring or girdle, e. called the z<ma 
 pelliicicla. The discus pridiyerus, d, arises from a thickening ot the aiembiana granulosa in the neigh- 
 borhood of the zone e The'ovule it.-elf contains the yolk or vitellus,/, the germinal vesicle, £r, and the 
 germinal spot, h. 
 
 explained in which pregnancy has occurred prior to any men- 
 strual flow, or in which pregnancy has taken place during lacta- 
 tion without the return of the monthly periods. 
 
 On making a section of the human ovary, it is found to contain 
 numerous transparent vesicles, those nearest the surface of the 
 organ being larger thau the deeper-seated ones. These cells are 
 the Graafian vesicles or follicles. Each contains a minute ovule 
 or egg. Each vesicle consists of a closed globular sac, having a 
 fibrous and vascular wall known as the follic ular membrane. This 
 membrane has a lining of fine granular cells, termed the 7nem- 
 brana granulosa ; the part of this layer nearest the surface being- 
 thicker than elsewhere, and being termed the cumulus proliger us, 
 or discus proligerus. In th^ centre of this circular mound is the 
 egg or ovule, surrounded by a ring called the zona pelhicida. As 
 the time approaches for the discharge of the ovule, the vesicle 
 enlarges and projects from the surface of the ovary. Finally,
 
 78 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 the vesicle ruptures; the serous contents rush out with the ovule; 
 and the latter, entering the fimbriated extremity of the oviduct, 
 begins its passage to the uterus. At the same time, the old fol- 
 licular cavity becomes filled with serum or blood, leading to the 
 formation of that dense yellow globular mass vdiich is known as 
 the corpus luteum. 
 
 In the human female the ovule is supposed to escape towards 
 the termination of the catamenial flow ; and sometimes one, or 
 even more, will be discharged from each ovary. The time oc- 
 cupied by the descent of the ovule through the Fallopian tube 
 and uterus is possibly eight or ten days, though nothing positive 
 can be said on this head. During this passage it either perishes, 
 if no fruitful sexual intercourse takes place ; or, on the contrary, 
 it becomes impregnated by the nuclei of the sperm cells — sper- 
 matic filaments or spermatozoa — of the male, and so gives rise 
 to the formation of the embryo. From all that has been ob- 
 served during the last few years, it seems most likely that the 
 material contact of the male and female generative elements, in 
 the human subject, takes place in the uterus; which organ must 
 therefore be regarded as the normal seat of conception. It is 
 probably only in exceptional cases, and as the result of some ac- 
 cident, that the spermatozoa reach the Fallopian tubes or traverse 
 them to the ovaries ; although this very commonly happens in 
 several of the lower mammalian animals. The researches of Mr. 
 ITewport on the ova of the frog confirm the opinion put forward 
 by Dr. Martin Barry in 1843, that impregnation does not take 
 place unless the spermatozoa actually pass througli the zona pel- 
 lucida, or bounding membrane of tlie ovule, and get into imme- 
 diate contact with the germ mass, in which they become lique- 
 fied. What is the nature of the force communicated by the 
 spermatozoon to the germinal vesicle or germ cell of the ovule, 
 we cannot tell. All that we know is, that those marvellous 
 changes in the ovule which lead to its conversion into the ovum 
 and the development of life, cannot take place without the agency 
 of the sperm cell. 
 
 To return from this digression, it may be remarked that the 
 suppression of the menses is generally looked upon as the first 
 reliable symptom of pregnancy; which, from its almost uniform 
 occurrence, is constantly used by women as the test of conception,
 
 MENSTRUATION DURING PREGNANCY. V'J 
 
 and also as affording the best means of calculating tlie date of 
 parturition. Too much confidence, however, must not be placed 
 upon this symptom ; for many circumstances tend to render it 
 inconclusive. Thus, the catamenia may recur regularly lor three 
 or four months after conception ; while a very few cases are even 
 recorded where they have continued to appear at natural intervals 
 throughout the whole period of utero-gestation. The explanation 
 of this occurrence will appear presently. " A woman," says Dr. 
 Bluudell, " supposing herself to be pregnant, asks whether ges- 
 tation is possible; for, it is added, the system is still regular. 
 To such a query, the answer is, that it is not only possible, but 
 probable ;* for — notwithstanding what Denman has said to the 
 contrary — I have myself known women in whom, during the first 
 three or four months, the catamenia have continued to flow, 
 though not in so large a quantity, nor so long, as if they were 
 not pregnant ; and in rare cases, I am told — though I have not 
 seen any such case myself — the catamenia may continue to flow 
 up to the very last month. "^ In my own case-book I find the 
 notes of a patient who had had one natural labor at the full term, 
 in whom the catamenia appeared regularly every month, usually 
 for three days, during the whole period of her pregnancy. Much 
 more curious are the cases where menstruation comes on for the 
 first time after conception. In 1817, Sir Everard Home related 
 to the Fellow's of the Royal Society, the history of a young woman 
 wdio was married before she was seventeen. She had never men- 
 struated, but pregnancy occurred. Four mouths after parturi- 
 tion, she became pregnant a second time ; and four months after 
 the second delivery, pregnancy again took place. On this occa- 
 sion she miscarried. Afterwards the catamenia appeared for the 
 first time, and continued to return for several periods until she 
 again became pregnant. 
 
 Still more remarkable are those very rare instances in which 
 women menstruate only during pregnancy, and at no other period. 
 Deventer has recorded a case in which he had the opportunity of 
 observing the occurrence of the catamenia during the time of 
 gestation only, in the four successive pregnancies of the same 
 woman. 
 
 It has been observed since the time of Aristotle — and the cir- 
 
 1 The Principles and Practice of Obstetric Medicine, p. 1053. London, 1840.
 
 80 THE SIGNS AND SYxMPTOMS OF PREGNANCY. 
 
 cumstance has been confirmed by many modern authors — that 
 not only may pregnancy take place without the previous occur- 
 rence of any catamenial discharge, but also after the total cessa- 
 tion of the menses. For pregnancy to happen during lactation, 
 without the recurrence of any menstrual period, is by no means 
 so uncommon. Several years ago I delivered a poor w^oman of 
 her second infant, while her first child — fourteen months old — 
 was unweaned, and was actually at the breast half-an-hour before 
 the completion of labor. The following case is another proof 
 that suckling will not always prevent pregnancy : 
 
 Mrs. A. K.,8etiit. 24. Consulted lue on the 16th January, 1867. Has 
 been married nearly five years. Has been pregnant three times: has had 
 three children, the last having been born on 1st July, 1866. Slie suckled 
 this infant for rather more than four months, and then weaned it, as the 
 courses came on and lasted from the 9th to the 15th November. 
 
 Since the time of her marriage in March, 1862, until now, the catamenia 
 have only been on twice; viz., in April, 1862, and November, 1866. Has 
 always got pregnant while suckling. The first child was weaned, owing to 
 pregnancy occurring, when it was nine months old ; the second, for the same 
 cause, when thirteen months old; and the third, as before stated, when it 
 was four months old Is now about two months advanced in her fourth 
 pregnancy. 
 
 The explanation of all such facts as the"foregoing seems to be 
 this, — that the capital phenomenon in the function of menstrua- 
 tion consists in the maturation and periodical discharge of the 
 ovules, the hemorrhage being but a secondary phenomenon. 
 Hence, the terms ovulation and menstruation are not strictly 
 synonymous. 
 
 On the other hand, the practitioner wall be liable to be misled 
 if he concludes, that because a patient states she menstruates 
 regularly, therefore she really does so. Every woman who has a 
 discharge of blood from the vagina during pregnancy — or indeed 
 at any other time — will attribute it to " her courses ;" though the 
 bleeding may be due to a polypus lianging from the cervix uteri 
 into the vagina, or even — as in an instance which came under 
 my own observation — to a mass of epithelial cancer. The irreg- 
 ular hemorrhages which occur during the latter portion of gesta- 
 tion from placental presentation, have also been mistaken for the 
 catamenial secretion. There can be no doubt, also, that in some 
 cases the discharge is due to inflammation and excoriation of the 
 cervix uteri; the excoriated surface bleeding freely on being
 
 MENSTRUATION DURING PREGNANCY. 81 
 
 touched, or on the uterus becoming more than usually congested 
 by the pressure of a loaded rectum, &c. These cases are very 
 important, not merely in a physiological point of view, but really 
 as regards the patient's welfare ; for if the diseases to which I 
 have alluded are allowed to go unchecked by art, abortion is very 
 likely to be the result. 
 
 From the foregoing it seems to me, that if we take a certain 
 number of the cases in which menstruation is reputed to take 
 place regularly during pregnancy, and subtract those in which 
 there is merely hemorrhage from some morbid condition of the 
 uterus, we shall reduce the number very materially. Granting 
 this, then, the question arises — How are the real cases of men- 
 struation during the first three or four months of gestation to be 
 accounted for ? The explanation of this point has been for many 
 years a stumbling-block to physiologists ; for so long as the de- 
 cidua was regarded as a distinct exudation from the mucous 
 membrane of the uterus, the occurrence of menstruation after the 
 formation of this membrane seemed impossible. Until the last 
 few years the opinion has always been maintained, that the ear- 
 liest effect of successful impregnation was the formation of a new 
 membrane in the cavity of the uterus ; which membrane (the 
 decidua) was believed to resemble a complete bag, occluding the 
 OS uteri and the orifices of the Fallopian tubes. As the fecun- 
 dated ovum descended, it was said to push before it that portion 
 of the decidua which had been formed over the uterine extremity 
 of the Fallopian tube : and so the embryo entered the uterine 
 cavity, covered really with two layers of decidua. The layer of 
 this membrane lining the uterus was called the decidua vera ; 
 while that part pushed forward by the ovum, and closely envelop- 
 ing it, was termed the decidua reflexa. 
 
 The fallacy of these specious hypotheses has now been proved 
 by the simple discovery that the decidua is not a new tissue, but 
 merely the congested and swollen uterine mucous membrane ; 
 so that' the orifices of the Fallopian tubes and of the cervix are 
 not closed, "When the ovule or egg, propelled by the vermicular 
 action of the Fallopian tube, enters the cavity of the uterus, it 
 finds the mucous lining of this organ considerably hypertrophied. 
 The progress of the ovule being much impeded by this swollen 
 velvety membrane, there is more time given for fecundation to 
 occur. Should it happen, the fecundated ovum either takes root, 
 
 6
 
 82 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 as it were, and becomes embedded in a fold of decidua which 
 closes around it, forming the decidua reflexa; or, possibly, having 
 dropped into one of the openings leading to the utricular follicles, 
 it there forms the decidua reflexa by drawing around it — as sug- 
 gested by BischofF, Farre, and Otto Funke — the soft and spongy 
 decidua constituting the walls of the orifice. Kow it is clear that 
 until the ovum so enlarges as to force the decidua reflexa into 
 close and firm apposition with the decidua vera, there can be no 
 mechanical obstacle to the flow of the menstrual blood ; and by 
 consequence — as will again be shown in a succeeding chapter — 
 none to the occurrence of superfoetation. Dr. J. Matthews Duncan 
 has given a description of a beautiful preparation taken from the 
 body of a pregnant woman, who died in consequence of disease 
 which was quite unconnected with the uterus or its functions. 
 Judging from the development of the foetus, she had arrived at 
 least at the eighth week of pregnancy. The mucous membrane 
 lining the body of the uterus was seen to be of great thickness, 
 while that coating the cervix Avas unchanged. The openings of 
 the cervix uteri and of the Fallopian tube of the left side were 
 easily seen, but that of the right tube had been destroyed in dis- 
 section. The decidua reflexa completely covered the ovum, being 
 a thin layer without glands, springing from the decidua vera. 
 The cavity of the uterus was still not closed, there being ample 
 space all around the ovum between the two parts of the decidua, 
 from the os uteri to the tubes. 
 
 There are only two remaining points to notice. In the first 
 place, with regard to the time at which the decidua reflexa comes 
 into apposition with the decidua vera. On this head it seems to 
 me diflicult to speak, positively. According to Dr. J. Matthews 
 Duncan it is probably about the third month ; but I am inclined 
 to believe that it does not hap[)en until later. Certainly, the 
 surfaces of the decidua vera and reflexa do not become fused into 
 a single layer until towards the end of the seventh month. And 
 indeed, it is not impossible that in some rare instances the decidua 
 vera and the decidua reflexa remain non-adherent during the 
 whole term of pregnancy. It is in such cases, probably, that 
 menstruation has continued to recur regularly during the whole 
 term of gestation; the discharge coming from tlie decidua vera, 
 as it ordinarily does from the uterine mucous membrane in the 
 non-pregnant state. Secondly, physiologists assert that the menses
 
 MENSTRUATION DURING PREGNANCY. 83 
 
 cannot escape from the cavity of the uterus during pregnancy, 
 because a plug of viscid cervical mucus acts as an obstacle. To 
 this it need only be replied, that the plug is as dense in the non- 
 menstruating and unimpregnated uterus as in the impregnated; 
 and, since it oifers no obstacle in the one case, there is no reason 
 why it should do so in the other. 
 
 The menses become suppressed from many other causes than 
 pregnancy. In young newly-married women we not uncom- 
 monly find that two or three periods are passed over without any 
 assignable cause ; and as, at the same time, the breasts increase 
 in size, and get rather tender, the anxious wife readil}'^, but erro- 
 neously, believes that she is "as she would wish to be." More- 
 over, the catamenia often cease or become irregular from cold, 
 from shocks to the nervous system, and from disease — especially, 
 perhaps, in consequence of advanced ovarian aifections and con- 
 firmed phthisis ; — or thej^ may stop at an unusually early age, 
 owing to some constitutional peculiarity. At "the change of 
 life" too, intermissions of several periods, before final cessation, 
 are very frequent. The fact has already been noticed, that women 
 who are suckling ma}^ conceive — especially if they continue 
 nursing for too long a period — without the previous reappearance 
 of the catamenia ; and hence instances are met with where, from 
 a rapid succession of pregnancies, menstruation has not occurred 
 for years. It must also be remembered that the discharge of the 
 catamenia may be prevented by adhesions forming between the 
 vaginal labia, or by an imperforate hymen ; and as the retained 
 secretion enlarges the uterus, so it gives rise to symptoms which 
 are not unlikely to be attributed to the presence of a foetus. An 
 attempt at a vaginal examination will detect the obstruction ; 
 while a cautious division of the membrane will give exit to the 
 collection of fluid. This has been found to amount to two or 
 three pints, or more. 
 
 Lastly, there is a source of deception which we cannot easily 
 prevent, and it is this. A 3'oung girl, fearing she is pregnant, 
 and presenting evidence to the eyes of others that she is so, will 
 assert boldly that her courses are regular, although they have 
 quite ceased. To prevent detection she will possibly carry the 
 trick so far as to stain her linen every month with blood.
 
 84 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 Section 3. — Xausea and Vomiting. 
 
 It is of course obvious, that the occurrence of gastric disturb- 
 ance is not of much value by itself as a sign of pregnancy. For 
 while, on the one side, obstinate nausea and vomiting are caused 
 by a great variety of circumstances quite independently of the 
 presence of a foetus in the uterus; so, on the other hand, the whole 
 period of gestation may be passed through without their occur- 
 rence. Nevertheless, when a woman has conceived, tlie stomach 
 frequently becomes very irritable, so that much suflering ensues 
 from the nausea and sickness which result ; these symptoms oc- 
 casionally coming on within three or four days of conception, and 
 sometimes being deferred until about the commencement of the 
 fourth week. 
 
 Speaking in general terms, there are certain facts with regard 
 to these attacks which should be borne in mind. Thus, they are 
 usually most distressing in the early part of the day; whence they 
 have commonly come to be spoken of as " the morning sickness." 
 The duration of the daily attack varies from a few minutes to an 
 hour or even longer. When it has ceased, there is often a desire 
 for food ; and a moderate breakfast seems to remove all discom- 
 fort, especially if the sufferer will remain quiet in bed for a 
 short time after taking it. The sickness is peculiar, inasmuch 
 as it is not due to dyspepsia, but to sympathetic gastric irritabil- 
 ity — reflex irritation. As a rule, the patient does not vomit her 
 food undigested, but merely ejects the mucous secretions of the 
 stomach. In exceptional instances, without a doubt, the irrita- 
 bility is so great that the stomach will retain nothing, not even 
 iced water ; but of these I am not now speaking. The nausea 
 may persist during the whole time of pregnancy ; or it may cease 
 spontaneously — as it does in the great majority of cases — about 
 the beginning of the fourth month. Sometimes, the sudden ces- 
 sation is said to have been the first indication of some unfavor- 
 able change in the woman's system, or of the death of the embryo, 
 or it has proved the immediate forerunner of abortion. The au- 
 thorities who promulgate this opinion generally assert also that 
 utero-gestation proceeds more regularly and favorably when 
 vomiting is present than when it is absent. But I am inclined 
 to believe that this is one of those traditions which has met with
 
 MAMMARY SYMPATHIES. 85 
 
 credence more from frequent repetition, than because it contains 
 any germ of truth ; just as is the case with the old midwife's 
 proverb that a sick labor is a safe one. In instances where the 
 sickness continues during the whole of pregnancy, or when it 
 returns in the latter months, it will generally be found that there 
 is some concomitant uterine disease. This point, with others 
 bearing on this matter, wnll be again referred to in the chapter on 
 the disorders of the digestive organs. 
 
 The same sympathetic action w'hich gives rise to the morning 
 sickness may likewise induce loss of appetite, a distaste for animal 
 food, longings for unusual articles of diet, as w^ell as a disposition 
 to diarrhoea, l^ot very uncommonly, also — as has been noticed 
 since the days of Hippocrates — the salivary glands become 
 affected, inducing copious salivation. The latter is distinguished 
 from mercurial ptyalism by the absence of sponginess and sore- 
 ness of the gums, by the non-existence of any ulcerations upon 
 the sides of the tongue, by the freedom from pain about the jaws, 
 and by the odor of the breath remaining inoffensive, or compara- 
 tively so. Moreover, there is no fever, and little or no constitu- 
 tional disturbance. The quantity of saliva which is discharged 
 is sometimes surprising. In one case, with the particulars of 
 which I am acquainted, three or four quarts were excreted daily. 
 
 Section 4. — Mammary Sympathies. 
 
 When the catamenia have been suppressed for about two pe- 
 riods, the pregnant woman begins to experience a feeling of 
 fulness, increased firmness, tenderness, and throbbing of the 
 breasts ; together, frequently, with a sensation of soreness in the 
 nipples. Sometimes these symptoms set in much earlier. I 
 recollect attending a delicate lady in her confinement, who assured 
 me, that from the end of the first fortnight of pregnancy until 
 the termination, she was seldom free from very great uneasiness 
 in both mammse ; the tension and weight and throbbing being 
 at times almost unbearable. Generally speaking, however, it is 
 not until the end of the eighth w^eek of gestation that the breasts 
 increase in size and firmness. They then present a knotty and 
 uneven and glandular feel ; the blue veins coursing over them 
 begin to be more developed; the circles around the nipples get
 
 BQ THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 gradually altered in color and in structure, constituting the areolae ; 
 while about the same date, or perhaps somewhat later, milk may 
 be secreted. If it be a first conception, the glands lose their conical 
 shape and become more hemispherical. At the same time it 
 must be remembered, that some of these changes can occur from 
 other causes than pregnancy ; for the breasts often enlarge simply 
 from the excitement produced by marriage, from accidental sup- 
 pression of the menses, and from some diseases of the uterus or 
 its appendages. In more than one case of cancer of the uterus 
 I have witnessed the sympathetic pains in the breast form a source 
 of serious distress ; while I have seen the same thing happen 
 occasionally in instances of chronic metritis, uterine fibroid tu- 
 mors, and more especially in subacute ovaritis. So, again, a 
 feeling of fulness and pain in the breasts, with a slight deepening 
 in the color of the areola, may be experienced by delicate women 
 of an irritable temperament upon each appearance of the cata- 
 menia; although then, these symptoms instead of being persistent 
 decrease as the discharge ceases, and in a few days afterwards 
 subside entirely. 
 
 The alteration in that part of the breast around the nipple — 
 the areola — deserves great attention ; since when all the changes 
 to be detailed occur, a very strong presumption of the existence 
 of pregnancy is afibrded. At the end of the second month, the 
 pufi:y turgescence of the nipple and surrounding disk is usually 
 visible ; the little glandular follicles, sixteen or twenty in number, 
 are seen to be getting more developed ; and the color of the areola 
 is observed to consist of a deep shade of flesh tint with a slight 
 brownish hue. These appearances have been admirably described 
 by Dr. Montgomery, who says, — "During the progress of the 
 next two or three months, the changes in the areola are in general 
 perfected, or nearly so ; and then it presents the following char- 
 acters : a circle around the nipple, whose color varies in intensity 
 according to the particular complexion of the individual, being 
 usually much darker in persons with black hair, dark eyes, and sal- 
 low skin, than in those of fair hair, light-colored eyes, and delicate 
 complexion. The area of this circle varies in diameter from an 
 inch to an inch and a half, and increases in most persons as 
 pregnancy advances, as does also the depth of color. I have 
 seen the areola, at the time of labor, almost black, and upwards 
 of three inches in diameter, in a young woman of very dark hair
 
 MAMMARY SYMPATHIES. 87 
 
 and complexion ; while in another instance, in a lady who had 
 borne several children, its breadth aronnd the base of the nipple 
 did not, at any time of gestation, amount to a quarter of an 
 inch, and, at first, was not more than an eighth ; this circle, 
 however, narrow as it was, was studded at nearly regular inter- 
 vals with the glandular tubercles, which were not unlike a ring 
 of beads. In negro women the areola becomes jet black, with 
 somewhat of a purple shade through it. In the albino it is of a 
 delicate rose color. "^ While the alterations thus described are 
 taking place, the breasts get fuller and firmer, and the veins ram- 
 ifying over their surface increase in size; the nipples become 
 turgid, slightly enlarged, and covered at their apices with small 
 branny scales; the glandular follicles on the areolae appear prom- 
 inent, and the integuments covering these parts become raised 
 and soft and moist and turgescent; and, lastly, numerous small 
 mottled patches are seen scattered over the outer portion of the 
 areola and the parts immediately around, presenting an appear- 
 ance as if, says Dr. Montgomery, " the color had been discharged 
 by a shower of drops falling on the part." This last appearance 
 is seldom observed before the fifth month, and is a distinctive 
 sign of pregnancy. 
 
 The formation of the color of the areola depends upon the 
 deposit of actual pigment beneath the cuticle ; and it is curious 
 that a similar deposition is also often found in pregnancy around 
 the umbilicus, down the middle of the abdomen forming a brown 
 line, and sometimes around the eyes. More rarely the skin of 
 the arms and hands has been found to assume a yellowish-brown 
 hue, like that of a mulatto. The evidence derived from the color 
 of the areola is most conclusive in a first pregnancy; for, although 
 the coloring matter is sometimes rather rapidly removed after 
 delivery, yet most frequently it is not entirely absorbed. The 
 varied a[)pearances presented by the areolae, at different periods 
 of pregnancy, are well shown in the excellent drawings by Dr. 
 "Westmacott prefixed to this volume. The sketches for Plates I 
 and IV were made from primiparae : those for Plates II and III 
 were from multiparfe. The woman who furnished the sketch for 
 Plate III was a brunette; while the complexion was fair of the 
 patient whose breast is shown in Plate IV. 
 
 ^ An Exposition of the Signs and Symptoms of Pregnancy. Second edition, p 106. 
 London, 1856.
 
 88 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 William Hunter had such faith in these altered states of the 
 areolfe, that he always asserted he could judge by them alone 
 whether or not a woman was pregnant. The story goes, that on 
 one occasion a subject was brought to him for anatomical pur- 
 poses. On carefully looking at the breast, he declared, from the 
 appearance of the areola, that the female had died while preg- 
 nant. One of his pupils, on examining the genitals, found the 
 hymen perfect ; but Hunter still maintained his opinion, and, on 
 opening the uterus, it was found to contain a small foetus. 
 
 The shining silvery streaks or scars, which are often seen 
 radiating from the centre to the circumference of the breast, af- 
 ford conclusive evidence that pregnancy has existed at some time 
 or other. They are, however, of no importance as signs of a 
 present conception. Such streaks are the result of over-disten- 
 sion of the gland, and when once formed are never removed. 
 Very similar appearances are produced in the integuments of 
 the abdominal walls, through the stretching of the skin by a 
 large gravid uterus or an ovarian tumor. 
 
 The secretion of milk by the breasts is not, if taken by itself, 
 usually considered to be of any diagnostic value ; though when 
 it occurs in combination w^ith other symptoms of pregnancy — 
 especially if the woman has never given birth to a child — most 
 observers allow that it then assumes a certain degree of impor- 
 tance. The reason for this reservation is the well-known fact, 
 that the breasts may occasionally take on their natural functions 
 without the existence of pregnancy, or indeed, without the woman 
 ever having indulged in sexual intercourse. Before mentioning 
 the grounds for my opinion that the secretion of milk in a first 
 pregnancy is a valuable sign of the existence of this condition, 
 reference had better be made to the chief cases which are usually 
 quoted to show the fallacy of this test. Thus, M. Donnd has 
 noticed that he found a fluid in the breast of a young woman, 
 who was said never to have been pregnant, which presented all 
 the microscopic characters of milk.^ Baudelocque mentions the 
 case of a girl, eight years old, who milked her breasts before the 
 Royal Academy of Surgery in Paris ; while Belloc refers to a 
 similar instance. In both of these instances the cause of the 
 secretion was the same, namely, the application of a child to the 
 
 ' Cours de Microscopic, p. 441. Paris, 1844.
 
 MAMMARY SYMPATHIES. 89 
 
 breasts. I am told that it is not uncommon in \yestern Africa 
 for young girls who have never been pregnant to regularly em- 
 ploy themselves in nursing the children of others ; the glands 
 being excited to action by friction with the juice of one of the 
 Euphorbiacese. Many of the native women of New Zealand en- 
 deavor to keep up a flow of milk from the breasts for years ; so 
 that a Maori woman who cannot find a child in need of a foster- 
 mother will suckle a little pig. One gentleman informed Dr. 
 Tuke, that he actually saw a child, five or six years of age, alter- 
 nately " taking a pull" at his mother's pipe and breast. So, 
 again, it is certain that the stimulus imparted by sucking the 
 nipple will make the mammary glands of old women perform 
 their functions anew. Dr. Livingstone, speaking of the Bechu- 
 auas, tells us that he examined several cases in which a grand- 
 mother took upon herself to suckle a grandchild. He relates 
 especially, that — 
 
 Marina of Kuruman had no children after the birth of her daughter Sina, 
 and had no milk after Sina was weaned, an event which usually is deferred 
 until the child is two or three years old. Sina married when she was seven- 
 teen or eigliteen, and had twins; Masina, after at least fifteen years' interval 
 since she last suckled a child, took possession of one of them, applied it to 
 her breast, and milk flowed so that she was able to nurse the child entirely. 
 Masina was at this time at least forty years of age. I have witnessed several 
 other cases analogous to this. A grandmother of forty, or even less, for they 
 become withered at an early age, when left at home with a young child, ap- 
 plies it to her own shrivelled breast, and milk soon follows. In some cases, 
 as that of Ma-bogosing, the chief wife of Mahure, who was about thirty-five 
 yegrs of age, the child was not entirely dependent on the grand motiier's 
 breast, as tlie mother suckled it too. I had witnessed the production of milk 
 so frequently by the simple application of the lips of the child, that I was 
 not therefore surprised, when told by the Portuguese in Eastern Africa of a 
 native doctor who, by applying a poultice of the pounded larvae of hornets 
 to the breast of a woman, aided by the attempts of the child, coul^ bring 
 back the milk. Is it not possible that the story in the "Cloud of Witnesses," 
 of a man during the time of persecution in Scotland, putting his child to his 
 own breast, and finding, to the astonishment of the whole country, that milk 
 followed the act, may have been literally true ? It was regarded and is quo- 
 ted as a miracle; but the feelings of the father towards the child of a mur- 
 dered mother must have been as nearly as possible analogous to the mater- 
 nal feeling ; and as anatomists declare the structure of both male and female 
 breasts to be identical, there is nothing physically impossible in the alleged 
 result. The illustrious Baron Humboldt quotes an instance of the male 
 breast yielding milk j and though I am not conscious of being over credulous, 
 the strange instances I have examined in the opposite sex make me believe 
 that there is no error in that philosopher's statement.* 
 
 1 Missionary Travels and Researches in South Africa, p. 127. London, 18-57.
 
 90 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 The two instances noticed by Dr. Livingstone in the above 
 quotation are without a doubt quite authentic ; since the fact has 
 been noticed by others that, under certain circumstances, the 
 male breasts will secrete milk. The Bishop of Cork has given 
 an account, in the Phil>sophieal Transactions for 1741, of a man 
 who succeeded in suckling and rearing his child after the death 
 of the mother. In Captain Franklin's Narrative of a Journey to 
 the Shores of the Polar Sea in 1819, ^-c. (p. 157, London, 1823), 
 there is a most interesting description of a young Chipewyan, 
 whose wife died three days after giving birth to a boy. To pre- 
 serve the life of this inflmt, the widower nourished the child from 
 his own breast, and was successful in rearing him. The case of 
 a robust soldier, twenty-two years of age, with well-formed geni- 
 tal organs, whose raamm?e acted so efficiently that on one occa- 
 sion a wineglassful of milk was drawn off, is related in Schmidt's 
 Jahrb'dclier for July, 1837. The most perfect case of this kind, 
 and perhaps the most satisfactory, is given in the writings of Dr. 
 Dunglison. This gentleman says : 
 
 Professor Hall, of the University of Maryland, exhibited to his obstetrical 
 class, in the year 1837, a colored man, fifty-five years of age, who had large, 
 soft, well-formed mammje, rather more conical than those of the female, and 
 projecting fully seven inches from the chest, with perfect and large nipples. 
 The glandular structure seemed to the touch to be exactly like that of the 
 female. This man had oflSciated as wet nurse for several years in the family 
 of his mistress; and he represented that the secretion of milk was induced 
 by applying the children intrusted to his care to the breasts during the night. 
 When the milk was no longer required, great difficulty was experienced in 
 arresting the secretion. His genital organs were fully developed.^ 
 
 Now it may at first sight appear strange, that notwithstanding 
 these cases, I am very much disposed to believe that the presence 
 of mUk in the breasts of a woman who has never given birth to 
 a child is an early and reliable sign of pregnancy. I may even 
 go further and sa}', that when there has been a previous preg- 
 nancy the presence of milk is an important sign that the woman 
 is at the time gravid, provided three or four years have elapsed 
 since the date of last giving suck. It is necessary to make these 
 limitations, because the fact is beyond dispute, that a snuill quan- 
 tity of milk may remain in the breasts for some months after 
 suckling has been abandoned, and may easily be expressed by 
 
 ' HmnRii Pliysiology. By R. Dunglison, M. D., &c. Seventh edition. Vol. ii, p. 
 514. Philadelphia, 1850.
 
 M A M M A R Y S Y M P A T H I E S. 91 
 
 tlie fingers. I have so often succeeded in doing tins, where there 
 has been neither pregnancy nor lactation going on at the time, 
 that I can speak positively on the matter. But the reasons for 
 my reliance on the milk test are founded on the experience which 
 was obtained during a long attendance in the hospital out-patient 
 room ; in which place I have, in at least two or three dozen cases, 
 diagnosed the existence of pregnancy from the presence of the 
 mammary secretion alone, though the fluid could be expressed 
 only in a very small quantity. So early as the ninth and tenth 
 weeks has this sign held good ; and, as far as can be known, it 
 never led me into error. In resorting to this test, the fluid must 
 be pressed up from the mammary gland, and brought by persua- 
 sion, as it were, to the point of the nipple. A single drop of a 
 slightly viscid, serous-looking fluid is sufficient ; provided the 
 drop, on being microscopically examined, is found to contain the 
 characteristic milk globules, with large oil particles, and colos- 
 trum granules. The latter seem always to be present under the 
 circumstances mentioned, just as they are found in the secretion 
 of recently-delivered women. Of course, if there were reasons 
 for believing that the girl had been stimulating the mammary 
 glands by the application of any galactagogue, or bj' allowing the 
 nipples to be sucked by an infant, I should reject the evidence 
 aflfordcd by the existence of a few drops of milk. But young 
 women who come to us to be cured of amenorrhoea, though they 
 may have been unable to curb their passions, have not usually 
 been anxious to prematurely develop their breasts. Whatever 
 may be the case in IsTew Zealand and in South Africa, it is cer- 
 tain that in this country, girls and single women do not occupy 
 themselves as wet-nurses. 
 
 By way of summing up the preceding observations it may be 
 said, that the circumstances which ought to be specially con- 
 sidered in examining the breasts for the purpose of ascertaining 
 the existence or absence of pregnancy are as follows: The in- 
 crease in the fulness and firmness of the entire gland ; the enlarge- 
 ment of the veins coursing over the breast, especially if they 
 traverse the areola; the development of the glandular follicles or 
 tubercles; the progressive increase of color in the areola; the 
 soft, humid, slightly raised condition of the cuticle within the 
 areola; the formation of small round spots or mottled patches 
 about the circumference of the areola, and on the adjacent skin;
 
 92 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 and the secretion of milk. Where these conditions all coexist 
 in any given instance, a positive opinion may be entertained 
 that the woman is pregnant ; though the absence of any one or 
 more of them is not to be taken as indicative of the reverse. 
 The mammaiy sympathies are sometimes entirely wanting, not- 
 withstanding that gestation is progressing favorably. Conversely, 
 when all these changes are present and well-marked they may 
 at once begin to fade on the foetus perishing, even though the 
 dead body should be retained in the uterus for some time after- 
 wards. And, finally, it may be laid "down as a law, that when a 
 woman is gravid for the first time, and has missed two monthly 
 periods, a drop or more of fluid may be expressed from the 
 breasts, which, on minute examination, will be found to present 
 all the characters of true milk; while from the presence of even 
 this small quantity, in the great majority of cases, we may alone 
 successfully predicate the existence of pregnancy. 
 
 Section 5. — Enlargement of the Abdomen. 
 
 The progressive enlargement of the abdomen, if not a very 
 certain, is at all events a very familiar symptom of pregnancy, to 
 which the unlearned attach much more importance than we shall 
 find it merits. During the first thirty or forty days after impreg- 
 nation the uterus falls rather low down in the pelvis, whilst its 
 fundus is inclined backwards ; so that the abdomen is even flatter 
 above the pubes — as is proverbially known to be the case — than 
 it was prior to this event. It is not until about the end of the 
 twelfth week that the womb ascends just above the level of the 
 symphysis pubis, and that the flattening gives place to augmented 
 fulness in the hypogastric region ; the enlargement increasing 
 from week to w^eek, as the — at first round, but afterwards oval 
 — uterine tumor becomes more and more developed. 
 
 About the middle of the fifth month the fundus of the uterus 
 can generally be felt midway between the umbilicus and pubes; 
 by the end of the sixth month it may be detected reaching to 
 the umbilicus, or a little above it; in another month it is two 
 inches higher; at the close of the eighth month it is found in the 
 epigastric region; while before the termination of the ninth 
 month, the fundus closely approaches the scrobiculus cordis — as
 
 ENLARGEMENT OF THE ABDOMEN. 93 
 
 the depression whicli exists immediately below the ensiform 
 cartilage of the sternum is usually termed. The annexed dia- 
 grams illustrate the most marked of these changes. A few days 
 prior to the setting in of labor the uterus sinks rather lower; 
 this being more particularly noticeable in women who have a 
 roomy pelvis. 
 
 The foregoing statements are to be regarded as approxima- 
 tions to the truth rather than as absolutely correct ; for it is of 
 course obvious that the elevation of the fundus must vary some- 
 what according to the size of the ioetus, the quantity of liquor 
 amnii, &c. In all instances, however, we find that the uterus 
 fills completely the fore part of the abdomen at nearly the end 
 of pregnancy. The ascending and descending colon then occupy 
 either side; the transverse colon, stomach, and omentum are 
 pushed up between the fundus and diaphragm; while the re- 
 mainder of the viscera lie posterior to the womb. The position 
 of the small intestines — which, owing to their connection with 
 the mesentery, cannot be displaced — between the vertebral 
 column and the posterior surface of the uterus, is not only that 
 in which they best escape any injurious pressure, but one where, 
 by their elasticity, they can serve to protect the aorta and vena 
 cava from any undue weight. Occasionally it happens that a 
 piece of intestine slips between the uterus and the ventral pa- 
 rietes ; an anomaly, the possible occurrence of which should not 
 be forgotten in performing the Csesarean section. M. Dubois 
 met with it in practising this operation in 1839. 
 
 The enlargement of the abdomen which is due to pregnancy 
 must not be confounded with that which arises from mere 
 tympanitic distension of the intestines ; from which it should be 
 remembered, some women suffer for many days after conception. 
 Still more important is it to distinguish the enlarged pregnant 
 uterus from the increase in size due to ascites, ovarian dropsy, 
 fibroid tumors of the uterus, hydatid tumors of the liver, and 
 renal enlargement. The diagnostic signs between these various 
 conditions require to be considered at some length, and hence the 
 succeeding chapter will be chiefly devoted to this subject. It may, 
 however, be here remarked that the enlargement of the abdomen 
 from pregnancy is always greater anteriorly than laterally, espe- 
 cially in multipara ; that the inferior part of the thorax is less 
 ex^Dauded than in diseases of the viscera producing large tumors ;
 
 94 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 that change of posture alters very slightly the appearance or 
 form of the swelling ; and that the flanks do not bulge outwards 
 as in ascites, when the patient is placed upon her back. 
 
 Fig. 2. 
 
 Fig. 3. 
 
 ABDOMEN AND UTERUS IN UNiMl'REaNATED 
 
 STATE. 
 
 ABDOMEN, AND UTl-RU.S -WITH ITS CONTENTS, 
 
 IN THE THIKD CALENDAR MONTH 
 
 OF GESTATION. 
 
 When the foetus dies, whatever the period of gestation may be, 
 the groAvth of the uterus is of course arrested ; and consequently 
 the abdomen then ceases to enlarge, even though the dead body 
 be retained until the ninth month. Cases of this kind are always 
 very puzzling, and sometimes it is impossible to give a decided 
 opinion upon their nature. The following is an illustration of 
 this difficulty. 
 
 About the end of the year 1859, I was consulted by a married lady, forty- 
 four years of aire, who complained of an abdominal tumor. She told me that 
 her husband was some ten years older than herself, that she had been married 
 twenty-three years, and that it was twenty-two years since her first and only' 
 pregnancy. Six months before consultin<r me she began to suffer from morn- 
 ing sickness, while her courses ceased. She referred these symptoms to the
 
 ENLARGEMENT OF THE ABDOMEN. 
 
 95 
 
 chanfre of life ; and did not give up her opinion even on finding the abdo- 
 men beginning to enlarge. After passing over four catanienial periods the 
 sickness ceased, and the enlargement remained stationary. On examining the 
 abdomen, T found a soft, oval, elastic tumor, reaching nearly to the navel; 
 there was dulness on percu.ssion over it, but I could detect only a feeble uterine 
 murmur, %nd no foetal heart-sounds. The finger introduced into the vagina 
 discovered the cervix of normal condition, and the uterus enlarged ; while 
 on practising ballottement, I fancied I could detect a foetus falling with a 
 very light pat on my finger. I gave a guarded diagnosis ; but at the same 
 time stated that I thought she was pregnant, and that the child was dead. 
 This proved to be the case. Three months afterwards labor pains came on, 
 and she was delivered of a shrivelled foetus about the size usually attained at 
 the fifth month. 
 
 As the abdomen enlarges, the umbilicus becomes gradually 
 less hollow than before conception, so that by the sixth iiwnth 
 
 Fig. 4. 
 
 Fig. 5. 
 
 ABDOMfN. AND UTERUS 'WITH IT8 CONTENTS, 
 
 IN THE SIXTH CALENDAR MONTH 
 
 OF 0E8TATI0N. 
 
 ABDOMEN. AND UTERUS WtTH ITS C'lNTENTS, 
 
 IN THE NINTH CALENDAa MO.NTU 
 
 OP GESTATION. 
 
 its depression has almost disappeared ; while a few weeks later 
 it is on a level with the integuments of the abdomen, or even pro- 
 jects above them. Occasionally also, a dark disk or areola is
 
 96 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 developed around the navel ; from which discoloration a brown 
 streak, about a quarter of an inch in breadth, runs downward to 
 the pubes. This line, however, often exists quite independently • 
 of pregnancy. I have seen it on several occasions in single 
 women suffering from fibroid tumors of the uterus, about whose 
 chastity there could be no doubt.^ The emergence of the um- 
 bilicus likewise takes place whenever the abdomen becomes 
 greatly distended, being merely due to the mechanical stretch- 
 ing of tlie parts. 
 
 During the last four or five weeks of pregnancy, careful palpa- 
 tion of the abdominal surface will often enable us to learn the 
 position of the foetus in utero. "We may even in transverse pre- 
 sentations rectify the position by external manipulations : al- 
 though, as the child is very movable in the amniotic cavity, it is 
 difficult to permanently keep the head in the superior strait of 
 the pelvis when we have turned it in this manner. To learn the 
 presenting part, the patient must be calm, and willing to have 
 the examination made ; she should be placed in the recum- 
 bent posture, with the legs and thighs flexed, so as to relax the 
 integuments. A clear diagnosis will be prevented by unusual 
 thickness or tension of the abdominal walls, or by great tender- 
 ness of the uterus forbidding pressure. The head is first sought 
 for, and may generally be found as a globular mass, by pressing 
 downwards and inwards from just above the symphysis pubis. 
 From the head in the lowest and smallest part of the uterus, the 
 remaining portions of the foetal body are to be traced. If the 
 position be a dorso-anterior one, the small spinous processes of 
 the foetal vertebrae will be detected by passing the fingers upwards 
 until they sink into the groove which divides the nates. With a 
 ventro-anterior position of the foetus, the flat surface of the belly 
 will be found occupied by the fore-arms, elbows, knees, and legs, 
 which may be separately felt. A presentation of the trunk is 
 
 1 Of still lo«s value, in otlier words, of no sitrnificance vvliatever, is the discoloration 
 of the forehead, to which old Daniel Turner alludes in the following passage: ''There 
 is a Spot on the Faoe, I must just stay to mention, more peculiar, according to our great 
 Master Hipjiocrates, to big Belly'd Women, and reckon'd as one of the Signs of Concep- 
 tion, nay, according to one of his Aphorisms, a Criterion (tlio" fallible) of the Sex also; 
 Where he saith Qua Ulero gerenlcs, Maculvni in facie velnti ex so/is aduslione habent. em 
 famellnf. plerunique ^estant. To this Spot or Mark authors have generally giv^ the name 
 of Efihelis. Sennertus describes it as a tawny, dark, or dusky spot, principally seated 
 on the Foreheads of breeding women, and spreading both in length and breadth at some- 
 times to the compass of the palm of the liand, without asperity or inequality: contrary 
 to Celsns, wlio calls it ^speritas (jvadam el durities, muli colons." A Treatise of Diseases 
 Incident to the Skin, p. Ibl. London, 1714.
 
 ENLARGEMENT OF THE ABDOMEN. 97 
 
 indicated by the shape of the maternal belly, the transverse diam- 
 eter of which will exceed the longitudinal. The child's head will 
 also be felt in one of the iliac fossse ; and if a vaginal examina- 
 tion be made, no portion of the presenting part of the foetus can 
 be detected. Dr. G. C. P. Murray states,^ that by palpation, 
 together with auscultation, we may determine, in a vertex pre- 
 sentation, whether it be a first, second, third, or fourth position. 
 Thus, if the foetal spine is to the left of the maternal umbilicus 
 or mesial line, it is a first position ; if to the right, it is a second 
 position ; if the prominent knee and elbow are found to the right 
 of the maternal umbilicus or mesial line, and the sounds of the 
 foetal heart are heard most distinctly near the mesial line, it is a 
 third position ; while, if the prominent knee and elbow are found 
 to the left of the mother's umbilicus, and the sounds of the foetal 
 heart are heard distinctly quite towards the right flank of the 
 mother, it is a fourth position. In speaking of first, second, &c., 
 the nomenclature of Churchill is adopted. Should two foetal 
 heads be felt, we have of course evideuce of a plural pregnancy. 
 The successful way in which unmarried females who are preg- 
 nant manage to conceal all external appearances of their condi- 
 tion, by some arrangement of the dress and a skilful mode of 
 walking, is often very remarkable. It not unfrequently happens 
 that servants are delivered at the full period of gestation, in the 
 houses of their employers, who have seen them daily at their 
 work without entertaining the least suspicion of the state of 
 affairs. A mistress, however, will possibly overlook an alteration 
 in her servant's appearance which a keen-eyed stranger will at 
 once notice ; simply because the increase in size has taken place 
 by imperceptible degrees, and the sight has become accustomed 
 to it. Tlie practical hint which should be deduced from the fore- 
 going circumstance is this : That when consulted as to the cause 
 of the catamenia having ceased, the physician had better put no 
 trust in appearances ; but if there be morning sickness, enlarge- 
 ment, &c., of the breasts, or other conditions such as to arouse 
 his suspicions, he ought carefully to examine the abdomen by 
 inspection and palpation and percussion. Where there is any 
 tumor, auscultation must be practised. The dress and petticoats 
 are to be removed; and the woman — her bladder being empty — 
 
 1 The Lancet, p. 262. Loncion, 13th March, 1S58. 
 7
 
 98 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 sbonld be lying down on her back in bed, with the knees slightly 
 drawn up. 
 
 Section 6. — Movements of the Fcetus. 
 
 The movements of the foetus are usually felt by the mother 
 about the sixteenth week after conception ; the term quickening 
 being commonly employed to designate the parent's first percep- 
 tion of motion. This exj^ression is an unfortunate one. It tends 
 to perpetuate the erroneous idea — still maintained by the English 
 law' — that at this period the child first becomes alive, or quick ; 
 
 ^ By tlie Ellenboroiigh Ant, passed in 1S03, it was ordained that any person wilfully 
 causing abortion in a woman not quick with child should be fined, imprisoned, whipped, 
 or transported for any term not exceeding fourteen years; but if the otience were com- 
 mitted after quickening^ it was punishable with death. Within the last few years the 
 law has been twice altered. By the statute for the consolidation of criminal law (24 
 and 25 Vict. c. 100, ss. 58, 59), which came into operation in 1861, it is now clearly 
 enacted : " Every woman, being with child, who, with intent to jirocure her own mis- 
 carriage, shall unlawfully administer to herself any poison or other noxious thing, or 
 shall unlawfully use any instrument or other means whatsoever with the like intent, and 
 whosoever, with intent to procure the miscarriage of any woman, whether she be or be 
 not with child, shall unlawfully administer to her or cause to be taken by her any poison 
 or other noxious thing, or shall unlawfully use any instrument or other means whatso- 
 ever with the like intent, shall be guilty of felony, and being convicted thereof shall be 
 liable, at the discretion of the court, to be kept in penal servitude for life, or for any term 
 not less than three years — or to be imprisoned for any term not exceeding two years, 
 with or without hard labor, and with or without solitary confinement. — Whosoever shall 
 unlawfully suj)ply or procure any poison or other noxious thing, or any instrument or 
 thing whatsoever, knowing that the same is intended to be unlawfully used or employed 
 with intent to procure the miscarriage of any woman, whether she be or be not with 
 child, shall be guilty of a misdemeanor, and being convicted thereof, shall be liable, at 
 the discretion of the court, to be kept in penal servitude for the term of three years, or to 
 be imprisoned for any term not exceeding two years, with or without hard labor." It 
 had been previously ruled by the judges (Regina v. Goodall, Notts. Assizes, 1846), that 
 a person making the attempt to produce abortion on a female erroneously deemed to be 
 pregnant, could be convicted under the former statute of 1 Vict. c. 85, s. 6. The intent 
 was very properly said to be the same whether the woman were pregnant or only 
 thought to be so. On this point the French code is the same as the law of England. In 
 1846, a woman was sentenced to eight years imprisonment for attempting to produce 
 abortion in a female who was subsequently proved to be only afllicteil with an ovarian 
 tuinor (Annales d'Hygifene, &c., vol. i, p. 466. Paris, 1847). — The law in this country, 
 moreover, makes no exce])tion with regard to medical men inducing premature labor 
 to benefit the female or her child ; but as this operation would be undertaken without 
 any criminal design, and only fiom an obvious necessity, so it could not be held as un- 
 lawtul. It ought, however, to be laid down, as a rule of medical ethics, that no practi- 
 tioner is justified in having recourse to this proceeding without a consultation with one 
 ot more of his professional brethren. 
 
 With respect to the plea of pregnancy in bar of execution, the English law is still 
 ridiculous and cruel; for when a woman is fia|)itally convicted, and pleads pregnancy, 
 the question of pregnancy is allowed to be iletermined by a jury of twelve ignorant 
 women, and the respite is made to depend, not upon the j)roof of pregnancy, but upon 
 the question of the woman having quickened. As Paris and Fonblanque remark, in their 
 work on Medical Jurisprudence (vol. iii, p. 141, London, 1823) : "The law of the land 
 is not only at variance witli what we conceive to be the law of nature, but it is at variance 
 with itself; for it is a strange anomaly, that by the law of real property an infant en 
 ventre sa nitre may take an estate from the moment of its conception, and yet be hanged 
 four months afterwards for the crime of its mother."
 
 MOVEMENTS OF THE F(ETUS. 99 
 
 whereas, of course, it is well known that not only is there vitality 
 from the earliest period of conception, but that positive indica- 
 tions of life are given long before the mother feels them. 
 
 The remark has been made more than once, and to a certain 
 extent it is doubtless true, that the life enjoyed by the embryo is 
 a peculiar and circumscribed life ; and that a wide difference 
 exists between the born and unborn child. Still, allowing this, 
 I am not aware that any physicians or jurists in our country have 
 yet adopted the extreme views of Dr. Jorg, who, after tracing 
 the development of the foetus and showing how closely it is de- 
 pendent on the mother for existence and growth, states his 
 opinion that this body is merely to be regarded as a higher species 
 of intestinal worm, being neither endowed with a human soul nor 
 possessing any claim to human attributes while in the uterus.^ 
 It is no argument in favor of these and such like conceits to say, 
 that there is no distinct anastomosis between the bloodvessels of 
 the uterine and foetal portions of the placenta ; or that the mem- 
 branes round the .foetus constitute an essential part of it ; or that 
 the rudimentary organs are adapted only to a future use ; or 
 lastly, that the foetus cannot receive mental impressions. The 
 formation and growth of a human being are very gradual pro- 
 cesses ; embryonic development consisting of a series of stages 
 so closely dovetailed into each other that no two admit of separa- 
 tion. Neither physiological laws nor plain reason enable us to 
 restrict the period at which the embryo acquires life. Hence it 
 is just as absurd to assert that it is less criminal to induce abortion 
 at the twelfth week of intra-uterine life than at the sixteenth, as 
 it is extravagant to maintain that the foetus is merely a water- 
 worm the day before parturition, only becoming a human being 
 after it has breathed. A foetus in utero may not be a living infant 
 in the eye of the law, but it is strange to find a man of science 
 upholding so preposterous a doctrine. On the contrary, instead 
 of maintaining such an error, we should all exert ourselves to have 
 the law altered; for the present state of it is practically injurious 
 to society in at least two ways. Thus, in the first place, guilty 
 women are frequently acquitted of the crime of infanticide be- 
 cause it cannot be proved that the child was alive and wholly 
 
 1 Die Zurechmingsfahigkeit der Schvvangern und Gebarenden beleuchtet. By Dr J. 
 C. G. Jbrg, Professor of Midwifery in the University of Leipzig. Pp. 146 and 148. 
 Leipzig, 1837.
 
 100 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 born when the fatal violence was inflicted. In the pages of the 
 Provincial Medical and SurgicalJournal for 23d April, 1845, a case 
 is reported, in which it was proved that a murdered infant had 
 breathed ; though, when found, the child's head w^as nearly severed 
 from its body. Mr. Justice Erie directed the jury, tliat before 
 they returned a verdict of guilty they ought to be satisfied that 
 the child had an existence distinct from, and independent of, the 
 mother, when she murdered it. As this point could not possibly 
 be proved, of course the prisoner was acquitted. Then secondly, 
 a married woman far advanced in pregnancy may die, a live child 
 being in utero. Supposing a medical man to be present, he 
 might be able to save the infant's life by performing the Caesarean 
 section : yet he cannot safely do so without the consent of the 
 husband. The late Dr. Lever met with two cases, in both of 
 which the women died in the eighth month of pregnancy. The 
 children were both alive immediately after the death of the 
 mothers: nevertheless, the father in each instance refused to 
 allow the live infant to be removed from the uterus of the dead 
 mother. Legally, the conduct of these men was justifiable; 
 morally, they would certainly appear to have been guilty of 
 homicide. A child in its mother's womb, not being a living child 
 in law, its extraction must be quite unnecessary. Yet this is 
 hardly the view we can take as physiologists. And it might be 
 thought that even an ordinary legislator would hold, that a living 
 child, an hour before its birth, had as much right to receive pro- 
 tection and aid from the laws of society as one just born. 
 
 Although quickening is usually ascribed to the first movements 
 of the child which are felt by the mother, yet some authorities 
 deny this ; agreeing with the suggestion of Burns, that it may be 
 produced by the sudden rising of the uterus out of the true into 
 the false pelvis. When we find the cause of such a familiar 
 occurrence the subject of dispute, it would appear not only pos- 
 sible but probable, that the efiect may result from different con- 
 ditions. Dr. Evory Kennedy believes that this is the case. Hence 
 he very wisely advises us not to agree with such as assert that 
 quickening is solely attributable to the sudden change in position 
 of the uterus, nor with those who would make it appear to be 
 invariably due to the first sensation which the mother has of the 
 motion of the child ; but rather to define it as a sense of the first 
 perceptible motion in the uterine region about the sixteenth week
 
 MOVEMENTS OF THE FCETUS. 101 
 
 after impregnation, having for its cause either change of position 
 of the uterus or the movements of the fa3tus. Women who think 
 themselves pregnant usually look forward to quickening as the 
 event which is to confirm their hopes. They describe the sensa- 
 tion which is produced as a peculiar flutter, or thrill, or slight 
 tapping movement, or pulsation in the uterine region ; which is 
 followed or accompanied by a sense of nausea, a disposition to 
 fainting or to a fit of hj'steria, and a feeling of fear or general 
 depression. Not unfrequently after quickening has occurred, the 
 morning sickness, as well as man}' of those other sympathetic 
 aftections which have annoyed the pregnant female during the 
 early months of gestation, subside ; so that better health is en- 
 joyed than has been experienced for several previous weeks. 
 
 The period at which the movements of the child are first felt by 
 the mother is not only somewhat uncertain, hue, in a few instances, 
 where healthy children are subsequently brought forth, they are 
 not experienced at all during the whole term of gestation. As a 
 rule, however, the time may be said to vary between the end of 
 the twelfth and sixteenth weeks from the day of conception; the 
 movements becoming stronger and more perceptible as gestation 
 advances. Thus, the motions which at first merely resembled a 
 slight flutter, or creeping, can afterwards be classified into two 
 divisions. In the one case, they consist of a general quivering, 
 sensible to the mother, and probably due to a change in position 
 of the foetus ; while, in the second instance, they are compared to. 
 short blows or knocks, and are produced by the abrupt actions of 
 the legs or arms of the child. The educated hand of the practi- 
 tioner laid flat upon the patient's abdomen can, as a rule, readily 
 detect these movements; which may also be generally excited by 
 practising palpation on the side of the abdomen opposite to the 
 examiner's hand. Some obstetricians advise that the hand should 
 be dipped in very cold water and then suddenly laid upon the 
 abdomen, so as to aggravate these movements when they are 
 feeble. There are, however, serious objections to this proceeding. 
 I would especially mention, that the cold diminishes the acuteness 
 of the sense of touch; while it is very likely to induce spasmodic 
 contractions of portions of the recti muscles, which are almost 
 certain to be mistaken for fcetal movements. When the move- 
 ments which have been active all at once become feeble and in- 
 distinct, without any appreciable cause, we may reasonably fear
 
 102 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 that the foetal health is suffering; and care should be taken to 
 improve it by attending to the condition of the mother, and re- 
 moving any local congestion, &c. When the pregnancy is com- 
 plicated with ascites, the movements appear indistinct to the 
 mother in proportion as the fluid increases in the peritoneum, and 
 so separates the anterior wall of the uterus from the abdominal 
 parietes. This fact has led to the supposition that it is the wall 
 of the abdomen, and not that of the uterus, which perceives the 
 impulse. 
 
 Finally, the student must not imagine that no mistake can be 
 made with regard to these movements. On the contrary, not 
 only is it possible for a woman who is not pregnant to persuade 
 herself that she feels the motions of the child, but occasionally 
 she may lead even medical men to believe that they also detect 
 them. It is related of our first Queen Mary, of inglorious memory, 
 that being very anxious to have issue, she fondly gave credit to 
 any appearance of pregnancy ; and at one time fancied she felt 
 "the embryo stir in her womb." Despatches were immediately 
 sent to inform foreign courts of this event, while orders were 
 issued to give public tlianks. It was determined that the child 
 must necessarily be a male ; and Bonner, Bishop of London, di- 
 rected public prayers to be offered that heaven would please to 
 render the prince beautiful and vigorous and healthy. The result 
 proved that the queen's sensations were due to the commence- 
 ment of a dropsy.^ Without a doubt it seems strange that a 
 woman should make such a mistake, especially if she has pre- 
 viously had children ; but it cannot be denied that the pulsation 
 of the aorta in dyspepsia, or the rapid movement of air in the 
 intestines, or some spasmodic action in the uterus, will so simu- 
 late quickening — particularly when aided by a vivid imagination — 
 as occasionally to deceive the most experienced and intelligent. 
 
 1 Refer to The History of England, by David Hume. Vol. iii, p. 348. New edition, 
 London, 1S41. Also, Lives of the Queens of England, by Agnes Striclvland. London, 
 1851. This author, speaking of Mary's deplorable state of health from dropsy, says 
 (vol. iii, p. 550): "The females of her household and her medical attendants still kept 
 up the delusive hope that her accouchement was at hand. Prayers were put up for her 
 safe delivery in May, 1555; and circulars were written, similar to those prepared at 
 the birth of Queen Elizabeth and Edward the Sixth, in wliich blanks were left for 
 dates, and for the sex of the royal offspring. The news was actually published in 
 London, and carried to Norwich and Flanders, that a prince was born."
 
 CHANGES IN THE UTEKUS. 103 
 
 Section 7. — Changes in the Uterus. 
 
 To appreciate thoroughly the changes which take place in the 
 uterus after conception, as well as to comprehend the nature of 
 some of the diseases that occur during pregnancy, it is necessary 
 to have a distinct idea of the form and structure of this organ in 
 its unimpregnated state. Hence, the leading features in the 
 anatomy of the womb may be first treated of with advantage, 
 before speaking of the effects of impregnation. 
 
 The virgin, or unimpregnated, or nulliparous uterus, is a 
 slightly-flattened and pyriform-shaped and hollow organ ; the 
 fundus being nearly flat or very slightly convex, the anterior 
 surface of the body smooth and rather convex, the posterior 
 surface more convex and sometimes presenting a ridge or 
 prominence along the median line, while the cervix is a smooth 
 and firm truncated cone. The thick muscular walls are so nearly 
 in apposition, that they leave only a small intermediate space 
 called the cavity of the uterus. The weight of the womb is from 
 one ounce to an ounce and a half; and it measures about two 
 inches and three-quarters in length, two inches in breadth at 
 the widest part, and rather more than an inch in thickness. 
 The multiparous organ is in every respect rather larger and 
 heavier, the fundus is more arched and expanded, and the cervix 
 is of greater size and flaccid. 
 
 The uterus is situated in the true pelvis between the bladder 
 and rectum, being loosely retained in position by the round and 
 broad ligaments on each side, as well as by the vagina and fibres 
 of connective tissue. It is artificially divided by anatomists into 
 the fundus, body, and cervix. The fundus or upper third is 
 covered entirely by the peritoneum, the body being only par- 
 tially so. At the points of jinion between the sides of the 
 fundus with the body are two projecting angles, to which the 
 Fallopian tubes are attached, and from whence pass off dupli- 
 catures of the peritoneum forming the broad ligaments. The 
 cervix, or neck, or lower third of the uterus, is embraced by the 
 upper end of the vagina, into which the uterine cavity opens. 
 This aperture is known as the os uteri. The os uteri — trans- 
 verse in the virgin, irregularly round and puckered in the mul- 
 tipara — is bounded by two thick lips, an anterior and a posterior ;
 
 104 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 the latter being the thinnest and rather the longest of the two, 
 although from the position of the uterus in the pelvis the reverse 
 seems to be the case. The epithelium of the mucous coat cover- 
 ing the lips and vaginal portion of the cervix uteri is of the 
 tessellated or squamous variety ; and beneath this epithelium 
 are numerous vascular papillae or villi. 
 
 On carefully dissecting this organ — so justlj^ spoken of by 
 Swammerdam as the miraculum naturae — its walls will be found 
 to consist of three layers ; which, however, are so blended to- 
 gether that no actual line of demarcafion can be seen, even by 
 the microscope, to exist between them. First, we find the thin 
 peritoneal or serous coat forming an external investment to the 
 body and fundus. Secondly, there is the proper substance of 
 the uterus — the thick muscular structure — composed of pale and 
 unstriped muscular fibres, interlacino; in all directions ; these 
 fibres forming, with a homogeneous connective tissue, longitu- 
 dinal and transverse, oblique, a»d circular and transverse layers. 
 The external stratum of longitudinal and transverse fibres is 
 thin, the middle layer is strong and thick, whilst the fibres of 
 the internal coat are fine and delicate. Thirdly, we have the 
 vascular mucous membrane lining the cavity of the uterus, and 
 constituting the internal coat of the organ. 
 
 The peritoneum is reflected from the posterior surface of the 
 bladder on to the anterior surfiice of the uterus at about the part 
 where the body joins the cervix: it then ascends over the body 
 and fundus of the organ, and descending down the posterior 
 surface, covers the upper end of the vagina before turning up- 
 wards to invest the rectum. At the sides of the superior portion 
 of the uterus, the peritoneum is continued on to the Fallopian 
 tubes, the round ligaments, and the ligaments of the ovaries; 
 the duplicatures between which these appendages of the uterus 
 are contained forming the broad ligaments. During pregnancy, 
 the component elements of the peritoneum increase pari passu 
 with the other uterine tissues ; so that without becoming atten- 
 uated, this serous membrane still invests those parts of the uterus 
 which were covered by it in the non-pregnant condition. 
 
 According to the microscopic researches of Kilian and Rainey 
 and others, the substance of the uterus would seem to be made 
 up of fibrous and connective tissue, together with a vast number 
 of muscular fibre cells, fibre germs, or embryonic nucleated
 
 CHANGES IN THE UTERUS. 105 
 
 cells, which have the power of development into non-striated 
 involuntary muscular fibres. The diameter of these cells is 
 about the ^^^q ^th of an inch, and their length somewliat greater. 
 In the unimpregnated or nuUiparous uterus, under ordinary cir- 
 cumstances, the contractile fibre cells or germs remain quiescent; 
 but on the occurrence of impregnation, the growth of a polypus 
 or fibroid tumor, or the continued application of an irritant to 
 the cavity or walls, they commence a career of growth and mul- 
 tiplication. During pregnancy, every muscular fibre cell is said 
 by Kolliker to increase from seven to eleven times in length, 
 and from two to five times in breadth. Each cell is then seen 
 to have a distinct oval nucleus. These fibre cells are of great 
 importance, as it is to their development that the gravid uterus 
 owes its contractile properties. "They may be compared," says 
 Dr. Tyler Smith, "to the derivative germ cells by which lost 
 parts are reproduced in the lower animals, and which, but for 
 the loss which calls forth their development, would forever 
 remain inactive. In the case of the uterus, unless impregnation 
 or some other stimulus be applied, these germ fibres remain 
 through life in a rudimentary state. In the unimpregnated con- 
 dition it is probable that the germ fibres or fibre cells are in a 
 more advanced state in some uteri than in others, particularly 
 in multipara. Cases are met with in which the uterus expels 
 coagula, or the dysmenorrhoea membrane, by contractile efibrts, 
 even in the unimpregnated condition. It is probable, indeed 
 certain, that, by relaxation of the fibre cells of the os and cervix, 
 and contraction of those of the body, the os uteri may be opened, 
 and matters frequently expelled from the cavity of the virgin 
 uterus."^ As soon as the fecundated ovum has settled in the 
 uterus the fibre cells begin to elongate; so that, as just men- 
 tioned, at the time of labor they are very many times longer 
 and wider than before impregnation, while new generations of 
 cells are likewise formed. The development of new cells is most 
 active in the early part of pregnancy, and is supposed to cease 
 at the sixth month. The contractile power of the uterus at the 
 completion of gestation is owing to these colossal muscular fibre 
 cells ; this power being retained even for some few hours after 
 death, so that a foetus may be expelled subsequent to the decease 
 of its mother. 
 
 ' A Manual of Obstetrics, by W. Tyler Smith, M.D.,&c., p. 36. London, 1858.
 
 106 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 The uterine cavity is about two inches and a half in length ; it 
 is of a triangular shape in that part belonging to the fundus ; and 
 its narrowest portion is found at the junction of the body with 
 the cervix — a part sometimes spoken of as the os uteri internum. 
 Three apertures open into it : i. e., the two uterine extremities of 
 the Fallopian tubes at the angles formed by the junction of the 
 fundus and body, and the os uteri. The cavity is lined by ciliated 
 mucous membrane, continuous with that lining the Fallopian 
 tubes and the vagina. This membrane is composed of numerous 
 minute follicles, capillaries, epithelium, free nuclei, fibre cells, 
 and amorphous connective tissue. In the body the mucous mem- 
 
 FiG. 6. 
 
 SECTION OF THE UTERUS ABOUT THE END OF THE FIRST WEEK OF PREGNANCY. 
 
 The drawing shows the mucous memhrane of the uterine cavity develojiefl into the metnlirana 
 deciJua. The fecundated OTum is seen cmbi'ddi'd in tlie liypertrophied mucous membrane. In the 
 cervix, there are two distended glands filled with mucus; but the mucous lining of this part retains 
 its original condition. 
 
 brane is smooth, pale in color, and can be seen by a lens to be 
 dotted throughout with the orifices of numberless simple tubular 
 glands, resembling the follicles of Lieberklihn in the intestine ; 
 these glands being about a quarter of an inch in length, being 
 arranged vertically side by side, and probably having for their 
 function — according to Goodsir, Kolliker, Tyler Smith, and
 
 CHANGES IN THE UTERUS. 107 
 
 others — the office of elaborating the material out of which the 
 clecidua reflexa is formed. The mucous coat of the cervix is 
 marked by four longitudinal ridges, from all of which rugoe are 
 directed obliquely upwards on each side, presenting an appear- 
 ance which has been named the arbor vitae uterinus. All parts 
 of these rugae, as well as the grooves or sulci between the columns, 
 are covered with multitudes of mucous cysts or follicles. i The 
 viscid secretion from these follicles is of alkaline reaction ; it 
 keeps the cervix uteri moist in the ordinary condition of this 
 part, it forms a kind of mucous plug which is often present, 
 and it serves to freely lubricate the cervix and vagina during 
 labor. 
 
 When the ovule has become fertilized, the mucous membrane 
 lining the body of the uterus very quickly takes on a remarkable 
 activity of growth, and becomes much increased in thickness 
 and softness and vascularity. The minute tubular follicles in- 
 crease in length and width, while the vascular network encircling 
 them gets much developed. The rich and soft and velvety ap- 
 pearance presented by the hypertrophied mucous membrane, 
 may perhaps be imagined from the wood-cut on the preceding 
 page. 
 
 Fecundation having been accomplished, the uterine mucous 
 membrane is now spoken of as the decidua vera, or the decidua 
 uteri, and it forms the external envelope of the foetus. The new 
 structure is the thin decidua reflexa, or decidua ovuli. This is 
 probably produced by the ovum sinking into a depression or 
 follicle of the decidua vera, the walls of which depression become 
 developed around the projecting part of the germ so as to en- 
 velop and fix it in position.^ Thus, in a few days, the ovum 
 
 1 "In a portion of the cervix, comprising only three rugae and their two interspaces, 
 upwards of five hundred mucous folHcles were easily counted, so that it is within the 
 limits of moderation to say that a well-developed virgin cervix uteri must contain at 
 least ten thousand mucous follicles; indeed, even this number is probably greatly ex- 
 ceeded." On the Pathology and Treatment of Leucorrlicsa. By W. Tyler Smith, M.D., 
 &c., p. 26. London, 185.5. 
 
 "** 2 The mode of formation of the decidua ovuli is still a subject of dispute with physi- 
 ologists ; the difficulty of investigating the question being increased by the circumstance 
 that no such tissue is found in the gravid uteri of the lower animals. The explanation 
 given in the text is, I believe, the one generally received as correct; but Weber lias 
 thrown out another suggestion. He believes — to use Dr. Priestley's words — that this 
 membrane "is actually the primary lamina secreted before the ovum enters the uterus, 
 which separates in two-thirds of its extent from the layers immediately beneath it to 
 adhere to the ovum and retain it in position; the remaining third not separating, but re- 
 maining as a centre of nutrition by its union with the womb." On this principle the 
 decidua vera must be regarded as a subsequent formation on the uterine walls, or a
 
 108 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 gets confined in a distinct cavity of its own. For some time, 
 the membrane reflected over the ovum remains separated from 
 the uterine decidua by a well-marked space containing a little 
 pinkish fluid. But this space gradually diminishes as the em- 
 bryo increases in length and breadth; until the two membranes 
 are first brought into close contact, and then finally become fused 
 into a single thin and friable structure. The exact period when 
 this takes place is, as before mentioned, unknown ; but it is prob- 
 able that it occurs between the end of the third and seventh 
 months. Thus, the ovum is surrounded in two-thirds of its cir- 
 cumference by the decidua vera and the decidua reflexa; these 
 membranes, coalescing in the remainino^ third and constitutins; 
 a tliiek layer, by which the ovum and the uterus are closely 
 united to each other. It is at this part that the placenta is 
 formed. 
 
 While these changes have been progressing, the development 
 of the embryo, as well as of the chorion and amnion, has been 
 advancing. If, now, the decidua reflexa be laid open, the ovum 
 is seen surrounded by its own membranes, viz., first, by the 
 chorion with its villi, and then by the amnion. The villi of the 
 chorion take root, as it were, in the substance of the decidua, 
 and effect the process of imbibition from the maternal capillaries; 
 the internal surface of this tunic being smooth like a serous 
 membrane. If we examine the villi from this internal surface 
 we shall find that thej are hollow, like the fingers of a glove. 
 As development proceeds, a little vesicle — the allantois — from 
 the embryo approaches the inner surface of the chorion and 
 spreads over it, the umbilical vessels ramifying upon it. When 
 the surface of this minute sac unites with the chorion, it forms 
 the vascular layer of the latter, or the endo-chorion as it is 
 termed. From this layer, capillary loops are given off which 
 enter the villi ; and the latter then become largely developed, 
 forming numberless irregular branches, which ramify and con- 
 stitute a very intricate network in the decidua. The villi at first 
 branch out from the whole of the external surface of the chorion ; 
 but as those imbedded in the reflected decidua get separated 
 from the uterus by the decidual cavity, they become atrophied 
 
 deeper layer, secreted after the manner of the previous growth. Dr. Priestley accepts 
 this view as being probable; and states tlie reasons which have influenced him, in his 
 valuable work. — Lectures on the Development of the Gravid Uterus. London, 1860.
 
 CHANGES IN THE UTERUS. 109 
 
 and disappear. At the same time those branches in contact with 
 the uterine decidua undergo a kixuriant and progressive develop- 
 ment to ultimately form the fcetal portion of the placenta. The 
 amnion is a tough transparent membrane, which at first closely 
 surrounds the embryo, and is continuous with the integument 
 of the foetus at the umbilicus. As the liquor amnii is secreted 
 on its inner surface, the membrane gets separated more and more 
 from the foetus, and pari 2Jassu, is urged into contact with the 
 chorion, to which it becomes closely applied. During the first 
 and second months of pregnancy there exist, in the space be- 
 tween the chorion and amnion, the allantoid and the umbilical 
 vesicles, — temporary structures, whose pedicles form part of the 
 umbilical cord, and which are inclosed in a sheath of the amnion. 
 The sac of the allantois disappears within a few days of its for- 
 mation ; but the pedicle remains, ultimately becoming one of the 
 ligaments of the bladder, and being known as the urachus. The 
 umbilical vesicle — the analogue of the yolk-bag in the egg of 
 oviparous animals — is large during the first few weeks of gesta- 
 tion, and communicates freely by its duct with the fcetal intes- 
 tine at the situation of the umbilicus. The yolk-colored fluid 
 contained in it is a source of nourishment to the embryo ; and 
 when this supply is no longer needed, as after the second month 
 when the placenta becomes developed, the vesicle gradually 
 shrivels up. The pedicle receives an artery and vein from the 
 foetus, called the omphalo-mesenteric vessels; and these disappear 
 as the vesicle gets atrophied. 
 
 The uterus is very freely supplied with bloodvessels, receiving 
 the two ovarian or spermatic arteries from the aorta, and the two 
 uterine from the internal iliacs : with nerves from the sacral 
 plexus of the cerebro-spinal system, as well as with a great many 
 branches from the hypogastric plexus of the sympathetic : and 
 with very numerous lymphatics, which run into the pelvic and 
 lumbar glands. During pregnancy the lymphatics, arteries, and 
 veins ramifying through the uterine tissues undergo a very 
 marked increase both in length and breadth ; the veins especially 
 becoming broad flattened channels, which anastomose and form 
 large sinuses. The venous canals opposite the placental insertion 
 are larger than elsewhere. The very remarkable dissections of 
 Dr. Kobert Lee would serve to show that the uterus is much more 
 abundantly supplied with nerves than has hitherto been allowed,
 
 110 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 that tliese nerves have numerous ganglia connected with them, 
 and that they become much enlarged as gestation progresses. It 
 has, however, been denied that the structures regarded as nerves 
 by Dr. Lee are really such. And although the subject is still 
 
 Fig. 7. 
 
 
 Vu-^vv^^^lr^--^^- 
 
 A COMPLETE OVUM AT ABOUT THE EIGHTH WEEK. 
 
 The drawing shows the chorion, as well as the closed sac of Ihp amnion, containing liquor aninii and 
 the embryo witli its short umbilical cord. Between the inner surface of tlje chorion and the sac of the 
 amnion is the cavity of the allantois filled with fluid. The pear-shaped biig aboye is the umbilical 
 vesicle ; from which the canal (Ductus Vitello-intestinalis) and the mesenteric vessels of the umbilicus 
 (Vasa omphalomesaraica) lead into the umbilical cord. 
 
 involved in doubt, yet several eminent anatomists seem to think 
 that it is merely the fibrous neurilemma or nerve-sheath which 
 becomes spread out ; it being their opinion that no multiplication 
 or increased development of the nerve tubules and ganglionic 
 nerve corpuscles takes place during pregnancy. 
 
 In examining those changes which occur in the uterus after 
 conception, and which are appreciable as marks of diagnosis, we 
 have to consider the alterations presented by the os and cervix, 
 as well as those induced in the size and consistence of the whole 
 uterus. On making a vaginal examination in a female who has 
 neyer been impregnated — sexual intercourse 'per se having no 
 effect upon the uterus — the cervix uteri is found projecting into 
 the vagina to the extent of rather more or less than half an inch; 
 its component structures are firm and consistent to the touch, like
 
 CHANGES IN THE UTERUS. Ill 
 
 fibrous tissue ; there is neither hypertrophy nor congestion ; and 
 the OS uteri can be felt as a small transverse opening, with well- 
 defined margins. Immediately after conception the tissues of the 
 uterine neck begin to undergo certain alterations ; since the cervix 
 participates in that general congestion which the genital organs 
 then experience. Consequent upon these changes, the lips of the 
 OS uteri are found, about the end of the first month, to be more 
 swollen and softer than they were previously ; though this in- 
 creased fulness is frequently hardly sufiicient to be generally ap- 
 preciated. As gestation advances, the softening invades the whole 
 cervix, progressing from below upwards. Moreover, all the tissues 
 of this part seem thicker and more elastic than before ; while its 
 canal becomes slightly widened, so that each month the finger 
 can be made to penetrate deeper into it. After the eighth month, 
 the textures of the neck are often as soft as those of the vagina ; 
 though it must be remembered that this softening is not only 
 slower in primiparse than in women who have previously had 
 children, but is seldom as strongly marked. 
 
 All authors agree that the cervix undergoes no modification in 
 length during the early months of gestation. But only a few 
 years back it was universally taught, that during the fifth month 
 the projection of the cervix into the upper portion of the vagina 
 becomes lessened ; the shortening having been said to be due to 
 a gradual drawing up of the supra- and infra-vaginal portion of 
 the cervix, by which the walls of this part get added to those of 
 the body. So important have these views been deemed, that the 
 diagnosis of the difierent periods of pregnancy has been partly 
 based on this gradual shortening ; and even now we find some 
 writers laying down the rule that the neck loses one-third of its 
 length at the fifth month, one-half at the sixth, two-thirds in the 
 seventh, four-fifths in the eighth, and the remainder in the ninth 
 month. In the year 1826, M. Stoltz tried to prove that all this 
 is an entire error; and he attempted to demonstrate that the cer- 
 vix retains almost its whole length till the last fortnight of preg- 
 nancy. Many writers had previously noticed that sometimes the 
 neck did not shorten ; but the cases in which this was observed 
 were thought to be exceptional.' In 1839, M. Cazeaux advocated 
 
 1 For example, Smellie says: "The neck of the womb will, in some, be felt as long 
 in the eighth, as in others at the sixth or seventh month." — The Theory and Practice of 
 Midwifery, by W. Smellie, M.D. Fifth Edition, vol. i, p. 188. London, 1766.
 
 112 THE SIGNS AND SYMPTOMS OF PREGNANCY, 
 
 tbe views of Stoltz ; but still they were not general!}^ adopted. 
 And although much has been written on this subject during the 
 last twelve or fifteen years, yet in some of the most recent text- 
 books on midwifery the occurrence of this change is insisted 
 upon ; the authors giving very exact diagrams, probably drawn 
 from the imagination, illustrative of its gradual progress. M. 
 Cazeaux's opinion seems to have been that the cervix undergoes, 
 during pregnancy, at least in primiparse, a decided though slight 
 diminution of length; and that this diminution is produced, not 
 by the enlargement and distension of the cervical cavity from 
 above downwards, but by the approximation to one another of 
 its two extremities, the cavity becoming more markedly fusiform, 
 and filled with its ordinary mucous secretion. Now these observa- 
 tions appear to have stimulated Dr. J. Matthews Duncan to in- 
 vestigate the subject anew; and he says positively that the length 
 of the cavity of the cervix undergoes little or no change during 
 pregnancy, and certainly no change which can be measured or 
 appreciated during life.^ He founds this opinion on the results 
 of numerous vaginal examinations ; but chiefly on the more close 
 and exact examination of the uteri of women who have died at 
 difterent stages of utero-gestation. Dr. J. M. Duncan does not 
 allude to the latter days of the ninth month of pregnancy ; be- 
 cause it is undoubted that painless contractions are then slow^ly 
 going on, which of course end in the cervical canal becoming 
 completely obliterated. Without pretending to have made any 
 special observations upon this subject, yet I have for several years 
 taught these doctrines. Shortly recapitulated they are as follows : 
 The cervix uteri does not unfold or lose itself in the walls of the 
 bod}' of the uterus, nor does it get lost or merged into the tissues 
 of the vagina, during gestation. On the contrary, the whole cer- 
 vix — the supra- and infra-vaginal portion — remains unshortened 
 until the process of parturition commences ; when the walls gradu- 
 ally expand and unfold to allow of the exit of the infant. That 
 there is an apparent or simulated shortening, during the latter 
 weeks of gestation, is not denied ; a condition which is due to 
 the increased softening and greater breadth of the cervix, conse- 
 quent upon that hypertrophy of the connective tissue which re- 
 sults from pregnancy. 
 
 1 On the Cervix Uteri in Pregnancy, — Edinburgh INIedical Journal, p. 773. March, 
 1859.
 
 CHANGES IN THE UTERUS. 113 
 
 The body of the uterus becomes enlarged from many other 
 causes besides pregnancy. And yet the increase in size which 
 commences directly the commingling of the sperm-cell and germ- 
 cell have given origin to the embryo, and which gradually but 
 steadily progresses, will frequently enable us to diagnose the ex- 
 istence of pregnancy at an early period, — as early as the seventh 
 or eighth week. Suppose, for example, that on making a careful 
 vaginal examination, passing the finger well up between the uterus 
 and the empty bladder, the former organ be found enlarged. The 
 question of course arises as to the cause of this enlargement. Now, 
 in the first place, the amplification produced by early gestation is 
 peculiar. There is a more sodden feeling communicated to the 
 touch than is given by any tumor, or by a syphilitic or tubercular 
 or cancerous infiltration. Then, considerable light may be thrown 
 on the nature of this enlargement, if we can connect it with an- 
 other symptom. Thus should it appear that two monthly periods 
 have been passed over without any appearance of the catameuia, 
 it may be fairly assumed that neither a fibroid tumor, nor any 
 polypoid growth, nor any cancerous infiltration, can be present ; 
 since in these diseases there is a strong tendency to an excessive 
 flow, rather than to any suppression. So again, if the os uteri 
 appear healthy, and especially if menstruation have been previ- 
 ously regular, there can be no reason for supposing that men- 
 strual blood or serous fluid has been retained in the uterine 
 cavity. Simple congestion and hypertrophy will not account for 
 the enlargement, inasmuch as in such a case there will not only 
 be more or less menorrhagia but also uterine leucorrhoea. More- 
 over, the menses cannot be suppressed from constitutional disease 
 — such as tuberculosis — without there being other evidences of 
 this affection ; while in such cases there is no uterine enlarge- 
 ment. Obviously then, by excluding all these possible causes, 
 the conclusion becomes justifiable that the enlargement is in all 
 probability due to the presence of a foetus. 
 
 The development of the body of the uterus which results from 
 pregnancy, takes place whether the impregnated ovum arrives 
 in the uterine cavity or not; though it does not occur in equal 
 degrees in the two cases. Dr. Arthur Farre, in his elaborate 
 essay on "The Uterus and its Appendages,"^ states that in the 
 
 ^ Cyclopcedia of Anatomy and Physiology. Supplementary volume, p. 645. London, 
 1S58.
 
 114 
 
 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 case of extra-uterine pregnancy, a considerable thickening of 
 the uterine substance usually results, together with a general 
 enlargement of the entire organ ; this enlargement being equal 
 to that which is observed in the third month, and in some cases 
 — when gestation is not interrupted — even in the fourth month 
 of ordinary pregnancy. "Where gestation follows its normal 
 course, the uterus is found at the full period to have increased 
 about twenty-four times in weight, and rather more than five 
 times in length. The rate at which the womb amplifies is liable 
 to some variety, owing to differences in the size of the fcetus, 
 the number of ova impregnated, the quantity of liquor amnii, 
 &c. Making certain allowances, however, it may be laid down 
 as a general rule that the rate of increase, expressed in calendar 
 months, is as follows : 
 
 Dimensions of the Gravid Uterus at the Chief Periods of 
 Pregnancy. 
 
 
 
 
 
 Period of Pregnancy. 
 
 Length of Uterus. 
 
 Breadth. 
 
 Measurement. 
 
 End of 3 months, . 
 
 4i to 5 inches. 
 
 4 inches. 
 
 3 inches. 
 
 " 4 " 
 
 5^ to 6 " 
 
 5 
 
 4 
 
 " 5 " 
 
 6 to 7 " 
 
 5J " 
 
 5 " 
 
 " 6 " 
 
 8 to 9 " 
 
 6J " 
 
 6 " 
 
 "7 " 
 
 10 to 11 " 
 
 7^^ " 
 
 H " 
 
 " 8 " 
 
 11 to 12 " 
 
 8 " 
 
 7 " 
 
 " 9 " 
 
 12 to 15 " 
 
 9^ " 
 
 8 to 9 •' 
 
 The gradual change in the dimensions of the uterus just de- 
 scribed cannot of course occur without this organ also under- 
 going an alteration in its position. For the first three months 
 of gestation the womb remains in the pelvic excavation, being 
 not only congested and enlarged, but also slightly anteverted. 
 Occasionally, perhaps, as is often stated erroneously to be the 
 rule, there is a mild degree of retroversion. But from numerous 
 examinations I have satisfied myself, that most commonly the os 
 uteri looks towards the sacrum, while the fundus can be felt 
 making slight pressure on the bladder. The uterus then gradu- 
 ally rises out of the cavity of the pelvis, so that about the third 
 month and a half, or at the beginning of the fourth month, the 
 fundus may be felt above the symphysis pubis; while it is at this 
 time that the foetal movements are usually first appreciable to
 
 CHANGES IN THE UTERUS. 
 
 115 
 
 the mother. If we trace further the gradual elevation of the 
 fundus we shall find, that during the fifth month it has risen to 
 half way between the symphysis and umbilicus; during the sixth, 
 it has reached as high as the umbilicus; in the seventh, it is 
 
 Pig. 8. 
 
 THE UTERUS AT THE FULL TERM OF GESTATION. (After Valentin.) 
 
 Thp vagina, rr. utHriis with placenta at upper part, 6; symphysis pubis, c; urinary blaiider, d; 
 umbilicus, e; the rectum,/; promontory of sacrum, s"; and os uteri, h.
 
 116 THE SIGNS AND SYMPTOMS OF PKEGNANCY. 
 
 to be found nearly midway between the umbilicus and ensiform 
 cartilage of the sternum ; while by the end of the eighth month 
 it has almost reached the ensiform cartilage, and in another fort- 
 night has quite done so. The uterus, resembling a moderately 
 distended bladder of water, seems now to fill the whole abdomen ; 
 the liver being pushed upwards, and the coils of intestines pressed 
 backwards. Three or four days prior to the setting in of actual 
 labor, the womb sinks downwards to a lower level; so that, for 
 the last few days of gestation, the woman breathes more easily, 
 and appears smaller than she has done for some two or three 
 weeks previously. 
 
 A few words on the changes which the uterus undergoes after 
 parturition will serve to complete this section. Directly the 
 foetus and membranes and placenta have been expelled, the 
 organ which has contained them for forty weeks begins to di- 
 minish in size by a gradual contraction of its tissues ; so that in 
 six or seven days it only fills the pelvic cavity and the hypogas- 
 tric region, and is not much larger than a cricket-ball. The 
 following table by Dr. Heschl, shows the decrease in the weight 
 of the uterus : 
 
 lb. oz. lb. oz. 
 Immediately after delivery it weighs 1 6 — 1 8 
 At the end of the first week " 13 — 15 
 
 At the end of the second " 10 — 11 
 
 At the end of the fifth " 5 — 06 
 
 And in the second month it comes down to its normal weight of 
 1| to 2| oz. ; whence it appears that the most rapid diminution 
 takes place in the second week after delivery. Moreover, the 
 size of the womb directly after labor depends on the degree of 
 contraction which has taken place. But speaking generally, it 
 maybe said to be from eight to ten inches long, nearly the same 
 in breadth, with its walls an inch thick, and its tissues of a white 
 or pale red color. 
 
 A vast amount of time and trouble has been expended to dis- 
 cover the condition of the uterine cavity after the termination 
 of labor. It has been already shown that the decidua uteri con- 
 sists merely of the mucous membrane of the uterus. At first, 
 this membrane was much hypertrophied. Towards the end of 
 gestation, however, it falls into a state of atrophy, except at that 
 part which has entered into the formation of the placenta. As 
 this outer envelope of the foetus forms a portion of the secun-
 
 CHANGES IN THE UTERUS. 117 
 
 dines, and is consequently expelled after delivery, it has been 
 thought by many physiologists that the inner surface of the 
 uterus must be left entirely denuded. Cruveilhier, indeed, 
 asserts that under these circumstances there is no mucous 
 membrane at all to be found, except just at the inner surface 
 of the cervix uteri ; the muscular tissue of the uterus being 
 everywhere exposed, lie compares this condition with that of 
 a stump after an amputation, the gaping veins at the site of the 
 placenta being likened to the open-mouthed vessels left by the 
 knife ; while he believes that a false membrane, the result of 
 local inflammation, is thrown over the surface prior to the for- 
 mation of a new mucous coat. More recent researches seem to 
 have shown that this view is incorrect. What really happens is 
 probably this : About one month prior to parturition setting in, 
 an imperfect mucous membrane begins to be developed under 
 the decidua vera; so that after labor, although the muscular 
 fibres are quite exposed at the site of the insertion of the pla- 
 centa, yet at other parts of the body of the uterus there is a 
 distinct semi-transparent film, which subsequently becomes de- 
 veloped into a perfect mucous membrane. 
 
 The atrophy of the proper uterine tissue commences about the 
 fourth or sixth day after labor, and consists in the transformation 
 of the muscular fibres into molecular fat. While this degenera- 
 tion progresses, the uterus rapidly diminishes in volume and 
 weight. At the end of a week from the expulsion of a full-grown 
 foetus, the organ is about six inches in length ; when a fortnight 
 has elapsed, it is scarce!}^ five inches ; while by the completion of 
 the sixth or seventh week it is almost restored to the normal 
 volume of the unimpregnatecl uterus. The whole process of 
 degeneration and reconstruction is spoken of as the involution of 
 the uterus. 
 
 While the fatty degeneration of the muscular fibre cells, with 
 the absorption and escape of the oil particles, is steadily progress- 
 ing, a new series of nucleated fibre cells is developed to take 
 their place ; the change being ultimately so complete, that, ac- 
 cording to Heschl, not one single fibre of the uterus which existed 
 previous to childbirth remains behind. As the disintegration of 
 the old fibres and the development of the new advance, the uterus 
 loses its reddish color, and becomes very friable as well as of a 
 dirty yellow hue ; this latter color slowly disappearing as the new
 
 118 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 muscular fibre cells are at first gradually, but at length rapidly, 
 increased in number. It is not until about the end of two months 
 that the reconstruction of all the tissues of the uterus is com- 
 plete ; while sometimes it is much later than this, for the process 
 of involution may be retarded or arrested by puerperal inflam- 
 mation and other causes. When the involution is quite perfected, 
 the organ which weighed about one pound and a half immedi- 
 ately after delivery, is, as it were, replaced by a new compact 
 structure, usually weighing rather less than 2 oz. and having a 
 cavity only 2| inches in length. It must not be imagined that 
 the uterus thus formed minutely resembles the Avomb of the 
 virgin. On the contrary, as has been already mentioned, the 
 body is rather larger, and, so to speak, more clumsy ; the os is 
 more patulous and much better defined ; while the lips are more 
 fully developed, and frequently have their edges notched or 
 fissured. If, with respect to the reproduction of these imperfec- 
 tions, the question Cui bono? be asked, it cannot be answered. 
 Notwithstanding, however, that the reason for all this does not 
 at present admit of explanation, yet that it is so may be readily 
 understood. It is only necessary to remember, that although the 
 component structures of the skin — to take a familiar example — 
 are undergoing a constant process of growth and decay, of de- 
 generation and renewal, yet moles and cicatrices and other ab- 
 normal marks are all reproduced, time after time, with the most 
 accurate precision. 
 
 Section 8. — Ballottembnt, or Repercussion. 
 
 Ballottement {Ballotter, to toss ; as to toss a ball at tennis), or 
 repercussion, is a valuable means of acquiring information as to 
 the existence of pregnancy, being less liable to deception than 
 many of the other signs. It depends for its production upon the 
 tilting of the foetus, whether alive or dead, upwards in the liquor 
 amnii in which it floats ; the force being communicated in such a 
 manner, that the child descends upon the finger which dislodged 
 it with a slight impulse. 
 
 There are three ways of practising ballottement. The first, or 
 external method, is performed by placing the patient on her side, 
 on the extreme edge of the bed, with the abdomen projecting
 
 BALLOTTEMENT. 119 
 
 over it. One open hand is'then laid flat on the under surface of 
 the abdomen, and the other on the upper side to insure steadi- 
 ness; when by makiug a sudden impulse with the lower hand, 
 the foetus will be propelled to the opposite side of the bag of the 
 amnion, and will afterwards rebound on the spot from which it 
 was projected. The s^concZ external plan — hypogastric repercussion 
 as it has been termed — consists in placing the woman on her 
 knees with the shoulders depressed, or on her side with the hips 
 well raised. The foetus will consequently gravitate towards the 
 fundus uteri, which is in contact with the abdominal parietes; 
 and by then making a jerking pressure as before, the same result 
 will be obtained. The third, or internal method, is the best ; and 
 it should generally be resorted to when there is no objection to 
 instituting a vaginal exploration. The patient may be examined 
 in the upright position, if necessary ; though obviously it will be 
 better for her to be in bed, reclining upon her side v^'ith the 
 shoulders much elevated. Whichever position is adopted, the 
 bladder and rectum should both be empty, so as to afford as much 
 space as possible. The first two fingers of either hand are then 
 to be freely oiled and introduced into the vagina and carried up- 
 wards, as far as they can be made to extend, to that thin portion 
 of the body of the uterus situated between the cervix and poste- 
 rior wall of the bladder. Meanwhile the disengaged hand is to 
 make steady pressure downwards upon the abdomen, the woman 
 being directed at the same time to draw a deep inspiration. The 
 examiner taking advantage of the temporary depression of the 
 uterus, makes a quick jerking movement upwards, and forwards, 
 with the fingers in the vagina ; by which movement he will re- 
 ceive the impression as of a slight body bounding away, which 
 in a few seconds falls again on the tips of the fingers that have 
 been kept in contact with the uterus. 
 
 Most writers state that the discovery of this sign affords a posi- 
 tive proof of the presence of a foetus in the uterus. Such a pro- 
 position is rather too absolute. For example, it is doubtless 
 possible that a stone resting in the bas-fond of a distended bladder 
 might lead to an error. The same mistake would perhaps hap- 
 pen in ovarian dropsy, should, there exist a small pedunculated 
 tumor within a larger cyst. So, also, a somewhat hypertrophied 
 and indurated ovary, coexistent with ascites, has produced a 
 movable tumor which has caused an impulse very like that con-
 
 120 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 veyecl in pregnancy by the motion of the foetus in the liquor 
 amnii. M. Cazeaux relates that he once met with a case in which 
 the fundus of an anteverted uterus very nearly misled him. He 
 
 says,— 
 
 "During the time I acted at the Obstetrical Clinic as chef de clinique, a 
 woman was subjected to the touch, who declared herself pregnant and ad- 
 vanced to the third or fourth month. At first I examined her in the recum- 
 bent position, and found all the negative signs of gestation; but one of my 
 advanced pupils then performed the same manipulation in the standing 
 posture, and declared that he perceived the^ballottement. When I I'e-ex- 
 amined her, I found the following condition of things ; the neck was strongly 
 pushed backwards, and a little to the left, it was slightly softened, and suf- 
 ficiently patulous to admit the extremity of the finger. (This woman ac- 
 knowledged she had been delivered only four months, previously.) As the 
 finger left the cervix and advanced just behind the symphysis pubis, it 
 encountered a large resisting surface, which was evidently the body of the 
 organ ; and then by giv^n^a slight blow, a movable body was felt there, 
 which immediately fell back upon the fingei", exactly as the foetus would in 
 the fourth month. I confess that at first I thought her enceinte; but 
 retouching her in the recumbent state, I once more remarked the negative 
 signs, though my finger could not now detect the substance which had been 
 so easily moved when she was standing. At the third examination I dis- 
 covered an anteversion of the womb, so complete that its anterior face had 
 become inferior or horizontal, and it was over nearly the whole extent of 
 this face the finger had passed in examining; and further, I found that the 
 fundus uteri, situated behind the symphysis pubis, was the light movable 
 body which had produced the sensation of ballottement."^ 
 
 The incapability of producing ballottement must not be taken 
 as a decisive proof that pregnancy does not exist ; since man}'- 
 circumstances may prevent even a careful examiner from detect- 
 ing it. Malposition of the foetus renders its appreciation difficult : 
 in foot or breech presentations, the soft tissues greatly impede 
 the rebound from being felt, while in transverse presentations it 
 is generally impossible to obtain it at all. Presentation of the 
 placenta may hinder its detection ; for the foetus must of course 
 rebound on this organ, the thickness and softness of which is 
 very likely to prevent any impulse being communicated to the 
 finger. 
 
 Repercussion can usually be practised with the greatest hope 
 of success, from the end of the fourth month of pregnancy to 
 about the termination of the seventh. At an earlier period than 
 
 1 A Theoretical and Practical Treatise on Midwifery, &c. Second American, trans- 
 lated from the Fifth French Edition, by W. R. Bullock, M.D., p. 150. Philadelphia, 1857.
 
 SIGNS DERIVED FROM AUSCULTATION. 121 
 
 the fourth month, the embryo is too small and light to be dis- 
 tinctly felt. After the end of the seventh month, the foetus is 
 usually too bulky to move or float freely; while the liquor amnii 
 is then also relatively less in quantity. 
 
 In the exploration of the vulva and vagina and cervix uteri by 
 the touch, the jihysician should accustom himself to use the 
 fingers of either hand; for without going so far as to assert that 
 a good obstetrician must necessarily be ambidextrous, it is still 
 certain that he will find it very advantageous to be so. This 
 will be especially the case in certain displacements of the gravid 
 uterus, when the riglit and left hands may have to be alternately 
 employed to make a positive diagnosis; as well as when the ac- 
 coucheur is incapacitated from using one hand by a wound, 
 whitlow, &c. It occasionally becomes necessary to learn the 
 condition of the uterus by instituting an examination per anum ; 
 a proceeding, however, which is only to be resorted to when ab- 
 solutely necessary, since it shocks the sense of decency in most 
 women. In practising it, the patient ought generally to be 
 placed u]3on her left side; while the examiner should carefully 
 introduce the index or second finger of his left hand, so that its 
 sensitive pulpy extremity may be applied to the back of the 
 uterus. The chief conditions which render an examination by 
 the rectum advisable are as follows : (1) The hymen being intact 
 it is not only difiicult to practise the vaginal touch, but we ought 
 to avoid rupturing this membrane, because the suspicion of preg- 
 nancy may be unfounded. (2) The existence of a tumor in the 
 recto-vaginal septum w^ill possibly render the ordinary examina- 
 tion almost useless. (3) The increased bulk of the uterus during 
 the first two months of gestation can be more easily detected per 
 rectum than per vaginam ; a fact to be recollected when it be- 
 comes desirable to ascertain very accurately the extent of this 
 enlargement. And (4) it may be demanded by the existence of 
 extreme sensibility of the vagina, or by the union of the sides of 
 this canal owing to abnormal adhesions, or by the presence — 
 imaginary or real — of some malformation. 
 
 Section 9. — Signs derived from Auscultation. 
 
 A very great advance was made in the value of the diagnostic 
 signs of pregnancy, when M. Maior — an eminent surgeon of
 
 122 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 Geneva — announced his discovery of the sounds of the foetal 
 heart by the aid of auscultation. This happened towards the 
 end of the year 1818. But owing either to this gentleman's 
 want of energy, or to his entertaining only a slight conception 
 of the results which his discovery might lead to, he remained 
 content with merely publishing the circumstance that he had 
 heard the foetal heart's action, by applying his ear to the abdo- 
 men of a woman far advanced in pregnancy ; while he left to 
 others the task of prosecuting the inquiry further, and establish- 
 ing the results. Hence, little attention was paid to the subject 
 until some four years later, when Dr. Lejumeau de Kergaradec 
 gave to the world his systematic treatise; in which he not only 
 proved that the foetal heart-beats could be detected at a much 
 earlier period than M. Maior had suspected, but also pointed out 
 a new and important sound — the uterine souffle.^ Ko further 
 progress was made for some few j-ears. Then, in 1833, Dr. 
 Evory Kennedy drew attention to the sounds heard in advanced 
 pregnancy in the arteries of the umbilical cord ; which were de- 
 scribed by him as the funic pulsation and the funic souffle.^ 
 Again an interval elapsed, though a short one, before Dr. H. F. 
 Kaegele proved that the noise produced by the plunging move- 
 ments of the fcetal limbs in utero may be heard as gentle taps 
 repeated at intervals, at an earlier period than they can be de- 
 tected by the hand of the practitioner applied over the mother's 
 abdomen.^ 
 
 In considering separately these phenomena, the order in which 
 they have just been mentioned will be reversed ; so that the most 
 important may be the last treated of.^ Before entering upon this 
 task, a few words will suffice to show the best mode of practising 
 obstetric auscultation. As in other branches of medicine so in 
 this, a certain amount of knowledge and tact is necessary to de- 
 tect the various grades of the phenomena presented, and to ap- 
 
 1 M^moire sur rAnsoultation appliqnee a rEtiule de la Grossesse. Paris, 1822. 
 
 * Observations on Obstetrical Auscultation, with an Analysis of the Evidences of Preg- 
 nancy, &c. Dublin, 1833. 
 
 ' Die Gcbnrtshiilfliche Auscultation, p. 62. Mayence, 1838. Or Dr. West's transla- 
 tion, Obstetric Auscultation, p. 50. London, 1839. 
 
 * There are two other sounds which the stethoscope, applied to the abdomen of a 
 pregnant woman, may at particular periods detect; but a discussion as to their utility 
 does not full within the scope of this volume. The first is a supposed murmur, like the 
 sound of fermentation, which is said by M. Stoltz, of Strasburg, to accompany the de- 
 composition of the liquor amnii antl foetal fluids. The second is a crackling noise, imi- 
 tated by drawing the nail over a rush-bottomed chair, asserted by M. Caillant to be 
 caused by the separation of the placenta.
 
 SIGNS DERIVED FROM AUSCULTATION. 123 
 
 predate their value. Aud even after a familiarity with the 
 diflerent foetal and maternal sounds has been acquired by pains- 
 taking study, it must be still remembered that a well-schooled 
 ear, with steady attention and great' patience, will be found re- 
 quisite in the examination of the majority of cases. There are 
 very few, if any, occasions, on which mediate auscultation will 
 not prove very preferable to immediate ; for, independently of 
 utility and convenience, it is obviously better to apply the stetho- 
 scope to the patient's abdomen than the naked ear. Some 
 writers assert that the phenomena are best heard early in the 
 morning, when the patient is fasting, and when the bowels and 
 bladder have been emptied. Where the practitioner has confi- 
 dence in his sense of hearing, however, he need not wait for any 
 special time of the day; taking care rather to seize the oppor- 
 tunity as it presents itself The patient should be placed on a 
 couch of a convenient height, upon her back, and with the head 
 raised by a pillow ; the limbs being moderately flexed, so as to 
 relax the abdominal muscles. If the abdomen be covered, it 
 should only be with a thin chemise. Care must be taken, too, 
 that there is no retention of urine. Supposing the physician 
 fails in detecting the evidence sought for, he miist not rest satis- 
 fied with this kind of negative testimony; since many impedi- 
 ments to his success may be present. The chief of these obsta- 
 cles are, — too early a period of gestation ; great feebleness or 
 death of the foetus ; the maternal integuments being loaded with 
 fat ; the complication of loud noises made by the intestinal gases ; 
 and distension of the abdomen from dropsy, or from some tumor, 
 coexisting with pregnancy. On ausculting the abdomen of a 
 healthy woman who is not pregnant, whether at a catamenial 
 period or not, borborygmi and other noises due to the movement 
 of flatus in the intestines, will be heard ; together, generally, with 
 the pulsations of the abdominal aorta. 
 
 The observation has been already made that the fcetal move- 
 ments are generally first felt by the mother about the sixteenth 
 week after the fruitful coition. Dr. H. F. IsTaegele has shown that 
 very frequently the friction produced by these movements may be 
 heard a few weeks earlier than this time; when the foetus is very 
 small in proportion to the size of the cavity containing it, and 
 when, therefore, the free movements of the limbs are unrestrained.
 
 124 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 The sounds are perceptible as gentle taps, repeated at intervals ; 
 sometimes being continued so regularly, that an unpractised aus- 
 cultator might mistake them for the beatings of the foetal heart. 
 As pregnancy advances, and as the quantity of liquor amnii be- 
 comes proportionately diminished, these motions are rendered 
 more and more indistinct; so that at the end of gestation they 
 can scarcely be detected. 
 
 The umbilical cord in the human subject consists essentially of 
 one large vein, and two smaller arteries coiling around it; these 
 being bound together by a quantity of connective tissue, with 
 cells containing much gelatinous matter. The gelatinous mate- 
 rial varies in quantity in diflerent embryos : it gives thickness to 
 the cord, and likwise serves to protect the vessels from the in- 
 jurious effects of pressure. The funis is also covered by a layer 
 of chorion, and externally by a reflexion of the amnion. The 
 purified blood for the nutrition of the foetus is conveyed from the 
 placenta to the foetus by the umbilical vein, which enters the abdo- 
 men at the umbilicus, passes upwards to the under surface of the 
 liver, and at the transverse fissure divides into two branches. The 
 larger of these branches joins the portal vein ; while the smaller 
 — under the name of the ductus venosus — unites with the inferior 
 vena cava. The venous blood is returned to the placenta by the 
 two umbilical arteries, which are the continuations of the foetal 
 internal iliac arteries. At the time of labor, the funis is gener- 
 ally about twenty or twenty-four inches in length; but it has been 
 found as short as five or six inches, and as long as six feet. 
 
 Now, according to the observations of Dr. Kennedy, the pulsa- 
 tions in the umbilical arteries can — in certain positions of the 
 funis — be distinctly heard by the stethoscope ; the beats corre- 
 sponding to those of the foetal heart, and existing so long as the 
 circulation of the foetus in utero continues. The funic pulsations 
 are particularly observable when a portion of the cord intervenes 
 between some prominent part of the child's body and the anterior 
 wall of the uterus ; though unless the abdominal integuments of 
 the mother are also rather delicate, the sounds will be detected 
 with difliculty. The funis also presents another phenomenon, 
 viz., a soufile, or murmur; which is weaker than the uterine 
 souffle, has a shorter and less hissing sound, and corresponds in 
 frequency with the action of the child's heart. This funic souffle
 
 SIGNS DERIVED FROM AUSCULTATION. 125 
 
 is said to be due to the transmission of the blood through a part 
 of the umbilical arteries where a narrowing of their calibre exists. 
 Such a diminution in size can readily be produced either by the 
 compression of a foetal limb, or by a knotting of the funis, or by 
 the winding of the cord round the neck of the foetus, or even by 
 the moderate pressure of the stethoscope. 
 
 These phenomena, it must be confessed, do not possess much 
 practical value. Two circumstances account for this. In the first 
 place, it will at least be very difiicult to detect either the pul- 
 sations or the murmur, unless the abdominal parietes and the 
 uterine wall are so thin that the funis and foetal limbs can be 
 distinguished by the touch. And secondly, these sounds are 
 only to be heard at the latter part of pregnancy, when we can 
 resort to other and more useful sources of information. 
 
 The uterine souffle — or placental murmur, as M. Kergaradec 
 termed it — is usually audible a few weeks earlier than the foetal 
 heart. It consists of a single and intermitting and hissing or 
 blowing sound, without impulse or pulsation, and is synchronous 
 with the mother's pulse. The murmur has been compared to a 
 prolonged whispered "who," or to the sound emitted by blowing 
 a pair of bellows ; occasionally it is brief, like an abrupt whiff 
 with each pulsation of the mother's heart; while sometimes it as- 
 sumes all the variations in tone of the hruit de soufflet of the heart, 
 such as a whistling, roaring, cooing, or sawing sound. More- 
 over, firm pressure with the stethoscope will frequently obliter- 
 ate it. 
 
 The question as to the seat of this murmur has given rise to 
 some controversy. At one time, it was the current belief that it 
 existed in the utero-placental circulation ; and hence it became 
 designated the placental murmur. Then many auscultators as- 
 signed its seat to the large arteries — the aorta and iliac — at the 
 back of the abdomen, considering it as produced by the pressure 
 of the gravid uterus. They named it, therefore, the abdominal 
 murmur. M. Cazeaux has suggested that it is due to pressure 
 on the iliac vessels, conjoined with the existence of an altered 
 condition of the blood. But the most plausible view is that which 
 regards it as originating in the arterial vessels ramifjdng through 
 the uterine tissues ; whence it appears to be very properly des- 
 ignated the uterine souffle, or murmur. The fact that it may
 
 126 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 generally be most distinctly heard over that portion of the uterus 
 which corresponds with the insertion of the placenta, is by no 
 means surprising ; since we should naturally expect to find it 
 most audible at the part where the develoj^ment of the uterine 
 vascular system is the most considerable. But Hohl's assertion, 
 that it is to be heard only over that part, can I think be contra- 
 dicted by daily observation. 
 
 The period at which the uterine souffle may be first distin- 
 guished is liable to vary in difterent cases. Dr. Kennedy states 
 that he has detected it as early as the tenth week ; but I cannot 
 recall any instance where I have been equally fortunate, though 
 I have certainly heard it at the end of the twelfth. As a general 
 rule, it will be heard at the third month and a half, or at the be- 
 ginning of the fourth month, when the fundus uteri is above the 
 pubes. In seeking for it at this early period, the stethoscope 
 should be applied just above the pubes; for the soufile is then 
 diffused over the whole uterus. But at a later date, it will be 
 most commonly detected by placing the stethoscope over either 
 of the lumbar or iliac regions ; though it must be remembered 
 that this murmur changes its situation in a remarkable manner, 
 so that no certain rules can be laid down upon this point. In- 
 deed, the space over which it may be heard varies not only in 
 different individuals, but in the same woman on separate days ; 
 being sometimes limited to one spot, at other periods existing 
 over a much larger surface, and occasionally being found — even 
 at an advanced period of gestation — over the whole of the anterior 
 wall of the uterus.' Moreover, in the course of a few hours, its 
 seat will fluctuate ; so that, in the afternoon, it may be distinctly 
 audible over a spot where it could not be heard in the morning. 
 It is not improbable that it might be detected at an earlier period 
 than ordinarily by means of M. Kauche's metroscope; but the 
 necessity of introducing one extremity of this instrument into 
 the vagina is an insuperable objection to its general employment. 
 The same remark applies to the uterine stethoscope constructed 
 by Dr. Keiller. The end of this instrument is introduced into 
 
 1 Dr. Depaul i?tates that in 295 cases (2^1 ?) wliere gestation had exceeded the fifth 
 month it was heard distinctly on both sides in 182 ; on one side only, in 27 ; towards 
 the fundus alone, in 4-3 ; in 18 the stethoscope could not be placed over any portion of 
 the uterus without detecting it; while in 12 it existed strongly marked in three places, 
 viz., at the fundus, and just above Poupart's ligament on each side. — Traitfe d'Auscidta- 
 tion Ohstetricale, p. 179. Paris, 1847.
 
 SIGNS DERIVED FROM AUSCULTATION. 127 
 
 tlie vagina and applied to the uterine wall, not to the os or cervix. 
 In this way it is contended, that the auscultatory signs of preg- 
 nancy may be detected at a much earlier period than by auscult- 
 ing the uterus through the abdominal walls. The uterine souffle 
 being quite independent of the foetal circulation, it is not in the 
 least affected by the life or death of the infant ; for it may be 
 heard after the expulsion of the child, and even for twenty-four 
 hours after the delivery of the placenta. Where the uterine 
 contractions after labor are very vigorous, however, the sound 
 will usually be found to have ceased. 
 
 Too much importance must not be attached to this uterine 
 souffle; for at the best, its presence can only allow us to conclude 
 that pregnancy is probable. I am inclined to think, that as a 
 single sign, it is of most value when heard at an early period of 
 gestation, before much uterine or abdominal enlargement is ob- 
 servable ; since it is then less likely to be due to any other con- 
 dition than pregnancy. I may take, for an example, the following 
 case from my note-book : 
 
 In the year 1857, I was consulted by a young unmarried lady for general 
 debility and amenorrhoea. The catamenia had been on for the hist time 
 twelve weeks previously. A drop or two of milk could be expressed from 
 the nipples. There was no morning sickness. On a careful examination, 
 no uterine tumor could be detected. By applying the stethoscope just above 
 the pubes, I discovered the uterine souffle very distinctly. Coupling this 
 sign with the absence of abdominal tumor, and the presence of milk in the 
 breasts, little hesitation was felt in stating that she was pregnant. Six 
 months afterwards I delivered her of a live child. 
 
 The fact is unfortunate but it is undeniable, that sometimes 
 this murmur cannot be detected, even after many examinations, 
 and yet pregnancy may exist. Instances of this, however, must 
 be rare. On the other hand, I have frequently heard it in large 
 uterine fibroid tumors, and in one instance when the uterus was 
 considerably increased in size from the presence of a vesicular or 
 hydatidiform mole. A few practitioners also state that they have 
 detected it in ovarian dropsy, an observation which I cannot cor- 
 roborate. The souffle, moreover, when present during pregnancy 
 indicates nothing as to the child's position, nor as to its strength 
 or weakness, nor as to the number of ova which have been 
 fertilized. 
 
 The beats of the foetal heart are to be detected during the last 
 half of intra-uterine life, as distinct rapid sounds, which bear a
 
 128 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 close resemblance to the muffled ticking of a watch, — to that of 
 a watch covered with two or three folds of a blanket. The beats, 
 which can frequently be easily reckoned, vary in frequency from 
 120 to 140, or even 150, in the minute; and eachbeat or ventric- 
 ular contraction is accompanied by two sounds. The first sound 
 is weak, short, and obscure: the second is more sonorous and 
 distinct, and is the one which is usually counted, for from their 
 great rapidity it is generally impossible to compute both. The 
 beats bear no relation to the mother's pulse, as regards frequency 
 or force ; they are uninfluenced by the'uterine contractions ; they 
 are only temporarily accelerated by the movements of the foetus ; 
 and the further pregnancy is advanced, and the greater the 
 strength of the foetus, the more easily will they be detected. A 
 good idea of the nature of the foetal heart-sounds may be acquired 
 by listening to the chest of the new-born infant. The student 
 will in this way learn that the heart's action is commonly audible 
 over a considerable extent of surface ; since it may be heard by 
 applying the stethoscope to any part of the chest, to the arm 
 while pressed against the thorax, and perhaps to the loins. If 
 then he also remembers, that while in utero the solid foetal lungs 
 act as good conductors of sound, he will see nothing incredible 
 in the statements here made. 
 
 Dr. Depaul asserts that he has been able to distinguish the 
 pulsations of the foetal heart as early as the eleventh week. Very 
 few other practitioners have been equally lucky. I have fre- 
 quently tried to obtain them about this time by using the double 
 stethoscope, and so placing the woman on her face that the uterus 
 might fall into close apposition with the anterior wall of the ab- 
 domen ; but the experiment has not been attended with success. 
 In a large lying-in hospital to which Naegele was attached, the 
 eighteenth week of pregnancy was the earliest period at which 
 the sounds could be distinctly heard, while in by far the largest 
 number of cases it was not until the end of the twentieth week. 
 These results agree with those obtained in this country. Hence 
 it may be affirmed, as a general rule, that the sounds of the pul- 
 sations cannot be discovered until just about midway between 
 the day of conception and that of labor at the full term. 
 
 The double sounds of the foetal heart will perhaps, in rare 
 cases, be heard over half of the maternal abdomen. Usually they 
 are confined to a spot about two inches in diameter; which
 
 SIGNS DERIVED FROM AUSCULTATION. 129 
 
 spot — owing to the variety of the positions of the child — may 
 exist over ahiiost any part of the abdominal wall, though at 
 nearly the full term it is most frequently to he found rather be- 
 low and about two inches to the left of the umbilicus. When 
 the quantity of liquor amnii is small, the foetal thorax gets pressed 
 into close apposition with the uterine wall, and then the sounds 
 are heard very distinctly, but only over a limited space. On the 
 contrary, if there be an excess of liquor amnii, the extent of 
 surface over which the beats can be distinguished is much in- 
 creased, whilst their intensity is diminished in a corresponding 
 deo;ree. If we detect the foetal tictac beatina; about 130 in the 
 minute, while the maternal pulse is 90 or any number except 130, 
 we may be positive that there is the heart of a live child beneath 
 our stethoscope. Nothing can render such a proof invalid. But 
 if we fail, after a careful and prolonged exploration, to discover 
 the beats, it must not be rashly concluded that the woman is not 
 pregnant. For clearly she can be so, and yet the child may be 
 dead; or, possibly, the sounds are obscured by a very great 
 abundance of liquor amnii ; or there may be a fold or two of in- 
 testine between the uterus and abdomen, the borborygmi in 
 which mask all other phenomena. M. Stoltz has also stated that 
 these foetal heart-sounds cannot be heard when the dorsal region 
 is directed backwards, unless some part of the child's thorax be 
 in contact with such a portion of the uterine walls as admits of 
 exploration. As a matter of fact, however, the position of the 
 foetus is always such, that if it be alive and its development suf- 
 ficiently advanced, the sounds can almost always be detected. 
 Thus, M. Cazeaux asserts that in examining some seven or eight 
 hundred women, advanced beyond the sixth month, he never 
 failed in hearing the pulsations whep the child was alive.^ Pro- 
 fessor Anderson, of Glasgow, in ausculting 180 pregnant women 
 at the full time, only missed in 12 instances to find the sounds of 
 the foetal heart; and in these 12 cases, and in these only, was the 
 child born dead.^ Had I kept notes of all the cases in which I 
 have resorted to obstetric auscultation, they would certainly con- 
 firm these observations of Cazeaux and Anderson. Only one 
 
 ^ A Theoretical and Practical Treatise on Midwifery, &c. Second American, trans- 
 lated from the Fifth French edition, by W. R. Bullock, M.D., p. 153. Philadeljihia, 1857. 
 
 2 The London and Edinburgh Monthly Journal of Medical Science, vol. iv, p. 101. 
 London and Edinburgh, 1844.
 
 130 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 fallacy can arise with respect to this sign, viz., when the ma- 
 ternal heart is beating with abnormal rapidity, and the aortic 
 pulsations are conveyed to the abdominal walls by some uterine 
 fibroid, or by an ovarian tumor, or by some other growth. At- 
 tention to two points will prevent our entertaining an unjust 
 suspicion of pregnancy in such instances. In the first place, we 
 shall find that the pulsations, as well as the sounds of the beats, 
 are uniform over the whole tumor, whatever its size may be; in- 
 stead of being confined to a small circle, as are the sounds of the 
 foetal heart. And, secondly, the abdominal beatings will be per- 
 fectly synchronous with the pulse at the wrist. 
 
 The sign under consideration, moreover, is valuable on many 
 grounds besides its certainty. Thus, it is quite independent of 
 the patient's emotions ; it can be sought for without her having 
 any idea of the nature of our suspicions; while if found, it will 
 render a vaginal examination unnecessary. In the diagnosis of 
 twin-pregnancy, the only sign on which any reliance can be 
 placed, is the detection of the distinct pulsations of two foetal 
 hearts at a distance from each other. Such a diagnosis is iree 
 from all chance of error, if the beats vary in frequency in the 
 two situations; or if a spot exists between the two where neither 
 can be distinguished, but from which both can be reached by 
 passing the stethoscope upwards on the one side and downwards 
 on the other. It can readily be understood that in these cases 
 one heart is very generally heard below and to the right or left of 
 the linea alba, while the other is above and on the opposite side. 
 
 When a woman is pregnant of twins, and one dies at an early 
 period of gestation, the dead child is usually retained until its 
 fellow has arrived at maturity. But it sometimes happens that 
 the dead foetus is expelled within a few days of its ceasing to 
 live; while the other remains alive in utero until the completion 
 of the full term. Now in such a case, the mother, knowing that 
 she had aborted, would not believe herself pregnant ; and con- 
 sequently might be much alarmed at finding that the catamenia 
 did not reappear, nor her abdomen diminish in size. This 
 anxiety would be at once dispelled by our detecting the foetal 
 heart, and explaining positively the cause of her condition. 
 
 The presence of three distinct double sounds, not isochronous, 
 would warrant the diagnosis of triplets. 
 
 The assertion has been made by Dr. Frankenhauser, and has
 
 SIGNS DERIVED FROM AUSCULTATION. 
 
 131 
 
 been reiterated by M. Zepulder (see p. 48), that the mean number 
 of the beats of the foetal heart, as ascertained by auscultation, are 
 more frequent in female than in male foetuses. The mean fre- 
 
 FiG. 9. 
 
 THE ABDOMEN LAID OPEN TO SHOW THE UTERUS, CONTAINING TWINS, AT THE 
 FULL TERM OF PREGNANCY. 
 
 The umbilicus of the mother corresponds to a spot about the centre of the uterus. The circles across 
 the foetal trunks indicate the situations where the sounds of the hearts would be heard: the larger the 
 circle, the more distinct the sounds. 
 
 quency of twenty-eight female foetuses is 144 in the minute, the 
 lowest figure, 138 ; the mean frequency of twenty-two male 
 foetuses is 120, the highest figure, 132. By applying this rule, 
 Dr. Frankenhauser has often been able to say correctly, before 
 birth, what was the sex of the child ; and, indeed, he seems to
 
 132 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 infer that the rule has never failed him, provided it was put to 
 the test before the contractions of the uterus during labor had 
 deranged the natural frequencj^ of the foetal heart. In order to 
 put this observation to the test of experiment, I carefully exam-^ 
 ined six women, who were all in the last month of gestation. 
 In the first, the beats were 136 in the minute, and the child, 
 when born ten days afterwards, was found to be a male; in the 
 second, the pulsations were so quick that I could not count 
 them, and the patient was delivered of a dead male foetus four 
 days afterwards ; in the third instance, the beats were 140, and 
 three days afterwards delivery proved that the child was a male; 
 in the fourth, the beats amounted to 140, and the patient bore a 
 girl ; in the fifth, the beats were 128, and the ofl*spring proved 
 to be a boy on the following day; while in the sixth, the pulsa- 
 tions were 136, and the woman gave birth to a girl ten days 
 subsequently. These experiments seem at least to prove that 
 Dr. Frankenhauser's observations will not apply to the intra- 
 uterine children of this metropolis. 
 
 If the mother's abdomen be ausculted at the commencement 
 of labor, the sounds of the foetal heart will generally be detected 
 in one or other iliac fossa; and more frequently in the left than 
 in the right. The precise locality depends mainly upon the 
 position of the foetus; the maximum of intensity almost always 
 corresponding to the part of the uterus with which the child's 
 thorax is most closely in contact. In ordinary vertex presenta- 
 tions the back of the thorax is the part nearest to the uterus, 
 owing to the child's legs being doubled up on the abdomen, the 
 chin depressed on the chest, and the whole body bent forwards 
 so as to present a considerable convexity on its posterior part. 
 Hence, in the first and second positions of the head (where the 
 back of the child is anterior), we may expect to find the foetal 
 pulsations most audible in the left and right inguinal regions 
 respectively; whilst in the third and fourth positions they should 
 be more posterior towards the woman's loins. In presentations 
 of the face, tlie front of the chest is the part which lies most 
 contiguous to the uterine parietes; and the situations of the 
 foetal pulsations have been found to agree therewith, being 
 audible anteriorly (in the iliac region) when the head holds the 
 mento-pubic position, and rather posteriorly when it is in the 
 opposite or meuto-sacral position. As regards l)reech prescnta-
 
 MINOR SIGNS. 133 
 
 tions and footling cases, the foetal heart is most distinctly heard 
 near the mother's umbilicus. These views were learned lone: 
 since from an excellent essay which was read before the Dublin 
 Obstetrical Society bj^ Dr. McClintock.' The experience which 
 has since been gained has convinced me that they are in the 
 main correct. 
 
 The illustrious Harvey speaks of the auricles as the primum 
 vivens, ultimum moriens ; an expression which might with some 
 license be more justly applied to the whole heart. The moving 
 power of this organ — the life of the flesh — is the blood ; and it 
 can hardly be deemed an extravagant conjecture if we suppose 
 that this being to any serious extent diseased, the foetal heart's 
 action must become appreciably affected. At present, however, 
 we cannot do much to ascertain by means of auscultation the 
 condition of the child's health while in utero; for we really 
 know nothing beyond the simple facts, that excessive frequency 
 of the pulsations, or a diminution in their force, or intermission 
 and irregularity of their rhythm, are so many symptoms betoken- 
 ing feebleness and proportionate danger. When in tedious and 
 difiicult labors we find the foetal pulse becoming slower and 
 slower, we may reasonably infer that undue pressure is being 
 exerted on the funis, thereby causing the aeration of the blood 
 by the placenta to be imperfectly performed. Where, on the 
 contrary, the beats of the heart increase in rapidity, and especi- 
 ally when they likewise become irregular and intermittent, it is 
 probable that the danger does not result from the pressure upon 
 the umbilical cord, but from compression of the brain, or from 
 a source causing cerebral irritation. Under any of these circum- 
 stances we have an indication that the child's life is in danger. 
 And hence the labor should if possible be terminated, either by 
 turning or the application of the forceps. 
 
 Section 10. — The Minor Signs. 
 
 The first of these minor signs which claims some slight atten- 
 tion is derived from the urine. The examination of this secre- 
 tion during pregnancy, for the detection of some peculiar phe- 
 nomenon, has long been a favorite practice with physicians; 
 
 1 The Dublin Quarterly Journal of Medical Science, vol. iv, p. 34. Dublin, 1847.
 
 134 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 since we find even Hippocrates, Aviceuna, Galen, Oribasius, and 
 other ancient authors, noting the changes which they thought 
 were induced. More than three centuries ago, Savonarola wrote, 
 that from the commencement of gestation to the sixth month, 
 more or less, the urine is clear, of a pale lemon color, having a 
 cloudiness on its surface, and a deposit in its centre resembling 
 carded wool ; while towards the sixth or seventh month it as- 
 sumes a turbid appearance with a reddish tinge, the redness be- 
 coming more marked as the time of labor approaches. He also 
 warned his readers not to place too much reliance on these ap- 
 pearances ; since they are commonly seen in women with simple 
 suppression of the menses, in cases where the uterus contains a 
 mole, and in some instances of gouty or rheumatic inflammation.^ 
 Although the amount of information contained in these para- 
 graphs could never have proved of much practical utility, yet it 
 may be questioned whether it would be judicious to inquire, — 
 In what respect is our knowledge on this head more valuable 
 now, than it was in the year 1560 ? 
 
 About thirty-six years ago (in 1831) the British and foreign 
 medical journals published accounts of a peculiar product dis- 
 covered by M. I^auche, and named by him kiestein ; which ma- 
 terial was supposed to exist only in the urine of women during 
 utero-gestation. This substance becomes visible in the urine of 
 pregnant women, and more exceptionally in that of non-pregnant 
 females suffering from uterine or ovarian disease, when the renal 
 secretion is allowed to repose in a cylindrical glass, protected 
 from the dust. The kiestein begins to make its appearance at a 
 period varying from one day to six or seven, after the urine has 
 been voided ; signs of its gradual development being distinguish- 
 able, in the majority of cases, before the end of forty-eight hours. 
 At first it appears either as a cotton-like cloud in the centre of 
 the glass, which cloud breaks up and forms a pellicle by its par- 
 ticles rising to the surface ; or else as a copious sediment of a 
 whitish color, floating loosely at the bottom of the vessel, par- 
 ticles of which deposit ascend to the surface and form tlie pelli- 
 cle, at the end of some hours or days ;- or again, as a thin trans- 
 
 ' Praclica canonica de febribus, pulsibus, urinis, egestionibus, vermibus, et balneis 
 Italiu', &c. By Joannes Michael Savonarola, p. 685. Lugduni, 15G0. 
 
 '■^ Dr. Stark proposed to designate this substance by the name of gravidine, both from 
 gravidus, big with young, and also from gravis, heavy, seeing that it falls to the bottom 
 of the vessel ; reserving the term kiestein to denote the pellicle which results from the 
 ascent of its particles on the occurrence of decomposition.
 
 MINOR SIGNS. 135 
 
 parent film on the surface of tlie urine, which fihn quickly he- 
 comes thicker and more distinct. When perfectly formed, the 
 pellicle somewhat resembles the scum of fat which forms on cold 
 broth; a character it preserves for about three days. It then 
 begins to break up ; the urine remaining faintly acid up to this 
 time, and often emitting an unpleasant cheesy odor. The pel- 
 licle shortly becomes disintegrated into small flakes ; the com- 
 plete destruction being generally anticipated by the decompo- 
 sition of the secretion. A pellicle somewhat resembling this of 
 kiestein will frequently form on any specimen of urine, when it 
 becomes decomposed : but it will be evident from the foregoing 
 remarks, that decomposition which produces the one, really de- 
 stroys the other. On making a microscopic examination of the 
 true pellicle numerous infusoria of the genus Vibrio are seen, 
 and perhaps some flat globules ; together with large crystals of 
 ammonio-phosphate of magnesia and amorphous phosphate of 
 lime, as well as minute granules of urates of soda and ammonia. 
 
 Dr. Elisha Kane, amongst others, has published the results of 
 numerous observations on this subject. He states, that in eighty- 
 five cases of pregnancy, he obtained a well-marked pellicle in 
 sixty-eight, a modified but recognizable one in eleven, while six 
 afibrded no evidence.^ By many observers kiestein has been 
 found before the end of the second month of pregnancy, and 
 sometimes as early as the beginning of the second week after 
 conception. I have always failed to obtain it when the urine has 
 contained an excess of lithates, even in cases arrived at nearly 
 the full term of gestation. Its presence is supposed to be con- 
 nected with the lacteal secretion, since when the lacteal elements 
 are secreted with a free discharge at the mamm?e carrying them 
 off, it can only rarely be found ; but if the escape of the milk be 
 prevented, or if the breasts are very full and turgid, then kies- 
 tein can generally be obtained. Dr. Kane remarked that in most 
 instances it continued in the urine for a short time after labor, 
 until the mother began to suckle freely ; while of ten women, 
 eight exhibited it at the time of weaning, when the discharge of 
 the milk was of course impeded. 
 
 The exact composition of this substance as it exists in newly- 
 passed urine is unknown. According to Dr. J. Braxton Hicks, 
 
 1 The American Journal of Medical Science, vol. xxx, pp. 13 to 38. Philadelphia, 
 1S42.
 
 136 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 there can scarcely be any doubt that the action of the air alters 
 kiesteiu into a substance very similar to casein ; for it is coagu- 
 lable by rennet, is insoluble in cold acetic acid, and generally also 
 in the hot acid. From this gentleman's researches it likewise 
 appears that the addition of about two teaspoonfuls of rennet to 
 some three ounces of the urine of pregnancy, produces the de- 
 posit from which the pellicle of kiestein afterwards results more 
 abundantly, and in about half the time required for its formation 
 by simple exposure of the urine to the air. If, when the deposit 
 is well formed, we take about half an ounce of the lower turbid 
 portion of the urine, add a few drops of liquor ammonite to it, 
 and boil for a couple of minutes, it will be found that the deposit 
 is formed into a semi-mucous mass, so that the urine becomes 
 almost tremulous. Where this occurs it may be said to be char- 
 acteristic of the presence of kiestein. This test can be employed 
 equally well without the previous use of rennet. The quantity 
 of phosphates thrown down by the ammonia may be known by 
 gradually adding acetic acid, so as slightly to acidulate : the de- 
 posit which remains undissolved being the kiestein.' 
 
 From the foregoing it will be seen, that taken alone, the exist- 
 ence of kiestein in the urine is hy no means sufficiently diagnostic 
 of pregnancy to enable us to form an opinion of an}^ value; but 
 when corroborative of other early signs, it may prove a useful aid 
 in assisting the practitioner to a correct conclusion. The fact is, 
 that although present in pregnancy, yet it may likewise exist in 
 the urine of virgins where there is some irritation of the sexual 
 organs; as well as in that of women with milk in their breasts, 
 the result of a gestation long since completed. It should like- 
 wise be borne in mind, that several physicians and chemists deny 
 that the presence of kiestein is of any value even as secondary 
 evidence. Thus, Dr. Yeit, who conducted a series of experiments 
 to determine the value to be attached to this product, came to 
 the same conclusion as Hofle and Lehmann, viz., that the so- 
 called pellicle of kiestein is no peculiar matter at all, and is not 
 of the slightest value as a sign of pregnancy.^ 
 
 ' 'I'lic^ rennet is to be thus prejjared : Take the fourth stomach of the calf directly it 
 is killed, scour it well inside and (Kit with salt to remove the curd, and let it drain a few 
 hours Tiien place it in a jar, and sprinkle a liandful of salt on it; shortly afterwards 
 the juice will exude and dissolve the salt, and this is then to be filtered through bibu- 
 lous paper and battled for use. Kennet, already salted, may be procured from most 
 butchers. The Lancet, p. 281. 17ih September, 1S5',). 
 
 2 The British and Foreign Medico-Chirurgical Review, vol. viii, p. 551. London, 1851.
 
 MINOR SIGNS. 137 
 
 More thantwenty years since, Mr. Ingleby observed that "in 
 advanced pregnancy the uterus when moderately grasped or 
 rubbed, slightly hardens, independently of actual labor, and al- 
 most instantly regains its yielding condition."* Dr. Oldham has 
 since pointed out, that this power of contraction possessed by 
 the uterus may be taken as a trustworthy characteristic of preg- 
 nancy; for he states that the large gravid uterus alters in a 
 marked manner, under the influence of pressure, from a condition 
 of flaccidity to one of tension. Thus, if we expose a pregnant 
 woman's abdomen, the outline of the tumor is seen to be less 
 defined before manual examination than it becomes afterwards ; 
 for on applying the hand, the tumor which at first is felt soft and 
 ill-circumscribed, rapidly assumes a tense rounded form, becom- 
 ing firm and resisting. Sometimes I have found that mere alter- 
 ation of position has been sufiicient to produce this change ; the 
 uterine walls which have been relaxed so that the foetal parts 
 could be easily distinguished while the patient was lying on her 
 back, becoming tense and hard directly the standing posture was 
 assumed. According to Dr. Oldham, no other tumor but the 
 pregnant uterus possesses this power of altering its form when 
 irritated by palpation -? but I must here beg to difler in opinion 
 from this gentleman. Only a short time before the publication 
 of the first edition of this work, in 1860, I was examining the 
 abdomen of a poor woman suffering from an attack of fiooding, 
 caused by the presence of a very large polypus in the uterus. 
 The loss of blood had been very great, so that all the tissues were 
 relaxed and flabby ; and on placing my hands — which were very 
 cold — over the tumor, I distinctly felt an increased rigidity of 
 the walls of the uterus. And in another instance, where there 
 was considerable development of the uterus owing to the presence 
 in the cavity of a large vesicular mole, the uterine walls became 
 sensibly firmer when pressure was made for a few moments. 
 The truth, indeed, appears to me to be this : That the uterus, 
 in common with other hollow viscera, has, when enlarged through 
 the presence of any substance in its cavity, a regular peristaltic 
 movement, consisting of slight contractions and dilatations. 
 Under the influence of the former the outline of the ore-an can 
 
 1 Facts and Cases in Obstetric Medicine, &c. By J. D. Ingleby, M.R.C.S., p. 250. 
 London, 1S36. 
 
 2 Medical Times and Gazette, 26th January, 1856.
 
 138 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 be easily appreciated, other conditions being favorable ; and these 
 contractions are undoubtedly the more evident the greater the 
 size of the womb, and the more it is irritated by external manip- 
 ulation. But as it seems that the peristaltic motions may occur 
 whenever the uterine cavity becomes enlarged from any cause, 
 it necessarily appears objectionable to instance such movements 
 as trustworthy symptoms of the existence of pregnancy. 
 
 A discoloration of the vagina, so that the walls of this canal 
 assume a dark violet or dusky hue, has been proposed as a test 
 of pregnancy by Dr. Kluge, of Berlin, and M. Jacquemin, of 
 Paris. The chief facts concerning this change are as follows: It 
 is seldom clearly visible until the end of the third month, though, 
 according to Kluge, it commences in the fourth week. The 
 shade is commonly of a livid purple or port-wine hue, very sim- 
 ilar to the tint of the vaginal mucous membrane during men- 
 struation : the color is not always uniformly diilused, but often 
 appears in patches : it can be distinctly seen about the clitoris 
 and urethra, as well as on the inside of the nymphte, though it 
 is most strongly marked at the upper part of the vagina about 
 the OS uteri : it increases from the time of its appearance until 
 the period of delivery, ceasing with the lochia : and it is probably 
 due to a general congestion of the capillaries. The value of this 
 change of color as a sign of foetation is impaired by the fact, that 
 pregnancy may exist without its occurrence; as well as by the 
 circumstance that the deepened hue is often present at the men- 
 strnal periods. Cattle-breeders are so well acquainted with the 
 latter fact, that they learn whether an animal is in heat or not by 
 examining the orifice and inner surface of the vagina, which be- 
 comes almost black when the female is in a condition to receive 
 the male. So, again, I have occasionally found it well marked 
 where a fibroid tumor has been of sufficient size to produce con- 
 gestion of the womb and vagina; in examples of hjq^ertrophy 
 of the uterus, with haemorrhoids and varicose veins; to a limited 
 extent in cases of vascular tumor of the urethra; in certain forms 
 of hepatic disease; and in dropsy attended Avith general conges- 
 tion of the abdominal viscera. Still, if this discoloration be 
 present in a healthy female, in whom the menses have been ab- 
 sent for three or more months, it may be taken as almost decisive 
 of the existence of pregnancy.
 
 MINOR SIGNS. 139 
 
 An examination of the blood might, in some doubtful cases, 
 assist ns in forming our diagnosis; since we know that this fluid 
 undergoes the most remarkable changes almost directly the 
 process of gestation commences. Firstly, the proportion of the 
 globules diminishes at a very early period ; this diminution con- 
 tinuing until the hour of delivery. If blood be drawn from a 
 pregnant woman, a bufty coat will be formed, as in cases of 
 inflammation ; owing to the rapidity with which the corpuscles 
 run together into piles or rouleaux, and sink below the surface of 
 the liquor sanguinis before the coagulation of the fibrine com- 
 mences. Secondly, the proportion of albumen is also sensibly 
 diminished, though not to an equal extent with the globules. 
 Thirdly, the fibrine undergoes a marked increase. And fourthly, 
 as the result of the above alterations, there is a diminished den- 
 sity both of the blood and serum. Moreover, if, as occasionally 
 happens, these changes proceed to a great extent, blowing mur- 
 murs will be audible on auscultation of the bloodvessels of the 
 neck ; while general cedema may result from the infiltration of 
 the connective tissue.^ Very probably also, in such extreme 
 cases, the urine will be albuminous. 
 
 The amount of carbonic acid exhaled from the lungs varies 
 with the age, sex, and state of the system. According to most 
 physiologists the expired air usually contains about four per cent, 
 of its volume of carbonic acid. In the male, there is a progres- 
 sive increase in the quantity of carbonic acid between the eighth 
 and thirtieth years, a rapid augmentation taking place at puberty : 
 after thirty, there is a gradual decrease. In the female, there is 
 a similar increase from the eighth year until puberty: at which 
 epoch the amount remains stationary, and continues so during 
 the period of sexual activity provided the catamenia occur regu- 
 larly. During this time, the average exhalation of carbonic acid 
 per hour is 714 cubic inches. At the change of life, the amount 
 exhaled increases to 915 cubic inches per hour; but after the 
 sixtieth year there is a diminution to 793, and later still to 670 
 cubic inches. During the whole period of pregnancy, the exhal- 
 ation rises nearly or quite to the amount given oft' at the change 
 of life, viz., to between 885 and 915 cubic inches per hour. When 
 
 1 Pathological Chemistry, in its application to the Practice of Medicine. Translated 
 from the French of MM. Becquerel and Rodier, by S. T. Speer, M.D., p. 96. Lon- 
 don, 1857.
 
 140 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 menstruation lias been again established, there is a fall to about 
 714 cubic inches per hour. 
 
 A knowledge of the value of frequent observations on the tem- 
 perature of the body in the diagnosis and prognosis of many 
 acute diseases, led me to inquire whether any reliable indications 
 could be obtained from the use of the thermometer in cases of 
 early pregnancy. To determine this question, I have made a 
 large number of experiments. The temperature has always been 
 taken b}' introducing the bulb of one of Casella's self-registering 
 thermometers into the vagina, and leaving the instrument there 
 for five minutes. It is unnecessary to do more than record 
 the general conclusions at which I have arrived. They are as 
 follows: 
 
 (1) The normal temperature of the vagina in healthy adults, 
 about midway between the catamenial periods, varies from 97.6 
 to 99° Fahr. 
 
 (2) In no case of pregnancy, beyond the first month, has the 
 temperature been found below 99°. 
 
 (3) There is no progressive increase in the temperature as 
 gestation advances. In some cases of healthy pregnancy, the 
 thermometer has registered 99.8 at the end of the second month; 
 while in the same patients, two months later, there has been a 
 fall to 99.5. 
 
 (4) During the last month of gestation, the average tempera- 
 ture has been 100°; but it has been found as low as 99°, and as 
 high as 103° without the existence of any appreciable disease in 
 the mother or fcetus. 
 
 (5) In chronic diseases of the vulva, vagina, uterus, bladder, 
 and rectum, occurring in non-pregnant women, the vaginal tem- 
 perature varies from 98° to 100.5. 
 
 (6) The fair conclusion from the foregoing seems to be, that 
 the data obtained by the employment of the thermometer have 
 no significance in the diagnosis of pregnancy. 
 
 Many other trivial signs have been alluded to by various ob- 
 servers; but none of them have individually much, if any value. 
 One gentleman — Dr. Pollender — writing in 1845, says that during 
 a practice of eighteen years, he has noticed a peculiar smell of 
 the vaginal mucus to be a constant and unerring sign of preg-
 
 MINOR SIGNS. 141 
 
 nancy. The smell is described as musty, something like that of 
 spermatic fluid or liquor amnii ; and, after a vaginal examination, 
 it cannot be mistaken for any other odor. In a great many cases 
 of pregnancy, during the first and second and third months, when 
 the condition of the patient was doubtful, Dr. Pollender never, 
 in a single instance, failed to make a correct diagnosis by means 
 of this sign. According to his experience, the odor is percepti- 
 ble as early as the eighth day of gestation. 
 
 In America, a physician has recently proposed to detect early 
 pregnancy by the administration of small doses of ergot. The 
 unimpregnated uterus gives no indication of the specific action 
 of this drug ; while the gravid organ almost invariably responds 
 to its influence, as is evidenced by some uneasiness in the back, 
 and by pain in the upper part of the thighs. These symptoms, 
 it is said, are sufficient to establish the diagnosis ; and may be in- 
 duced without any risk of injury to the mother or the ovum. 
 
 Stein, who wrote in 1770, taught that the most certain sign of 
 pregnancy is to be found in the shape of the os uteri ; which, 
 from being a transverse fissure, assumes a circular form after im- 
 pregnation. This assertion was propagated as true by most Ger- 
 man writers on obstetrics for many years ; but no one, in the 
 present day, attaches the slightest importance to this imaginary 
 change. 
 
 Dr. Osiander, of Gottingen, places some reliance on the de- 
 tection of arterial pulsations at the upper part of the vagina, or 
 on some point of the supra-vaginal portion of the uterus accessi- 
 ble to the finger. This vaginal pulse is due to the hypertrophy 
 of the vaginal and uterine arteries which has resulted from 
 fecundation. Such hypertrophy, however, occurs equally from 
 disease. 
 
 Beccaria suggested as a tost, the existence of severe pulsating 
 occipital headache ; which is accompanied with giddiness on 
 moving, and intolerance of light. The pain comes on suddenly, 
 induces a disposition to sleep, and often passes away without aid 
 from medicines. Moreover, it frequently assumes a distinctly 
 periodic character. It is said to have been observed prior to the 
 fourth month, in women who were not aware of its cause. How- 
 ever this may be, as a rule we must allow, that although this 
 peculiar pain is possibly an occasional concomitant of pregnancy,
 
 142 THE SIGNS AND SYMPTOMS OF PREGNANCY. 
 
 yet it is too rare and uncertain in its occurrence to bear any im- 
 portance as a symptom of this condition. 
 
 Lastly, the general physical and moral changes which take 
 place under the influence of pregnancy are regarded as symptoms 
 by some practitioners. These gentlemen particularly insist upon 
 the importance of noting the sharpening of the features, and, 
 indeed, of the whole body — excepting the breasts and abdomen — 
 w^iich often occurs ; the change of color in the complexion, or 
 even a discoloration of the skin in various parts of the body, as 
 of the forearms and hands, &c. ; the darkening of mole-spots; 
 the alteration in the cutaneous secretion, so that those who have 
 usually had a moist skin now find it harsh and dry, and the 
 reverse; the existence sometimes of an unpleasant and rather 
 powerful odor in the perspiration ; the increase in the strength 
 and frequency of the pulse; the attacks of toothache, salivation, 
 and giddiness ; the numerous fits of feinting which some women 
 experience at this time, and at this time only ; the frequent occur- 
 rence of varicose veins in the lower extremities ; the antipathies, 
 strange appetites, and longings for improper kinds of food which 
 annoy certain women ; and the distressing dreams which afilict 
 a few, in consequence, probably, of a disordered condition of the 
 alimentary canal acting upon an irritable temperament. The 
 changes in the nervous system are sometimes well marked. Thus, 
 there is often a peculiar alteration of taste and disposition. Wo- 
 men naturally irritable and hasty become cheerful and contented, 
 or vice versa; and many wdio are accustomed to give way to habits 
 of luxury and idleness now alter, and seem desirous" to be active 
 and industrious. One author cites a case where a lady during 
 pregnancy possessed sound judgment but lost her memory; and 
 wdio, after parturition, recovered her memory at the expense of 
 her judgment. Another instance is recorded in which a female 
 became — after an attack of inflammation of the brain — melan- 
 choly, pensive, and at length imbecile ; but happening to get 
 pregnant, she recovered her gayety and regained completely the 
 use of the intellectual faculties, though the improvement was 
 only manifested during the time of gestation. After her labor she 
 relapsed into her former miserable condition, until a second preg- 
 nancy occurred, during which the same phenomena were pre- 
 sented. I have seen a case in which there was complete loss of
 
 MINOR SIGNS. 143 
 
 voice during the last three months of gestation ; but the lady 
 was of a very peculiar temperament, and previous to her mar- 
 riage had long suffered from hysteria. The aphonia continued 
 for a fortnight after labor; when, under the stimulus of galvan- 
 ism, restoration took place. So, again, women afflicted with 
 deafness are said to have recovered and retained the sense of hear- 
 ing during the time of gestation. Beer has related the particulars 
 of a 3"0ung Jewess, who at the commencement of each of her 
 first three pregnancies became amaurotic, and continued blind 
 till after her labors ; but who subsequently bore children without 
 experiencing this inconvenience. Many other such examples of 
 amaurosis occurring during pregnancy are also known. But it 
 is scarcely necessary to remark that these instances are all excep- 
 tional, and establish no general law. Hence it can only be said, 
 as the result of the examination of a Iqrge number of women in 
 different stations of life, that pregnancy very commonly exalts 
 the general sensibility, and predisposes to the development of 
 nervous disorders in all their Protean varieties.
 
 144 THE DISEASES W II I C PI SIMULATE PREGNANCY. 
 
 CHAPTER in. 
 
 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 1. Spurious PREGNANCY. Phantom or muscular TusfORS. — 2. Ovarian dropsy. Dropsy 
 OP THE Fallopian tube. Acute inflammation of the ovary, ending in suppura- 
 tion. — 3. Ascites. Dropsy of the amnion. Great distension of the bladder. 
 — 4. Fibroid tumors of the uterus. — 5. Enlargements op the liver, kidneys, 
 spleen, etc. Tuberculated disease of the peritoneum. F^cal accumula- 
 tions. Encysted dropsy of the peritoneum. Cysts in the folds of the omentum, 
 etc. — 6. h^matometra, hydrometra, and physometra. 
 
 • 
 
 The diseases which may give rise to an unjust suspicion of the 
 existence of pregnancy, are principally those that produce enlarge- 
 ment of the abdomen. The chief of these are : (1) Spurious preg- 
 nancy ; (2) Ovarian dropsy ; (3) Ascites ; (4) Fibroid tumors and 
 large polypi of the uterus; (5) Enlargements of the liver, kidneys, 
 spleen, &c. ; and (6) Distension of the cavity of the uterus with 
 blood, water, or air. I shall make no remarks in this chapter on 
 the diagnosis of the vesicular mole — the so-called uterine hydatids 
 — from normal pregnancy, because the subject will be subse- 
 quently treated of. Neither is it necessary, for the same reason, 
 to speak of those curious cases where a woman with an extra- 
 uterine foetus in her abdomen, the result of a previous concep- 
 tion, again becomes pregnant, the child being then formed in 
 the uterus. 
 
 Before proceeding to the separate description of the diseases 
 above enumerated, let me urge upon the practitioner the neces- 
 sity for always exercising great caution and deliberation in form- 
 ing his diagnosis. He will find his investigations impeded at 
 every step unless he can avail himself of a practised eye, a sensi- 
 tive and well-trained ear, and a delicate sense of touch. Until a 
 large experience has rendered attention to rules unnecessary, it 
 is as well to follow some plan in examining a case of abdominal 
 enlargement. Thus in every instance, it should first be deter- 
 mined whether there be any tumor, or merely the appearance of 
 one. Secondly, if a tumor exist, is it within the abdomen, or
 
 SPURIOUS PREGNANCY. 145 
 
 only in tlie abdominal walls? Thirdly, if it be decided that there 
 is a tumor in the abdominal cavit}^, the question arises as to 
 whether that tumor be a foreign body like an ovarian cyst or 
 uterine fibroid; or some organ, such as the liver or kidney, which 
 has undergone hj^pertrophy, or has become infiltrated with cancer ; 
 or wdiether it be simply an enlarged uterus or a distended urinary 
 bladder? And, fourthly, some abnormal growth having been 
 detected and its nature determined, it ought still to be ascertained 
 that the case is not complicated by the coexistence of pregnancy. 
 But even when a careful examination has been made, and when 
 every precaution — such as placing the patient in a proper posi- 
 tion, having the bladder empty, &c. — has been taken to avoid 
 error, it may still only be possible to give an ambiguous opinion. 
 In many instances of abdominal tumor it is far easier to say what 
 the disease is not, rather than what it positively is. The diag- 
 nosis of pregnancy, when the foetus is dead, and the abdominal 
 walls of the mother are loaded wdth fat, will often be very diffi- 
 cult. Cases of renal cancer have over and over again been mis- 
 taken for tumors of the ovary. Spasmodic contractions of the 
 recti muscles of the abdominal wall have frequently given rise to 
 an unfounded suspicion of uterine enlargement; while accurately 
 to distinguish between a C3^stic tumor of the uterus, a similar 
 growth of the ovary, or a large collection of fluid in one of the 
 Fallopian tubes, is often impossible. Remembering then these 
 facts, I may without assumption remind the practitioner, that it 
 will be far better in any doubtful case for him to confess ignor- 
 ance, than to run the risk of inflicting pain and misery on a de- 
 fenceless woman or of forfeiting his own reputation by giving an 
 erroneous judgment. To be able to trace effects to their causes 
 is often a high proof of skill ; but unfortunately such ability can- 
 not always be show^n. In some cases the most experienced physi- 
 cian will have misgivings: hence, none need be so foolhardy as 
 to descend to guessw^ork. He, however, who really desires to 
 prove accurate will generally be so ; since he will take care not to 
 come to a positive conclusion without a careful review and calm 
 consideration of all the circumstances of the case. He will weigh 
 ■well all the data on which reliance can be placed ; for otherwise, 
 though his judgment may be founded on wdiat is apparently 
 strong evidence, yet from not considering or from being ignorant 
 of one or two small facts, the deduction is not unlikely to be wrong. 
 
 10
 
 146 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 1. Spurious Pregnancy. — Should an}^ of my readers entertain 
 the idea that the symptoms of pregnancy are so peculiar and 
 distinct that they can only be mistaken by the rash or ignorant, 
 the perusal of this chapter will probably serve to undeceive 
 them. An example of spurious parturition has been related in 
 a preceding page; but in this case no opportunity was afibrded 
 me of examining the patient until the close of the sham gesta- 
 tion. We shall now consider the subject in all its bearings; and 
 it will at least be found that few disorders are met with in the 
 practice of medicine more remarkable" than this one of spurious, 
 simulated, or pseudo-pregnancy — the fausse grossesse nerveuse, or 
 grossesse aimuUe far illusion pure, of French writers.^ It serves 
 to mislead not only old nurses and women who have given birth 
 to several children, but so puzzling are many of its features, so 
 striking is the resemblance which its symptoms bear to those of 
 pregnancy, that the best-informed practitioners may be led into 
 error by it unless they exercise considerable skill and wariness. 
 
 To convey a clear notion of this matter, let it be imagined that 
 we have before us a typical case. We shall find the following- 
 succession of phenomena, occurring possibly in a woman about 
 forty-five years of age, who now believes that she is nearly 
 seven months gone with child. She is the mother of a family ; 
 but since her last parturition there have elapsed some six or 
 eight years. The monthly periods have either ceased or become 
 irregular; or the flow comes on at the proper period, but is very 
 scanty. It is stated that the abdomen began to swell from the 
 pubic region, in the same gradual manner as in pregnane}^; but 
 on examination the enlargement is seen to be more difi'used 
 when the patient lies on her back than it is in true pregnancy, 
 while there is an appearance of unusual constriction around the 
 lower ribs or over the diaphragm. The spine is much arched 
 forwards, so that the hand of the examiner can easily be passed 
 between the back and the bed on which the patient is lying. 
 The breasts have become painful and enlarged; blue veins are 
 seen traversing their surface ; the areola is more or less dark- 
 ened ; and a serous fluid resembling milk is secreted, which 
 escapes on pressure from the orifices of the milk ducts. The 
 
 1 Dr. Mason Good speaks of lliis extraordinary affection under the term of pseudo- 
 cyesis, from ■\'itjSK, a lie, and kvho-k, pregnancy. This Greek name, however, has no 
 advantage over the plain Englisli employed in the text.
 
 SPURIOUS PREGNANCY. 147 
 
 digestive organs have got disordered: there is a capricious ap- 
 petite, a frequent sense of nausea with morning sickness, saliva- 
 tion, and diarrhcea alternating with constipation. There is 
 muscular debility, an excitable condition of the nervous system, 
 cramp, and retraction of tlie leg. The hue of the skin has be- 
 come changed, has darkened somewhat. The veins of the lower 
 extremities have become varicose. The patient is sensible of 
 movements in the abdomen, which she asserts can only be 
 those of a live foetus ; though if closely questioned she will 
 allow, that they are not altogether identical in character with 
 such as she has felt on occasions when really pregnant. As 
 these movements are at least partially due to the passage of 
 flatus from one portion of the intestine to another, they are ap- 
 preciable by a second party, who therefore confirms the patient 
 in her erroneous views. She is certain that she is pregnant, but 
 does not know exactly when labor may he expected. If the 
 phenomena here presented persist, the spurious gestation will 
 probably be succeeded by a spurious parturition ; and strong 
 labor pains may come on, possibly attended by all the peculiar 
 symptoms which may have characterized a previous lying-in. 
 In short, the illusion will be complete; and will be kept up until 
 the man of science steps in and dispels it by showing that the 
 uterus is empty, and that the phenomena are simply of consti- 
 tutional origin. 
 
 Spurious pregnancy is by no means an unfrequent disorder. 
 The unmarried, and such as have never borne children, are 
 liable to be afiected with it, as well as the mothers of families ; 
 though the latter suffer from it more frequently than the former. 
 It may occur early in married life ; or about the climacteric 
 period, when women so commonly present complex nervous 
 symptoms. The favorite season lor its happening is in the de- 
 cade following the thirty-seventh year. 
 
 The difliculty of diagnosing this condition is increased by the 
 curious fact, that women who have suffered from remarkable 
 idiosyncrasies in previous normal pregnancies have them re- 
 peated during spurious gestations. I have seen a lady who had 
 been pregnant three times, and on each occasion had suffered 
 from chronic urticaria of a very rebellious nature. When she 
 came under my care with symptoms of spurious pregnancy, she 
 was likewise afliicted with this eruption. A monthly nurse,
 
 '148 THE DISEASES WHICH SIMULATE PREGNANCY, 
 
 who gave evidence on the Gardner peerage trial, asserted that 
 she could always calculate the date of her labor, inasmuch as 
 she invariably fainted when quickening took place. She after- 
 wards applied to Dr. E.eid to be attended in her confinement ; 
 stating that she was seven months advanced in gestation, that 
 she had fainted as usual on quickening, and that she felt the 
 movements of the child. Yet, on a careful examination, it was 
 discovered that her symptoms were merely due to spurious preg- 
 nancy. Sir James Y. Simpson relates a curious case, where a 
 lady, who had previously given birth to eight children, passed 
 over one catamenial period, and imagined that she had again 
 fallen in the family-way, because the breasts had enlarged and 
 begun to secrete milk. The abdomen had also become promi- 
 nent, and she had felt movements resembling those of a foetus. 
 On examination the uterus was found to be perfectly normal, 
 except that there was slight ulceration around the os ; but the 
 lady was firmly convinced of her pregnancy, inasmuch as she 
 lost great quantities of hair, and she had always had such a fall- 
 ing oft' of the hair in her previous pregnancies. 
 
 The mode in which these cases terminate varies. Sometimes, 
 after the symptoms have persisted for a variable number of weeks 
 or months, they suddenly disappear, and the patient at once gets 
 well. This is an occurrence which happens most frequently in 
 women who have never borne children. In other instances the 
 symptoms continue for ten, twelve, or twenty months ; and, in 
 fact, do not cease until the employment of proper remedial meas- 
 ures. "While, in a third class, the spurious pregnancy is suc- 
 ceeded at the end of nine months by the phenomena of a spurious 
 parturition ; this termination being more rare than either of the 
 others. 
 
 To prevent the possibility of a suspicion that in the foregoing 
 remarks an exaggerated view has been taken of this form of mor- 
 bid action, the reader's attention is requested to a few of the 
 most interesting examples of spurious pregnancy which are scat- 
 tered through our medical literature. We shall find that more 
 than two centuries ago the illustrious Harvey, in his work on 
 parturition, attempted to prevent his readers from being deceived 
 by "erroneous tokens of pregnancy;" and he enforces his pre- 
 cepts by the relation of the two following cases:
 
 SPURIOUS PREGNANCY. 149 
 
 ''I am acquainted," he says, " with a young woman, the daughter of a 
 physician with whom I am very intimate, who experienced in her own per- 
 son all the usual symptoms of pregnancy. After the fourteenth week, being 
 healthy and sprightly, she felt the movements of the child within the uterus, 
 calculated the time at which she expected her delivery, and when she thought, 
 from further indications, that this was at hand, prepared the bed, cradle, 
 and all other matters ready for the event. But all was in vain. Lucina re- 
 fused to answer her prayers ; the motions of the foetus ceased ; and by de- 
 grees, without inconvenience, as the abdomen had increased so it diminished. 
 She remained, however, barren ever after." 
 
 " I am acquainted also with a noble lady, who had borne more than ten 
 children, and in whom the catamenia never disappeared except as the result 
 of impregnation. Afterwards, however, being married to a second husband, 
 she considered herself pregnant, forming her judgment not only from the 
 symptoms on which she usually relied, but also from the movements of the 
 child, which were fre(|uently felt both by herself and her sister, who occu- 
 pied the same bed with her. No arguments of mine could divest her of this 
 belief. The symptoms depended on flatulence and fat."^ 
 
 Harvey, moreover, notices in the Essay on Conception, the 
 occurrence in animals of phenomena similar to those we are here 
 considering. He says : 
 
 " Overfed bitches, which admit the dog without fecundation following, 
 are nevertheless observed to be sluggish about the time they should have 
 whelped, and to bark as they do when their time is at hand; also to steal 
 away the whelps from another bitch, to tend and lick them, and also to fight 
 fiercely for them. Others have milk or colostrum, as it is called, in their 
 teats, and are, moreover, subject to the diseases of those which have actually 
 whelped. The same thing is seen in hens, which cluck at certain times, 
 although they have no eggs on which to sit; some birds also, as pigeons, if 
 they have admitted the male, although they lay no eggs at all, or only bar- 
 ren ones, are found equally sedulous in building their nests." 
 
 Sydenham, Mauriceaii, Lamotte, and others, also allude to or 
 record instances of nervous pregnancy ; but neither the cases nor 
 the observations possess any special interest, beyond showing 
 that these authors were well acquainted with the subject. M. 
 Russel, of Vars, met with a remarkable example, from the pub- 
 lished narrative of which the chief particulars are selected.^ 
 They are as follows : 
 
 Mary Gibaud, residing at Vars, department of the Charente, enjoyed good 
 health prior to marriage at about thirty years of age. Shortly after "this 
 
 1 The Works of William Harvey, M.D. Sydenham Society's Edition, p. 528 Lon- 
 don, 1847. 
 
 2 The Medico-Chirurgical Review, New Series, vol. i, p. 495. London, 1824. The 
 paper is quoted from the Gazette de Sante, for January, 1824.
 
 150 THE DISEASES AVHICH SIMULATE PREGNANCY. 
 
 epoch, she apparently became pregnant. The menses ceased, nausea and 
 mornino- vomitings occurred, the abdomen enlarged, the motions of the foetus 
 were felt, or supposed to be felt — in short, every symptom of pregnancy was 
 present. At the end of nine months labor pains commenced, and went on 
 increasing for 06 hours, but without causing any enlargement of the os uteri. 
 The midwife, unable to make out the case, called in a surgeon of great repu- 
 tation. At the moment of his arrival, the patient had just fainted from a 
 considerable uterine hemorrhage, and the surgeon quickly proceeded to de- 
 liver. He was not a little surprised to find the uterus in an unimpregnated 
 state. On recovering from the syncope, the labor pains had gone, but in 
 two or three hours they returned as violent as ever. These were relieved byi 
 copious 'bleeding, and the patient recovered.^ But at the end of a month 
 she again had symptoms as if she had become pregnant, and went for an- 
 other nine months, until labor pains set in as before. A third time this 
 happened, and she was then treated for dropsy. Paracentesis abdominis was 
 performed, but no fluid came away. She recovered, and lived for twenty 
 years; having all the symptoms of pregnancy, her breasts being always 
 gorged with milk, and every nine months a kind of attempt at parturition 
 taking place, which was only relieved by loss of blood. She died in the 51st 
 year of her age, from phrenitis; and on examining the abdomen every organ 
 was found healthy, but there was a considerable quantity of fat in the 
 omentum. 
 
 A very similar instance to the foregoing has been published 
 by Dr. Annbroise Tarclieu. The subject of this gentleman's notice 
 was forty-four ^^ears of age, and had been delivered of a child 
 after a natural labor six years before she came under observation. 
 Three years after her confinement the catamenia ceased ; while 
 the breasts became full, and the abdomen gradually enlarged. 
 Then movements were felt; and at the end of nine months labor 
 pains set in, which resulted in nothing more than the escape of 
 some water and shreds of membrane. Still the abdomen con- 
 tinued enlarged, and a second spurious parturition occurred at 
 the close of another nine months ; and so again and again, for 
 four times in all.' 
 
 The Csesarean operation was performed on a patient at Berlin, 
 in August, 1828, by Professor DiefFenbach, at the desire of Dr. 
 Heim ; who, with many other eminent physicians, had diagnosed 
 the existence of extra-uterine gestation. The woman was twenty- 
 one years of age, and had experienced most of the symptoms of 
 pregnancy. More especially she asserted that she felt the move- 
 ments of the child daily. When the time calculated on for 
 delivery was past, and she had spent some days of suft'ering from 
 
 1 Annales d'Hygieiie Publifjiie et cle Medecine Legale. Tome xxxiv, p. 429. Paris, 
 1S45.
 
 SPURIOUS PREGNANCY. 151 
 
 the periodical recurrence of violent pains, the abdomen was 
 opened. To the amazement of all present, not only was no child 
 found, but not even a tumor of any kind. Dr. Heim states that 
 he introduced his hand into the abdominal cavity, and detected 
 nothing from which he could have inferred the existence of a 
 foetus. Fortunately, the wound healed completely in three weeks, 
 and finally the patient recovel%d. The operation, however, was 
 not the only source of danger to which she was exposed ; for 
 during her illness she lost upwards of sixty ounces of blood in 
 four venesections, had tAvo hundred leeches applied to the belly, 
 and had ice-cold applications day and night.^ 
 Dr. Gooch relates the following case. He says : 
 
 " I was introduced by an eniinent physician to a very younjr married lady, 
 for the purpose of attending her in her approaching confinement, of which 
 her projecting abdomen gave visible intimations; and I was directed to call 
 on her occasionally, that she might become accustomed to me before the 
 time for my attendance arrived. During these calls I learnt gradually the 
 particulars of her marriage. She had been attached to a young man, her 
 equal in station, but so profligate that her parents forbade him the hou.se. 
 Nevertheless, the lovers continued to meet by stealth, and one fatal evening 
 they became as man and wife in all but the marriage ceremony. After this 
 intercourse had been going on a few months, the young lady observed that 
 her belly was enlarging. It was at length noticed by her mother. This led 
 to an inquiry, and the young lady confessed all. The discovery of course 
 produced a great uproar in the family ; her parents agreed that, as the young 
 couple had gone so far, it was absolutely necessary that they should go a 
 little further. The lover was called upon ; and, as the young lady had 
 brothers who understood the use of the pistol, the young couple were soon 
 married and placed in furnished lodgings. It was at this period when I was 
 first introduced to them. I continued to call on the bride for some time; 
 but, after two months, I one day remarked that although she still continued 
 large, she was not larger than when I first saw her. When I pressed the 
 abdomen it had not the firmness of pregnancy, and she felt no internal 
 motions. When I inquired about her menstruation, I was told that she had 
 never menstruated in her life ; menstruation had not ceased, simply because 
 it had never begun. I now expressed strong suspicions that she was not 
 pregnant, and advised the question to be settled by an examination. It was 
 so. I found the umbilicus sunk, the abdomen distended by a soft flatulent 
 tumor; the neck of the uterus of its full length, its body not in the slighte.-^t 
 degree enlarged. I told my patient and her sister that she was not pregnant, 
 but they would not believe me, and directed a consultation with the same 
 eminent physician who had introduced me to them. He met me; and as he 
 was one of the very few medical phyvsicians who are expert at vaginal ex- 
 aminations, he was soon as well satisfied as myself that the young lady was 
 not pregnant. The communication caused great disappointment in the 
 
 1 Dr. Ernest Ludwig Heim's Vermischte Medicinische Scliriften, p. 402. Leipzig, 
 1S3G.
 
 152 THE DISEASES AVHICH SIMULATE PREGNANCY. 
 
 family, but in no one so much as in the young husband, whose rage was 
 boundless at discovering that he had been compelled to marry her on a false 
 supposition "^ 
 
 The particulars of a well-marked case were communicated to 
 Dr. Montgomery by Dr. Labatt. A lady who married rather late 
 in life, and remained some years j^^ithout conceiving, at length 
 had suppression of the catamenia ; from which, and other symp- 
 toms, she deemed herself to be pregnant. She increased in size, 
 and at the expected time pains came on, which were considered 
 as those of labor; in consequence of which she sent for her 
 medical attendant, who concurred in the opinion of her being 
 parturient, and remained with her. At the end of forty-eight 
 hours, as the pains continued severe, Dr. Labatt w^as called into 
 consultation, in order to determine whether she ought not to be 
 delivered with instruments. The gentleman in attendance was 
 doubtful as to the best instruments to apply ; remarking that he 
 was unwilling to use the crotchet, because he felt sure that the 
 child was alive, having applied the stethoscope several times 
 during the night, and detected the pulsations of the foetal heart. 
 Dr. Labatt, having examined carefully, suggested that there was 
 no necessity for the use of any instrument, as the lady was not 
 in labor ; and for the best of all possible reasons, because she was 
 not pregnant. This proved to be the truth. 
 
 Dr. Keiller related to the Obstetrical Society of Edinburgh, in 
 March, 1850, the history of a hysterical young woman, nineteen 
 years of age, who — from the large size of the abdomen, and the 
 occurrence of pains which caused such cries that the whole neigh- 
 borhood was disturbed — was considered by her friends to be 
 suiFering from a difficult labor. Her supposed labor had con- 
 tinued for a fortnight, when an irregular practitioner who was 
 in attendance, proposed performing the Caesarean section as a last 
 resource ; since he found the bones of the pelvis so grown to- 
 gether, that " the child could never be born in the natural way 
 dead or alive." When Dr. Keiller had seen her and made a 
 careful examination, he tried in vain to disabuse the minds of 
 her relations of the idea that she was pregnant. Various plans 
 of treatment were instituted, but without any marked benefit ; 
 
 1 An Account of Some of the Most Important Diseases Peculiar to Women. By 
 Robert Gooch, M.D. Second Edition, p. 'J-ilJ. London, 1831.
 
 SPURIOUS PREGNANCY. 153 
 
 indeed change of air was the only thing that seemed to do her 
 any good. After one of these removals, she was able to return 
 for a short.time to her usual employment at a mill, though her 
 abdomen always remained of a large size. Dr. Keiller then lost 
 sight of her for eight years, when she presented herself in Edin- 
 burgh, with a child that she had really been delivered of in the 
 interval. She complained, however, that all her old symptoms 
 were reappearing. The abdomen was very large and tympanitic ; 
 but on putting her under the influence of chloroform the belly 
 immediately became flat, and the uterus was felt to be of its 
 normal size. "When the efifects of the aneesthetic passed off, the 
 abdomen again enlarged in size and resumed its former bulk. 
 The enlargement continued for some months, during which she 
 was under observation. I am not acquainted with the final result. 
 
 The last instance which will be referred to, is one which oc- 
 curred in the practice of Sir James Simpson, who mentions that 
 he was one day summoned in great haste to a patient at the 
 Maternity Hospital of Edinburgh. The case was reported by the 
 house surgeon — a gentleman of remarkable acuteness — to be one 
 of placenta previa, requiring the operation of turning. The 
 woman had the phenomena of labor present, with severe menor- 
 rhagia ; but there was no child to turn, as she was not pregnant. 
 
 The question now naturally arises, — What is the nature of the 
 abdominal swelling in this affection ? It was long thought that 
 the symptoms of spurious pregnancy were due simply to the dis- 
 tension of the intestines by flatus, combined with the excessive 
 deposition of fat in the abdominal integuments and in the omen- 
 tum. We are told that on examining the body of Joanna South- 
 cott after death, the womb appeared smaller than natural, free 
 from disease, and containing neither " the promised Shiloh, nor 
 any other foetus." But the walls of the abdomen were four inches 
 thick from adipose tissue, the intestines were distended with 
 gas, and the omentum was one large mass of fat. Very possibly 
 the combination of these conditions may alone have sufficed to 
 produce the disorder in other instances ; though without a doubt, 
 in the majority of cases, there has been something more. This 
 additional something is probably irregular or excessive action of 
 the diaphragm and other abdominal muscles, by which the in- 
 testines are forced low down in the cavity of the abdomen. In 
 many instances, also, it has been thought that irritation or chronic
 
 154 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 inflammation of one or both ovaries existed ; this irritation pro- 
 ducing contraction of the muscles by reflex action. Again, it has 
 not unfrequently been found that the patient was suffering from 
 retroversion or retroflexion of the uterus. The chief evidence 
 which can be ofi*ered in support of the hypothesis here suggested 
 is, that in the ^^'rs^ place, in some marked examples, a long tube 
 was passed per anum, but not a bubble of air could be seen to 
 escape from the nozzle, which was held under water; though as 
 the patients became insensible from the inhalation of chloroform, 
 the enlargement disappeared. Secondly, that positive symptoms 
 of ovarian or uterine irritation are often present. There is es- 
 pecially pain on pressure over one iliac region, irregularity or sup- 
 pression of the catamenia, and intense backache ; while complaint 
 is made of pain extending down one leg with, perhaps, retraction 
 of the limb. And tliirdhj, that if the patient be slowlj- but thor- 
 oughly placed under the influence of chloroform, or of a mixture 
 of equal parts of chloroform and pure ether, the abdomen will be 
 seen to flatten and the tumor to entirely subside ; the latter slowly 
 melting away in proportion as the anaesthetic relieves the dia- 
 phragmatic and abdominal muscles from the influence of the 
 reflex nervous action. As consciousness returns, however, the 
 muscles become tense and prominent, and the swelling gradually 
 forms again ; until the phantom tumor is found possessing all its 
 original characters, by the time the anaesthesia has completely 
 passed away. 
 
 In some hysterical young women, the seeming enlargement 
 may be, perhaps, caused by a great arching forward of the lower 
 dorsal and upper lumbar vertebrae; in which instances the spine 
 becomes straightened on anaesthesia being induced. Whatever 
 may be the cause, however, if additional evidence be required in 
 any particular case that the tumor is not formed by the pregnant 
 uterus, it will be found in the fact that there is generally reso- 
 nance on practising percussion over the abdomen ; that the uterus, 
 on examination per vaginam, can be discovered small in size, and 
 with its body undeveloped; and tliat none of the auscultatory 
 phenomena of pregnancy can be detected. The first test is the 
 least reliable ; being often rendered uncertain by the deposition 
 of fat in the abdominal walls or in the omentum, or by over- 
 distension of the bladder, or by the existence of great tender-
 
 SPURIOUS PREGNANCY. 155 
 
 ness rendering a satisfactory tactile examination almost impos- 
 sible. 
 
 The cure of spurious pregnancy, tliougli difficult and almost 
 always tedious, is not beyond the reach of our art. At the com- 
 mencement, when symptoms of ovarian irritation are manifested, 
 the}^ must be relieved by the administration of chlorate of potash 
 in full doses, three or four times a day. For the lessening of 
 ovarian tenderness and congestion, no drug can be compared 
 with this in efficacy. If the uterus seem mainly in fault, and 
 there be an absence of ovarian fulness or pain, the bromide or 
 the iodide of potassium, or the iodide of ammonium will be in- 
 dicated. In either case, the progress towards recovery is expe- 
 dited by the employment of warm hip-baths ; by the use of 
 sedative injections ; or by the introduction into the vagina of 
 ointments containing belladonna, or conium, or henbane. A 
 very efficient medicated pessary, wliich may be used every night 
 at bedtime, can be made by mixing together four or five grains 
 of the extract of belladonna, two grains of the extract of opium, 
 ten grains of iodide of lead, a few drops of olive oil, and sixty 
 grains of the concrete oil of theobroma. If thought advisable, 
 twenty or thirty grains of the strong mercurial ointment may be 
 substituted for the iodide of lead. At the same time, all mental 
 anxiety is to be relieved ; the patient is to be impressed with the 
 conviction that she is not pregnant, and that she will get well ; 
 while, should she insist — as she is not unlikely to do — that if she 
 has not a child within her there is certainly a live animal of some 
 kind, the delusion must be got rid of by gentle reasoning. It 
 will often, also, be useful to place her under the influence of 
 chloroform ; and, while she is in a state of insensibility, to show 
 her flattened abdomen to her mother, or some confidential female 
 friend. The general health, moreover, is to be improved by a 
 course of mild' tonics, especially by such remedies as phosphoric 
 acid and quinine or bark, phosphate of zinc and nux vomica, the 
 oflicinal aromatic mixture of iron, &c. Change of air, particu- 
 larly to the sea-side, will be useful. Any sympathetic vomiting 
 which may be present is to be relieved by the administration of 
 ice, of drinks impregnated with carbonic acid gas, of bismuth 
 and morphia, of pig's pepsine at the meals, or especially by giving 
 one or two grains of the oxalate of cerium three or four times a 
 day. Where the patient is troubled with flatulence, ten grains-
 
 156 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 of tlie compound assafoetida pill given twice a day will most 
 probably relieve it ; especially if, at tbe same time, the abdomi- 
 nal walls be supported by a bandage. The condition of the 
 abdominal viscera and their secretions should be particularly 
 attended to. Any marked excitability of the nervous system is 
 to be suppressed by administering such antispasmodics as the 
 ammoniated tincture of valerian, galbanum, or assafoetida. And 
 finally, the abdominal muscles themselves ought to be strength- 
 ened and their irritability diminished by the application of gal- 
 vanism, by sponging with salt water, and by stimulating lini- 
 ments together with the frequent employment of gentle friction. 
 The remark has already been made, that the terms spurious 
 or pseudo-pregnancy are very unsatisfactory; for it is clear that 
 they convey no notion whatever of the nature of the disorder. 
 But I think the foregoing observations will show that we are not 
 at present in a position to suggest a better name for this affec- 
 tion, since the phenomena produce symptoms which seem at 
 present to defy any exact nosological arrangement. 
 
 Allied closely to cases of spurious pregnancy are those remark- 
 able instances in which we find a contraction or relaxation of the 
 abdominal muscles, simulating a simple but well-defined tumor. 
 These phantom or muscular tumors vary in size from a cricket- 
 ball to an adult head ; they may be stationary and firm and un- 
 yielding, or they may change their relative position from day to 
 day, or they may appear movable as if attached by a long pedi- 
 cle ; they may be insensible to the touch, or acutely tender ; and 
 they sometimes temporarily melt away under steady and pro- 
 longed manipulation, or they disappear for a long period and 
 then return, or they remain persistent for years. Occasionally, 
 moreover, it can be clearly distinguished that they have their 
 seat in the parietes, and then especially there is resonance on 
 percussing over them. In their diagnosis care must be taken 
 not to mistake these tumors for movable kidneys. It is well 
 known that occasionally both the renal organs present an un- 
 usual degree of mobility; or one kidney may be m.ovable to a 
 considerable extent, while the other is stationary. So also, a 
 spleen displaced downwards may form a palpable tumor, as low 
 as the left iliac region ; and should there also happen to be any
 
 PHANTOM TUMORS. 157 
 
 displacement of the pancreas, a veiy puzzling enlargement will 
 result. 
 
 Patients in wliom phantom tumors are found, very generally 
 appear to be in bad health ; being often anaemic, and presenting 
 phenomena which are commonly set down as due to hysteria, or 
 to "spinal irritation." They are also not unfrequently afflicted 
 with neuralgic pains ; and are sufferers from leucorrhcea, dysme- 
 norrhoea, dyspepsia, and constipation. They usually experience 
 great mental uneasiness and depression about the swelling; their 
 anxiety, indeed, being often the cause of their seeking advice. 
 Happily, however, these spasmodic contractions or relaxations of 
 portions of the recti or obliqui muscles need give rise to no anx- 
 iety on the part of the physician ; since they may be readily 
 dispelled by curing any uterine or ovarian disease, if such be 
 present, and then by improving the general health. In other 
 words, remedies which induce a natural performance of the 
 uterine functions, — ferruginous tonics, galvanism, small doses of 
 nux vomica, galbanum, mild aperients, good diet, and sea air, 
 will remove this tendency of the muscles to feign, as it were, 
 serious disease. The only danger that can arise is from these 
 shams being mistaken for dangerous morbid growths, when a 
 formidable plan of treatment is not unlikely to be proposed. It 
 is rather painful to know that such mistakes have not unfre- 
 quently been committed. In the statistical account of eighty-one 
 cases of ovariotomy collected by Mr. Benjamin Phillips, it is 
 shown that in as many as five instances no tumor at all was 
 found upon cutting into the abdomen ;' and at least two more 
 such instances have occurred since this report was published. 
 The most remarkable instance of this error with which I am 
 acquainted, is that recorded by Mr. Lizars, the chief features of 
 which are as follows : 
 
 In the year 1821, Mr. Lizars was called to see a woman with an abdomen 
 as large as at the ninth month of pregnancy. On examination the whole 
 abdominal cavity appeared to be occupied with a tumor, which seemed to roll 
 from side to side. The uterus per vaginam felt natural ; and the catamenia 
 had been regular, but attended with pain. The patient was 27 years of age, 
 had borne one child, and had experienced one miscarriage. The enlarge- 
 ment commenced towards the end of 1815; and a few months afterwards 
 she consulted numerous medical men, who agreed that she was pregnant. 
 Several of the principal practitioners of Edinburgh afterwards saw her with 
 
 1 Medico-Chirurgical Transactions, vol. xxvii, p. 4GS. London, 1844.
 
 158 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 Mr. Lizars, and all were of opinion that there was disease of one or both 
 ovaries. As the pain was intolerable, it was decided to remove the tunjor. 
 Accordingly, on the 24th of October. 18"i3, Mr. Lizars made a lono;itudinal 
 incision throuuh the parietes, parallel with the linea alba, from about two 
 inches below the ensiform cartilage to the crest of the pubes. Having thus 
 freely opened the abdominal cavity, he proceeded to examine the state of the 
 contents; when, to the astonishment of all present, the diaphragm was seen 
 to be acting with "great vigor and powerful impetuosity," but no tumor 
 could be found, for none existed. Fortunately the patient recovered ^ 
 
 In any similar case to the foregoing, or, indeed, in any instance 
 in which tlie practitioner is doubtful whether he has to deal with a 
 true abdominal tumor or with only a phantom, the exhibition of 
 chloroform, or of a mixture of equal parts of chloroform and 
 pure ether, will decide the question ; for muscular action, whether 
 it simulate pregnancy or a morbid growth, is temporarily anni- 
 hilated by the inhalation of an anaesthetic. 
 
 2. Ovarian Dropsy. — The diagnosis of this disease is by no 
 means always so easy as the physician might imagine from exam- 
 ining a well-marked case. jSTumerous errors are even now daily 
 made in practice, if I may judge from my own experience. I 
 might almost say that it has happened to me, as a rule, that when 
 consulted for what has been termed an ovarian tumor, I have 
 found the enlargement of the abdomen to be due either to exces- 
 sive flatulence, or to ascites, or to the presence of a fibroid tumor 
 of the uterus, or to be caused by pregnancy. 
 
 Many examples have been published in which either an ova- 
 rian tumor has been mistaken for pregnancy, or the converse. 
 Thus in the celebrated case of Mademoiselle Famin, published 
 by Valentin at Berlin in 1768, a charge of concealed pregnancy 
 and child-murder was erroneously instituted, in consequence of 
 an extreme case of ovarian dropsy. — Dr. Gooch relates that a 
 woman was taken into the operating theatre of an hospital to be 
 tapped for a supposed dropsy of the ovary. The surgeon, how- 
 ever, finding tliat she had not been carefully examined, sent her 
 back to the ward ; a precaution which was by no means super- 
 fluous, since she brought forth a child before the next operating- 
 day. — Dubois mentions that he has seen a female become preg- 
 nant two years after the cessation of the cataraenia. The woman 
 
 ' Observations on the Extraction of DiseasecJ Ovaria. By John Lizars. P. 6. Edin- 
 burgh, 182.5.
 
 OVARIAN DROPSY. 159 
 
 finding her abdomen enlarging, and mistaking tlie cause, entered 
 the medical department of an hospital ; and so little idea had the 
 physician, whose care she was under, that she was pregnant, that 
 he actually delivered a clinical lecture on the case, as being a 
 well-marked example of ovarian dropsy. On examination, Du- 
 bois distinctly heard the foetal heart, and soon afterwards labor 
 supervened.^ — Mr, Baker Brown says that he has seen at St. 
 Mary's Hospital, on the same day, no less than three cases, sent 
 by difterent medical men, in which pregnancy had been mistaken 
 for ovarian dropsy. In one of these cases the os uteri had begun 
 to dilate, and the woman was delivered the same afternoon.^ 
 And lastly. Sir James Simpson, in his clinical lectures, alludes 
 to an instance where, some thirty years ago, a female with en- 
 largement of the abdomen was supposed to be the subject of an 
 ovarian tumor by several gentlemen, who all concurred in the 
 propriety of, and necessity for, performing the operation of ova- 
 riotomy. The day was fixed, and everything prepared for remov- 
 ing the tumor by the abdominal section, when fortunately the 
 patient saved herself all the horrors and dangers of the operation 
 by giving birth to a child a few hours beforehand ; thus dispelling 
 most satisfactorily and efficiently the supposed morbid growth. 
 Even more painful, and much more recent examples might be 
 quoted ; but it is hoped sufificient has been said to put the medi- 
 cal man on his guard, to teach him that the diagnosis is often 
 difficult, and to prevent his giving a hasty opinion in any partic- 
 ular instance. 
 
 An ovarian tumor may consist of a single cyst, or of numerous 
 cysts inclosed in a parent cyst, or of solid matter. The latter are 
 comparatively rare ; for of all these tumors ninety-five per cent, 
 will be found to consist originally of cystic growths. The sim- 
 plest ovarian cysts are formed by the enlargement of one or more 
 Graafian vesicles ; their walls consisting of three coats, — i. e., peri- 
 toneum, fibrous capsule of ovary, and the greatly thickened wall 
 of the vesicle itself. The multilocular tumors probably depend 
 upon the formation of adventitious cysts ; in other words, they 
 are the result of entirely new growths. Ovarian cysts may con- 
 tain a pale amber-colored fluid like urine or the fluid formed in 
 ascites ; or a dirty chocolate-like fluid ; or a thick glairy gelatin- 
 
 ' Journal de Medecine et de Chirurgie, p. 207. Paris, May, 1850. 
 '•^ The Lancet, p. 117. London, 30th January, 1864.
 
 160 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 ous matter; or a quantity of fatty substance mixed with hair, 
 teeth, or small bones. Ovarian tumors are more common in 
 married than in single women : of 136 published cases, 88 oc- 
 curred in the married, 37 in the single, and 11 in the widowed. 
 It is very probable that they are commonly associated with 
 sterility, though it must not be imagined that the disease neces- 
 sarily prevents impregnation. They happen most frequently 
 between the ages of 20 and 35 ; though I have seen an ovarian 
 tumor taken from the body of an infant v/ho died of peritonitis, 
 and have had patients afflicted with tliis disease who were more 
 than 55 years old. The tumors vary very much in size. In the 
 infant just mentioned, the cyst was about the size of a hazel-nut; 
 while in the museum of the College of Surgeons is a preparation 
 showing a single cyst which measures four feet in circumference 
 in one direction, and three in another. Very frequently the abdo- 
 men, much distended, is found apparently quite filled by the 
 growth. It is a common opinion, that ovarian cysts run their 
 course slowly; whence Dr. Gooch asserts that the duration of the 
 tumor, always much beyond nine months, is alone a sufficient 
 guide for diagnosis. This opinion is in all probability erroneous. 
 From a careful examination of the question, I believe that if we 
 were to collect the histories of 500 patients, we should find that 
 about 70 had died before the end of the first year; 75 more before 
 the completion of the second ; 120 more before the termination of 
 the third ; about 150 more before the end of the fourth ; and 75 
 more before the completion of the tenth, leaving some 10 alive at 
 the end of ten years. It is certain also, that the growth of the 
 multiloeular tumors is much more rapid than of the unilocular 
 cysts. The causes of ovarian dropsy, as assigned by the patients 
 themselves, increase the difficulties of diagnosis; for we find that 
 in a large proportion of cases this disease is attributed to the 
 excitement of marriage, or to sudden suppression of the menses. 
 It has also been thought to be due to parturition, to abortion, to 
 exposure to cold, to disappointed aftection, and to falls or blows. 
 The diagnosis of a cystic ovarian tumor, as before mentioned, 
 is often attended with difficulty. In the early period, when the 
 tumor is confined to the cavity of the pelvis, the patient seldom 
 seeks advice; since she is either unaware of the existence of any 
 morbid condition, or, if she experience some slight inconvenience, 
 she deceives herself as to its cause. At this stage, however, if
 
 OVARIAN DROPSY, 161 
 
 an examination per vaginam be made, a tumor, varying in size 
 from a hen's egg to a large orange, will be discovered on one side 
 or other of the uterus ; while the vagina will be found elongated, 
 and the os uteri drawn upwards and towards the affected side. 
 At the same period, an inspection of the abdomen discloses the 
 existence of a certain amount of fulness on one side of the hypo- 
 gastrium, or in one of the iliac regions. As the enlargement 
 increases, the abdominal swelling becomes more symmetrical ; so 
 that when the tumor has reached the umbilicus, it is often some- 
 what diiRcult to decide whether one side of the abdomen presents 
 any greater prominence than the other. 
 
 Many practitioners imagine that an ovarian tumor always 
 occupies the side on which the disease is situated, while the 
 pregnant uterus has its centre as constantly in the median line: 
 neither of these propositions are absolutely correct. With re- 
 spect to the first, it may be allowed that in many instances the 
 most prominent side of the abdomen is that to which the dis- 
 eased ovary belongs. But in the majority of cases, as before re- 
 marked, the tumor is centrally placed ; while in some few it 
 happens that the side opposite to the disease is the most promi- 
 nent, owing to the morbid structures falling ove,r to it. In uni- 
 locular cysts, too, the enlargement is always more even and 
 rounded and symmetrical than in the multilocular varieties ; so 
 that the diagnosis between such cysts and ascites is frequently 
 very difficult. As regards the second opinion, the exceptions to 
 its truth are rare, though cases similar to the following show that 
 they sometimes occur : 
 
 In the early part of April, 1858, I was consulted by a married lady, forty- 
 one years of age, the mother of three or four children, who was supposed to 
 be sutiering from cystic disease of the ri^ht ovary. She was in a very bad 
 state of health, the catamenia had long been irregular, and her youngest 
 child was nine years old. The tumor occupied almost entirely the right 
 inguinal and right lumbar regions, and communicated to the touch the sen- 
 sation of a multilocular cyst, with gelatinous contents But on applying the 
 stethoscope the foetal heart was, after a little trouble, distinctly detected, 
 beating at the rate of 130 a minute, while the maternal pulse was 90. As 
 the foetal pulsations were not audible to the gentlemen who met me in con- 
 sultation, I am not sure that the diagnosis which was given was credited ; 
 but the truth of the opinion was proved by the patient's miscarrying at the 
 end of the following month. The only reason which could be as.signed for 
 the unusual site of the uterus was that the lady had suffered from hemiplegia 
 for a few years, and while confined to her bed had constantly rested on the 
 back and right side ; and so thoroughly, though gradually, had the uterus 
 
 11
 
 162 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 become accustomed to its unusuiil situation, that no subsequent change of 
 posture on the part of the patient affected its position. 
 
 A small ovarian tumor is more likely to be mistaken for a 
 fibroid tumor growing from the side of tlie uterus, or for an ab- 
 scess in the broad ligament, or for an extra-uterine gestation, 
 than for the pregnant uterus. Yet the former may often be dis- 
 tinguished by the feeling of great elasticity, hardly amounting to 
 fluctuation, communicated to the touch on making a vaginal 
 examination ; by the facility with whicli the sound can be passed 
 into the uterine cavity, and the manner in which the uterus can 
 be perceptibly^ moved away from the tumor, and independently 
 of it; by the non-existence of those constitutional symptoms 
 which arise from inflammation ending in suppuration ; as well 
 as by the absence of those inequalities of surface which are pro- 
 duced by the different parts of the foetus. The history of each 
 case, and the duration of the symptoms, will also afford material 
 help in forming the diagnosis. I have, however, seen recent 
 cases of ovarian dropsy where there has existed suppression or 
 irregularity of the catamenia, morning nausea and vomiting, in- 
 digestion, troublesome constipation, irritability of the bladder, a 
 sense of movement in the abdomen, and swelling wnth tender- 
 ness of the breasts. 
 
 The chief diagnostic marks of an ovarian tumor which has 
 attained a large size are the follow^ing : The abdomen is found 
 more or less completely occupied by the morbid growth ; the 
 enlargement being smooth and rounded without any promi- 
 nences when the disease is of the unilocular variety, but often 
 very uneven in the multilocular form. A practitioner has been 
 known to confidently assert, that the limbs of a child could be 
 distinctly felt through the parietes when there was only an ova- 
 rian tumor causing considerable inequality of surface. In the 
 erect posture as well as in the supine, the tumor projects for- 
 wards, the flanks being comparatively undistended. In the 
 multilocular, more commonly than in the unilocular tumor, the 
 superficial veins coursing over the abdomen are found enlarged; 
 while it has been thought by some observers that the vessels on 
 the side corresponding to the diseased ovary are generally the 
 most distended. This observation, however, I have not been 
 able to confirm. Pressure with the hand on the tumor commu- 
 nicates a sensation of great resistance ; this resistance being, most
 
 OVARIAN DROPSY. 163 
 
 equable in the case of the imilocular disease, though it is almost 
 the same in the multilocular tumor when there are large cells. 
 Fluctuation is always very distinct when there is only one cyst ; 
 being of course more imperfect and obscure when there are 
 several, and no single one of great size. Unless the morbid 
 growth is very large and projects into the loins, or unless ascites 
 coexists, fluctuation will not be detected in the flanks. The 
 more viscid the contents of the cyst, the more obscure will be the 
 fluctuation, as a general rule ; and the same remark holds good 
 when the cyst-walls are very thick. The pulsations of the aorta 
 are sometimes communicated to the hand laid over the tumor. 
 Percussion elicits a dull sound over the whole of the front and 
 sides of the tumor, as a general rule. The exceptions are, when 
 a coil of intestine passes between the growth and the abdominal 
 wall, as it sometimes does just above the pubes ; or when the 
 cyst has been tapped, and has afterwards filled with air ; or when 
 a cyst has emptied itself into the intestine, And flatus has passed 
 from the latter into the former. The dulness is uniform over the 
 mass of the tumor, and its note is not affected by change in the 
 posture of the patient. But there is resonance above the tumor ; 
 as well as in that lumbar region into which the intestines have 
 been pushed, which is always the one corresponding to the healthy 
 gland. By auscultation a murmur is sometimes heard in one or 
 both iliac regions, owing to pressure exerted b}^ the diseased mass 
 upon the iliac arteries. Otherwise only information of a negative 
 kind is gained ; there being an absence of borborygmi, and of 
 anything like the sounds produced by pregnancy. Cysts of 
 moderate size, when free from adhesions, do not modify the re- 
 spiratory movements ; but when large they restrain the descent 
 of the diaphragm, and especially do they do so when they are 
 adherent. A non-adherent cyst will usually descend to the ex- 
 tent of an inch during inspiration. Dyspnoea and even ortho- 
 pnoea are present when the tumor has acquired a large size. 
 Some stress is laid by many authors upon the fact of the gradual 
 emergence of the umbilicus during pregnancy, this emergence 
 increasing until the depressed portion of the navel gets on a level 
 with the integuments. But the same thing happens, even to a 
 greater degree, in large ovarian tumors, as well as in ascites ; and, 
 in fact, in every case where the abdominal walls become greatly 
 distended. Although in the early stages of ovarian dropsy the
 
 164 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 patient will freqneiitl}' be found in the enjoyment of good health, 
 yet, as the distension increases, her constitutional powers gradu- 
 ally fail. At the end of no long period she complains of a bear- 
 ing down and sense of weight in the pelvis ; of flatulence, nausea, 
 constipation, hemorrhoids, and throbbing in the fundament ; and 
 of a deepseated pain in the groins. She loses flesh and strength ; 
 the nights are restless ; the appetite gets poor, and the power of 
 digestion becomes impaired ; and there is great mental depres- 
 sion. Then, by and by, there sets in oedema of the lower part 
 of the abdomen, vulva, thighs, and legs ; with numbness of the 
 lower extremities, especially on the aflected side. The case 
 often terminates with more or less complete suppression of 
 urine, from the pressure upon the kidneys, and ursemic poison- 
 ing ; or there is increasing debility, which finally ends in ex- 
 haustion and death. 
 
 Dropsy of the Fallojnan tube is rather an uncommon affection. 
 The fimbriated extremity of this canal and the uterine orifice, 
 occasionally get obliterated from the action of chronic inflamma- 
 tion. In such a case, the portion of the tube between the open- 
 ings becomes the seat of a more or less abundant accumulation 
 of pus or serous fluid. Instances are recorded where an hyper- 
 trophied oviduct has alone weighed seven pounds, and has con- 
 tained twenty-three pints of fluid. The positive diagnosis of 
 this disease from a simple ovarian cyst is exceedingly difficult, 
 if not generall}^ impossible ; but only an inexperienced observer 
 could confound the abdominal enlargement produced in such a 
 case with that due to pregnancy. 
 
 Acute inflammation of the ovary, ending in suppuration, is one 
 of those rare diseases which could hardly be mistaken for preg- 
 nancy. The tumor formed by the abscess, however, may acquire 
 a great size ; a case having occurred to Kiwisch where the cyst 
 contained fifteen pints of pus. Such instances must not be con- 
 founded with those cases of ovarian dropsy in which the con- 
 tained fluid is formed almost entirely of pure pus ; this secretion 
 being the result of acute inflammation of the cyst-wall. 
 
 The fact that pregnancy may coexist with ovarian dropsy must 
 not be forgotten; since it is a combination which will materially 
 obscure the diagnosis. Many women have conceived and brought 
 forth children after an ovarian tumor has manifested itself; and
 
 PKEGNANCY AND OVARIAN DROPSY. 165 
 
 several cases are known where the same has happened subse- 
 quent to the extirpation of the disease. When hotli ovaries are 
 afi'ected, pregnancy is, of course, much less probable, yet it has 
 occurred; for there is no reason why we should not believe with 
 Morgagni, that a woman may conceive if there only remain so 
 much of one ovary sound as belongs to a single mature vesicle. 
 Mr. Hewlett has recorded an extraordinary case in which a lady, 
 with most extensive double ovarian disease, was delivered, after 
 a very difficult and tedious labor, of a putrid child. She died 
 ten days subsequently ; and at the post-mortem examination it 
 was found that both ovaries were converted into large malignant 
 tumors. The left gland was so large that it ascended from the 
 left iliac fossa to the diaphragm ; while the right tumor entirely 
 filled the hollow of the pelvis.^ In the diagnosis of pregnancy 
 under these circumstances, the points on which to rely for form- 
 ing an opinion must be the history, the appearances in the 
 mammary areolae, the possibility perhaps of obtaining evidence 
 by ballottement, an-d the audibility of the uterine murmur and 
 fcetal heart. By inattention to these points ovariotomy has been 
 performed, when in addition to the tumor there has been an un- 
 detected pregnancy ; and in consequence abortion has followed 
 the operation and proved fatal. In the succeeding case it will 
 be seen, that by deferring the removal of the tumor until after 
 the premature termination of pregnancy, the life of the patient 
 was saved: 
 
 On the 5th of August, 18G3, I saw Mrs. M. H. at the request of Sir Wil- 
 liam Fergusson. She stated that her age was 29, that she was ruarried on 
 3d June, 1860, that she has been pregnant once, and that delivery took place 
 on the 4th November, 18G1. She suckled this child for eight months. Her 
 size was so immense before delivery, that she suffered much from dyspnoea; 
 and the distension was almost as great after labor. Six weeks subsequent 
 to this event, her medical man tapped her. She went on for a year, and 
 then was tapped a second time. This present year (1863) has been tapped 
 five times ; on the last occasion three months ago, when three gallons of a 
 fluid like white of egg were removed. The catamenia have usually been 
 regular; but the last day of their last appearance was the 10th March of 
 this year. General health bad. 
 
 On examination, I found the abdomen as distended as at the full term of 
 pregnancy. Fluctuation was everywhere distinct: dulness on percussion, 
 except in the right loin where there was resonance. After a prolonged trial, 
 I distinctly heard the sounds of the foetal heart. By the vagina, the uterus 
 
 1 Medico-Chirurgical Transactions, vol. xvii, p. 226. London, 1S32.
 
 166 THE DISEASES WHICH SIMULATE PREUNANCy, 
 
 could be felt enlurped. The opinion given to Sir William Fergusson was, 
 that Mrs. H. had a niultilocular tumor growing from the left ovary, and that 
 she was five months advanced in pregnancy. 
 
 As the distension was great, it was determined that Mrs. H. should be 
 tapped on the 7th August. But this proceeding was rendered unnecessary 
 by her having a miscarriage the same morning. The foetus was of five 
 months growth. On the 28th October, Sir William Fergusson removed the 
 tumor by abdominal section. The growth weighed 14 lbs. and sprang from 
 the left ovary. The patient made a good recovery. Subsequently, she was 
 delivered of a live eight months female infant on the 23d November, 1864. 
 And again, on 18th December, 1865, she was delivered of twins; one child 
 being healthy and well-formed, the other dead and malformed. 
 
 The fear of an ovarian cyst rapturing from the pressure ex- 
 erted on it by the abdominal walls and the gradually increasing 
 pregnant uterus must not be overlooked. There is likewise no 
 little risk of the bloodvessels of the diseased ovary giving way, 
 while the ovarian and uterine arteries are conveying an increased 
 amount of blood under the influence of gestation. Should there 
 appear a chance of either of these accidents occurring, it may be 
 necessary to avert the danger by inducing premature labor. 
 When the ovarian tumor consists of a single cj'st, it will prob- 
 ably be worth while to resort to tapping instead of interfering 
 with the course of gestation. The performance of ovariotomy 
 during pregnancy is certainly unjustifiable. Abortion, and 
 probably death, would be sure to result. 
 
 3. Ascites. — The signs and symptoms of this disease are 
 generally so characteristic, that there would seem to be some 
 difficulty in mistaking the abdominal enlargement which it 
 produces for that due to any other cause. Yet errors in the 
 diagnosis of ascites are far from uncommon. Especially is it 
 sometimes perplexing to distinguish bet\veen a peritoneal dropsy 
 and an ovarian tumor, when the latter consists of a singe capa- 
 cious sac with thin walls. So again, in the case of a large uterus 
 over-distended with an unusual quantity of liquor amnii and 
 containing a dead fcetus, with some complication like ascites or 
 a tumor of the liver, the diagnosis may be sufficiently intricate 
 to try the skill of a shrewd observer. With regard to ordinary 
 pregnancy and ascites, however, there ought to be no question. 
 Nevertheless, cases similar to the following may perhaps occur 
 even in the present day: 
 
 Francis Mauriceau relates that about the year 1654, being in the city of
 
 ASCITES. 167 
 
 Saumur, there was near his lodging a young and very handsome daughter of 
 a citizen, who was five whole months under a physician's and apothecary's 
 hands to be cured of a dropsy which she complained of. "At length after 
 she had taken many violent remedies they had ordered her, she was cured 
 in a moment, by bringing forth a child at its full time, notwithstanding all 
 they had given her; which much astonished the physician and apothecary, 
 to be so grossly deceived, in trusting to the maid's relation, who counter- 
 feited the dropsy so well, that they could never perceive the truth till she 
 was brought to bed."^ 
 
 On examining a case of ascites in which the quantity of fluid 
 effused is abundant, a general fulness of the abdomen can be 
 noticed. If the patient be standing upright, the fulness will seem 
 to be most prominent below the level of the umbilicus ; but on 
 lying down the abdomen always becomes more flat, while both, 
 the flanks bulge outwards. When placed on one side, the lower- 
 most part distinctly exhibits the greatest prominence. Supposing 
 the quantity of liquid to be excessive, there will be found to be 
 general abdominal enlargement, uninfluenced by the posture 
 assumed; while the abdomen will also appear to encroach con- 
 siderably on the thorax, and the xiphoid cartilage with the car- 
 tilages of the lower ribs will be found much everted. The veins 
 of the parietes are generally also prominent and dilated, a condi- 
 tion which is often due to obstruction of the vena portse. "When 
 the dropsy is caused by structural disease of the liver, it is often 
 associated with a certain amount of jaundice. 
 
 By practising palpation two or three very characteristic signs 
 can be discovered. The great evenness of the enlargement, 
 together with the feeling of resistance and weight which is ex- 
 perienced on pressing the hand towards the spine, will first excite 
 attention. The elasticity of the swelling is remarkable. Then 
 the evident sense of fluctuation communicated to the fingers 
 arrests attention ; the waves being finer and following more or 
 less quickly upon the impulse, in proportion as the distension is 
 great and the fluid of a thin serous or watery consistence. CEdema 
 of the abdominal wall, or the presence of much fat, obscures this 
 last sign. 
 
 On percussing over the higher portion of the bell}^ there is 
 generally produced a resonant sound, owing to the floating of 
 the intestines ; although only dulness results if the distension be 
 
 1 The Diseases of Women with Child, and in Cliilddjed. Translated from the French 
 hy Hugh Chamberlen, M,D. 7th edition, p. 19. Lontlon, 1736.
 
 168 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 great and the breadth of the mesentery insufficient to allow the 
 intestines to reach the surface of the fluid, or if the intestines have 
 become matted together in consequence of peritoneal inflamma- 
 tion. By making the patient stand upright, we can trace the 
 height to which the fluid reaches, and thus roughly estimate the 
 quantity present ; dulness existing over the part occupied by the 
 eflTusion, and resonance above. If the patient be on her back, the 
 resonant intestines are commonly found grouped around the um- 
 bilicus, while the flanks are dull. By placing the woman on one 
 side, the uppermost flank is made resonant and the lowermost 
 dull. In the difl:erential diagnosis of ovarian dropsy, ascites, and 
 pregnancy, one sign — percussion of the lumbo-lateral region — is 
 worthy of recollection. If, in a case of ascites in which the dis- 
 tension is so great that the hydrostatic line of level is not changed 
 by posture, the patient be made to sit up in bed, and the loins be 
 percussed, it w^ill be found that the note is the same — generally 
 dull — on both sides. In the case of a large ovarian cyst, no matter 
 how great the distension may be, we find that one loin will give 
 out a clear note, while the other is quite dull. In the cases of 
 far-advanced pregnancy which I have examined in the same way, 
 I have found both loins resonant on percussion. The explana- 
 tion is easy. In ascites, the air-containing intestines float as far 
 forwards as their mesenteric attachment will permit; while in 
 the case of an ovarian tumor the coils of gut are pushed over to 
 the healthy side, and in pregnancy are forced backwards to either 
 side indiscriminately. I have elsewhere remarked, that ordinarily 
 when any real difficulty exists in the diagnosis of ascites from 
 ovarian dropsy, the mere fact of difficulty may be taken as pre- 
 sumptive evidence in favor of the case being one of ascites. I do 
 not at present remember having seen one instance where an ova- 
 rian tumor has been mistaken by a competent observer for a case 
 of ascites ; but I have known the opposite error often committed, 
 even by gentlemen who have had considerable experience. 
 
 "With regard to the general symptoms, a few words must suffice ; 
 since they of course differ materially, according to the cause of 
 the disease. But in the advanced stages of drops}- of the peri- 
 toneum we shall find more or less dyspnoea, owing to the pushing 
 upwards of the liver and spleen and stomach ; while auscultation 
 will show that the respiratory murmur cannot be heard so low as 
 in health, that there is tubular breathing in the interscapular
 
 ASCITES AND PREGNANCY. 169 
 
 regions and especially on the left side, and that the apex of the 
 heart is elevated and rather pressed to the left. In many cases 
 also there is general or partial OBdema, the lower extremities being 
 very often anasarcous ; this being especially the case when there 
 is renal disease. Moreover, in these instances the urine is usually 
 scanty and albuminous. Generally, the uterus occupies its normal 
 position ; but owing to the pressure of the fluid, together perhaps 
 with a relaxed condition of the vaginal walls, I have seen it dis- 
 placed downwards, forming a considerable tumor between the 
 upper part of the thighs. 
 
 Ascites and pregnancy may exist together, although the combi- 
 nation is not a frequent one. Very rarely it happens that im- 
 pregnation occurs subsequently to the setting in of the dropsy. 
 But much more commonly the pregnant uterus, at some period 
 after the third month, induces the ascites ; a pre-existing diseased 
 condition of the liver, or of the right side of the heart obstructing 
 the circulation, favoring its occurrence. "Where ascites is con- 
 joined with pregnancy, the abdomen becomes enormously dis- 
 tended as gestation advances. There is dulness on percussion, 
 with more or less distinct fluctuation. The uterine enlargement 
 can only be detected by making deep pressure with the fingers, 
 while the patient is on her back ; her head and chest being ele- 
 vated and the knees drawn up, so as to relax the abdominal 
 integuments. The signs of pregnancy are all obscured ; the aus- 
 cultatory phenomena, if detected at all, are muffled and indis- 
 tinct, and only the detection of ballottement by a vaginal ex- 
 amination, together with the changes in the areola, make the 
 diagnosis at all certain. 
 
 The general symptoms are distressing in the extreme. Great 
 pain is complained of in the back and loins and thighs. There 
 is oedema of the lower extremities. The renal secretion is scanty 
 and high-colored, often loaded with urates of soda and ammonia, 
 occasionally charged with bile, and sometimes containing albu- 
 men. There is urgent dyspnoea, increased by taking food or ex- 
 ercise. The countenance is livid, and bears an expression of 
 much anxiety. Sickness, vomiting, constipation, headache, and 
 palpitations increase the sufferings. There is an inability to 
 move about ; with such pain from difficult breathing on assum- 
 ing the recumbent posture, that the patient is obliged to be con-
 
 170 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 stantly propped up in bed. In short, so much severe general 
 distress exists, that in order to give relief it is often necessary to 
 remove the fluid by tapping through the abdominal wall ; or it 
 may be desirable to afford more permanent ease by inducing 
 premature labor. 
 
 An excessive secretion of liquor aranii — dropsy of the amnioti — 
 has been described by several authors as sometimes obscuring 
 the signs of pregnancy, and giving rise to several troublesome 
 symptoms. The quantity of fluid has occasionally been large ; 
 sixteen pints, and even more, having come away on rupturing 
 the membranes. The statements of obstetricians concerning: the 
 normal quantity of liquor anmii towards the end of gestation are 
 very contradictory. Hunter, Lowder, Burns, and others assert 
 that the average quantity varies from a pint to a quart. This 
 opinion, however, seems to me to be incorrect; and I believe, 
 with most Continental writers, that in the majority of cases there 
 is not more than from twelve to sixteen ounces. When the 
 quantity slightly exceeds a pint, the pains of labor may be found 
 weak and inefficacious, owing to the distension of the uterine 
 walls ; although there may not have been any particular suft'er- 
 ing during the last month of gestation. The presence of three 
 or four pints, on the contrary, can give rise to so much positive 
 distress during the last few weeks of pregnancy, that it may be 
 absolutely necessary to afford relief by rupturing the membranes. 
 
 Difierent causes have been assigned for dropsy of the amnion. 
 M. Mercier and others have generally attributed it to inflamma- 
 tion of the amnion alone. In by far the greater number of cases, 
 however, which have been examined of late years, it has been 
 noticed that there was an absence of anything like special in- 
 flammatory action in this membrane ; though in almost all, some 
 diseased condition of the entire involucra or of the placenta or 
 of the foetus existed, rendering the child incapable of supporting 
 life after its birth. 
 
 The signs produced by an excessive secretion of liquor amnii 
 are generally unequivocal. Thus, the uterus is always found con- 
 siderably larger than in normal pregnancy; and hence it appears 
 above the pubes, reaches, the umbilicus, and so forth, at an ear- 
 lier period than is customary. The uterine tumor is also tense, 
 often more globular than usual, and smooth ; its walls appear
 
 PREGNANCY AND A DISTENDED BLADDER. 171 
 
 thinner than in ordinary cases ; while the foetal limbs and move- 
 ments are for the most part inappreciable. Fluctuation is more 
 or less distinct, according to the extent to which the uterine and 
 abdominal walls are attenuated ; where this sign seems obscured, 
 it may sometimes be detected more clearly by pressing steadily 
 on the lower portion of the uterus with one or two fingers in the 
 vagina, while percussing the abdomen. Moreover, on practising 
 auscultation the uterine murmur can be heard distinctly, while 
 the foetal heart will be almost or quite inaudible. And then, an 
 examination by the vagina will reveal to us an unusual degree 
 of expansion of the inferior segment of the uterus ; at the same 
 time that we are able, with unusual ease and distinctness, to ob- 
 tain balldttement. 
 
 The general symptoms consist chiefly of a sense of great dis- 
 comfort, a feeling of tightness and distension, of inability to 
 move about to any extent, and often of despondency. The 
 patient believes that she is carrying twins. There are attacks of 
 dyspnoea, aggravated by the recumbent posture. Complaint is 
 made of constant pressure and weight in the pelvis ; while there' 
 are frequent calls to evacuate the bladder, and occasionally at- 
 tacks of tenesmus. Scarpa, Desormeaux, and Dr. Robert Lee 
 have related instances where the diagnosis of this affection has 
 been rendered unusually diflScult by its being complicated with 
 ascites. But even in simple cases of dropsy of the amnion mis- 
 takes have been committed. On one occasion, under the im- 
 pression that the patient was laboring under ascites from disease 
 of the liver, tapping was had recourse to. Had a correct view 
 been taken, however, and the membranes been artificially rup- 
 tured, a cure would in all probability have resulted instead of 
 death. 
 
 Advanced pregnancy is sometimes accompanied hy great distension 
 of the bladder, this viscus forming an oblong fluctuating tumor in 
 front of the uterus. Independently of pregnancy, however, a 
 distended bladder has been mistaken for ascites, for an ovarian 
 cyst, for pelvic cellulitis, and for a fibroid tumor of the uterus ; 
 errors which may almost be said to be unpardonable. Not un- 
 frequently too, pregnancy has been diagnosed when the enlarge- 
 ment has merely been due to an excessive accumulation of urine. 
 Many physicians have seen cases like the following :
 
 172 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 Sir Astley Cooper relates that Mr. Clive was called to a lady for a com- 
 plaint which was thought to be dropsy of the abdomen; and which Mr. Olive 
 at first conceived to be so himself. On examination, however, he observed 
 that the upper part of the abdomen was more free from fluctuation than the 
 lower; and it occurred to him that there might be some deception in the ap- 
 pearances, on account of a distended state of the bladder. On asking the 
 lady whether she passed water freely, she replied in the afiirmative ; but, not 
 feeling satisfied, he introduced the catheter, and drew off " an enormous 
 quantity" of water, which had occasioned the appearance of dropsy.' 
 
 When a retention of urine takes place in the latter months of 
 pregnancy, the bladder is unable to enlarge equally in all direc- 
 tions because of the resistance which it meets with posteriorly 
 from the gravid uterus. Hence, as the urine accumulates, the 
 vesical sac assumes a flattened form, and spreads upwards and 
 laterally to a great extent over the anterior part of the uterus, at 
 the same time giving under palpation such an evident sense of 
 fluctuation, that the case might be mistaken for a dropsy. An 
 unfortunate instance of this kind happened to a practitioner in 
 Ireland, who tapped his patient for such a supposed dropsy ; death 
 being the consequence. On examination it appeared that the 
 trocar and canula had passed through both sides of the bladder, 
 through the anterior wall of the uterus, and even into the head 
 of the child. ^ 
 
 Many other examples might be quoted to prove, that when 
 examining the abdomen for the detection of pregnancy or for the 
 purpose of deciding upon the nature of any kind of enlargement, 
 care should be taken that the bladder is empty. It is useless 
 trusting to the statements of the patient or her nurse; for they 
 will often assert, in good faith, that the urine is being passed too 
 freely, when in point of fact it is merely dribbling away from an 
 over-distended bladder. The chief constitutional symptoms of 
 an undue accumulation of urine are those of irritative fever. 
 There is a hot clammy skin, a furred tongue, bearing-down 
 pains, restlessness and sleeplessness, nervousness or despondency, 
 a feeling of nausea, and sometimes actual sickness. The sense 
 of bearing-down, together with the recurrrence of forcing pains 
 at intervals, may even lead to the erroneous suspicion that the 
 
 1 Lectures on Surgery. By Sir Astley Cooper, Bart., &c. Sixth Original Edition, 
 p. 418. London, 1839. 
 
 2 Lowder, MS. Lectures. Quoted by Dr. Goocli. Opus jam citat. P. 232. I have 
 gone through the copy of Br. Lowder's Lectures, written in 17S2, belonging to the Royal 
 Medico-Chirurgical Library, but cannot find this passage.
 
 UTERINE FIBROIDS. 173 
 
 patient is in labor. There is one symptom, moreover, which I 
 have seldom seen absent when the bladder has been distended 
 for some forty-eight or sixty-four hours, and that is a rapid pulse 
 — one varying from 96 to 120 beats in the minute. And it is 
 often remarkable to witness how quickly these beats diminish in 
 frequency when the cause of the disturbance is removed. 
 
 Seeing then the troublesome and very painful symptoms which 
 may arise from retention of urine, and remembering the fatal con- 
 sequences which must ensue if this condition be overlooked too 
 long, I would advise the practitioner to be very wary. He should 
 assure himself that a fair quantity of water is passed at proper 
 intervals ; instead of a few drops or a tablespoonful every ten or 
 fifteen minutes. And most decidedly, if any doubt be enter- 
 tained with regard to this matter, all uncertainty should immedi- 
 ately be set aside by the introduction of a catheter. 
 
 4. Fibroid Tumors of the Uterus. — Of all the organic diseases 
 of the uterus which first manifest themselves during the period 
 of sexual vigor, fibroid tumors are probably the most common. 
 These growths may be developed in any portion of the uterus. 
 According to their position they are often classified as sub- 
 peritoneal or surface tumors, when seated just beneath the peri- 
 toneum ; interstitial or intramural tumors, when imbedded in 
 the uterine walls ; and submucous or intra-uterine tumors, when 
 they are pressed into the cavity of the womb. Fibroid tumors 
 are met with at all ages after puberty, though they occur most 
 frequently between the years of 25 and 48. The earliest age at 
 which I have observed such a growth has been 18, the woman 
 being married. It is very probable that these tumors occur 
 equally in the married and single, in the sterile and fruitful. 
 They may be solitary or numerous. In one large uterus which 
 I removed from the body of an old woman, I counted as many 
 as nine distinct outgrowths from the external walls of this organ ; 
 while there are specimens in museums where a greater number 
 may be made out. These tumors vary in size from that of a bean, 
 to an orange, or an infant's head ; and occasionally they attain 
 even a very much greater bulk, some having been found to weigh 
 as heavy as thirty-nine or forty pounds. Waller, indeed, has 
 mentioned one which weighed seventy-four pounds. In the year 
 1859, I had a patient under my care whose uterus was enlarged
 
 174 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 by an oval and solid fibroid tumor, to at least a degree equal to 
 that found at the full term of gestation. Though a woman of 
 only ordinary stature, with the abdominal integuments very thin 
 and tightly stretched, yet she measured seventeen and a half 
 inches from the ensiform cartilage to the pubes ; from the umbil- 
 icus to the pubes ten inches and a half; and in circumference 
 midway between the umbilicus and pubes, thirty-seven inches and 
 three-quarters. A distinct uterine souffle could be heard at differ- 
 ent parts of the abdomen. It appeared almost certain that the 
 morbid growth had become pediculated and therefore could have 
 been removed, had it not been for the fact that its size was too 
 great to allow of its entering the pelvic cavity; while an adhesion 
 which it had contracted with the anterior wall of the uterus pre- 
 vented a ligature being passed around its pedicle by the aid of 
 Gooch's canulse. 
 
 When the cavity of the womb becomes much enlarged by a 
 fibroid projecting into it, the uterine walls get h3'pertrophied, 
 while their sinuses may undergo development as in pregnancy. 
 Under the influence of congestion — such as occurs at the men- 
 strual periods — the walls of one or more of these venous canals 
 are occasionally ruptured ; blood being poured out until a co- 
 agulum forms, or the opening heals, or the uterine contractions 
 compress the bleeding orifice against the tumor. 
 
 Fibroid tumors of the uterus are generally benign and harm- 
 less ; many patients having been known to live for twenty, thirty, 
 or even more years after they have first manifested themselves. 
 Malignant fibroids are not, however, so very uncommon. The 
 benign growths, although insensible in themselves, yet when pro- 
 jecting into the cavity of the womb are often very sensitive; this 
 condition depending ujion the irritability of the lining of the 
 uterine cavity, which forms a covering to the tumor in its descent. 
 Occasionally they thus become so painful as to prevent coition, 
 and hence may be a cause of barrenness. If, in spite of the 
 presence of one or more of these tumors in the cavity of the 
 uterus, impregnation take place, the periods of pregnancy and 
 labor are rendered unusually dangerous ; the latter especially 
 being liable to be followed by frightful hemorrhage, or severe 
 metritis. AVhere the existence of one of these growths has com- 
 plicated delivery or rendered it impossible, by its great size or 
 its situation, recourse has been had to the Ceesarean section : an
 
 UTERINE FIBROIDS. 175 
 
 operation which, in this country at least, is almost always fatal. 
 Tumors seated in the walls or at the fundus may interfere neither 
 with copulation nor gestation ; though they may even in these 
 situations, by impeding the expansion and growth of the uterine 
 tissue, produce abortion. 
 
 Before proceeding to speak of the symptoms produced by these 
 tumors, I shall briefly relate two cases where mistakes were made 
 in their diagnosis. In the first instance the error was very ex- 
 cusable, as the following history shows : 
 
 A medical man was called up one night to attend, as he was tokl, a woman 
 in labor. On his arrival he found the patient to be an unmarried lady, about 
 forty years of age, and apparently very near delivery. There were the usual 
 bearing-down pains recurring at intervals, and the ordinary uterine action. 
 On examination he could not exactly determine what the presentation was, 
 but imagined it to be the breech. He seated himself by the bedside, and 
 supported the perineum in the usual manner. The labor gradually advanced, 
 and at length delivery took place — to his great astonishment — of an enormous 
 polypus, which was attached to the fundus of the uterus. He very properly 
 cut off the tumor close to its attachment, and the patient quickly recovered.' 
 
 Dr. Bedford, of ISTewYork, records the second case, — that of a 
 young lady who was afflicted with a large fibroid tumor of the 
 uterus, which had been mistaken for pregnancy. "When the 
 Doctor saw her, she was dying of phthisis, possibly brought on 
 by intense grief and disappointment. The chief points are as 
 follows : 
 
 A gentleman of high standing in the Church of England had the misfor- 
 tune to lose his wife while his only child was young in years. He became 
 greatly attached to this daughter, and educated her himself; so that she was 
 his fond pupil and constant companion. Soon after having attaitied her 
 eighteenth year an attachment was formed between her and a young barrister 
 of great promise ; which attachment resulted in a matrimonial engagement. 
 A few months afterwards her health beiran to decline; the menstrual periods 
 became irregular, the abdomen and breasts enlarged, there was a marked 
 change in her personal appearance, and she took a strong dislike to society; 
 while at the same time she suffered from more or less constant nausea, loss 
 of appetite, inability to sleep, and feverishness. These changes attracted 
 the attention ofsomeof her female acquaintance, and the rumor soon spread 
 that they were the result of pregnancy. The man to whom she was affianced, 
 hearing of these reports, addressed a letter to the father requesting to be re- 
 leased from his engagement; a proposal which was assented to without any 
 hesitation. At the young lady's request a medical man was now called in ; 
 who, after an investigation of her symptoms, informed the father that she 
 
 ' The Dublin Journal of Medical Science, vol. vi, p. 33. Dublin, 183-5.
 
 176 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 was undoubtedly pregnant, and advised that steps should instantly be taken 
 to keep the unpleasant matter secret. The father indignantly spurned the 
 proposal, and requested an additional opinion. A consultation was accord- 
 ingly held, the result of which was a confirmation of the view previously ex- 
 pressed. Without delay the venerable and accomplished gentleman deter- 
 mined to resign his living, gather up his little property, and proceed with 
 his daughter to America. On the passage out she became extremely ill; and 
 there being a phy.sician on board the vessel his advice was requested. After 
 seeing the lady, who was then affected with excessive vomiting from sea- 
 sickness, he told the father that there was danger of premature delivery. On 
 Dr. Bedford examining the patient, he found that she was not pregnant, but 
 was in the last stage of consumption. Four weeks afterwards she died; and 
 at the post-mortem examination a large fibroid tumor was removed from the 
 uterus.' 
 
 This sad case, in which probably both character and life were 
 sacrificed by gross want of skill on the part of those whose aid 
 had been invoked, shows the fearful responsibility which is not 
 unfrequently thrown on the medical man, and the cruel result 
 which may follow from his being rash or ignorant. Well might 
 the broken-hearted father exclaim, as the tumor was removed 
 from the womb. " This is my trophy, and I will return with it 
 to England, and it shall confound the traducers of my child." 
 
 The symptoms produced by fibroid tumors are often neither 
 prominent nor well-marked. Indeed, these growths not unfre- 
 quently exist without giving rise to a suspicion of the presence 
 of any uterine disease. But on the other hand, when of a suffi- 
 cient size to be detected through the abdominal wall, they are 
 often the source of considerable disturbance. Thus, they may be 
 the cause of menstrual irregularity; of a dull aching, or throbbing 
 pain; of a sense of weight and bearing-down in the pelvis; of 
 cramp or numbness in one or both thighs ; of a difficulty in evacua- 
 ting or in holding the urine ; and of constipation, with hemor- 
 rhoids. Pediculated fibroid tumors — commonly known as uterine 
 polypi — are almost ahvays attended by one very prominent symp- 
 tom, and that is hemorrhage ; and witli a little latitude the same 
 remark applies to submucous tumors merely projecting into the 
 cavity of the uterus. When the first symptom of the existence 
 of a fibroid tumor is a sudden attack of hemorrhage, the patient 
 not unfrequently tries to persuade herself that she has been preg- 
 nant, and aborted ; and even though the fiooding returns after 
 
 • Clinical Lecture? on the Diseases of Women and Children. By G. S. Bedford. M.D., 
 Professor of Obstetrics in the University of New York, &c. Fourth Edition, p. 50 New 
 York, 183G.
 
 UTERINE FIBROIDS. 177 
 
 a time, she still endeavors to deceive herself. The practitioner, 
 however, must not be misled by her statements or opinions. He 
 will distinguish the true nature of the disease hy learning that 
 the loss of blood has probably been excessive, and accompanied 
 with coagula free from any pieces of membrane ; that the hemor- 
 rhage has returned more than once without warning, and without 
 being attended by uterine contractions or much pain ; and especi- 
 ally that the tissue of the cervix is firm and the os thin and small, 
 instead of being relaxed and swollen and patulous, as after abor- 
 tion. Ver}^ frequently, especially with submucous tumors pro- 
 jecting into the cavity of the uterus, the patient first has her 
 attention directed to the womb by noticing that the menstrual 
 discharge is more abundant than usual, that its duration is greater, 
 that it is attended wnth clots, and that its cessation is followed by 
 leucorrhoea. The monthly periods also recur more frequently 
 than is natural ; the intervals between them gradually shortening, 
 until at last there is scarcely more than a day or two of freedom. 
 Moreover, the periods are accompanied with great pain in the 
 back and thighs, and with bearing-down or dragging sensations; 
 there may be expulsive efibrts simulating labor pains, some- 
 times occurring only with the eatamenial flow and sometimes 
 coming on in the intervals with more or less frequency ; and • 
 while the courses continue, and even for some few days before 
 and afterwards, the patient is incapacitated from following her 
 usual duties. 
 
 On making a vaginal examination we shall generally find the 
 weight of the uterus increased, while its mobility is diminished; 
 the vagina also being lessened in length. If the tumor be in the 
 cavity, the os may sometimes be found patulous, and the tumor 
 projecting between its lips. But more frequently the mouth of 
 the uterus is closed, and the cervix absorbed into the substance 
 of the walls ; so that we feel merely a rounded body with a slight 
 depression and opening at its lowest part. When the tumor 
 occupies the posterior wall it often produces retroversion of the 
 uterus ; and consequently the fundus of this organ then lies upon 
 the rectum, while the cervix is pushed forwards and upwards 
 under the pubis. Supposing the growth to be in the anterior 
 wall, the uterus will perhaps be anteverted ; that is to say, with 
 its fundus on the bladder and its os looking directly towards the 
 sacrum. Instead of retroversion or anteversion, there may merely 
 
 12
 
 178 THE DISEASES AV II I C II SIMULATE PREGISrANCY. 
 
 be retroflexion or anteflexion ; or there is sometimes more or less 
 lateroversion or lateroflexion. And again, the tumors may even 
 be large and heavy, without causing any uterine displacement 
 whatever. Provided that the practitioner is certain of the non- 
 existence of pregnancy, he will derive great assistance in forming 
 a positive opinion on the nature of the growth from the use of the 
 uterine sound. When this instrument is introduced into the 
 healthy uterus, it passes for two inches and a half; and by it — 
 without any rough manipulations — the organ can be elevated, 
 or turned to either side, or bent backwards or forwards. In most 
 instances of fibroid growth the cavity is found elongated; while 
 if the tumor be in the walls or closely attached to them, the sound 
 appears to enter the mass so completely that the uterus cannot 
 be separated from it, both can be only moved simultaneousl3% and 
 at the same time the womb is discovered to have lost its healthy 
 mobility and freedom. 
 
 Whatever may be the cause of uterine enlargement — whether 
 it be a tumor or retention of the catamenia — the breasts generally 
 become somewhat developed and tumid ; while sometimes the 
 areola also darkens, or the follicles increase in size and number. 
 But it is only in pregnancy that the nipples and the areolae undergo 
 all those peculiar changes which have been previously described ; 
 for in no other cases do we find, combined with the development 
 of the glands, enlargement of the follicles and an increase in their 
 number, oedema of the areolae, moisture of these parts, and a 
 gradually increasing deposit of pigment in their tissues. 
 
 If we practise auscultation over a fibroid tumor of the uterus 
 we shall very frequently detect a souflSe ; wliich is synchronous 
 with the pulse, and either short and abrupt, or harsh and pro- 
 longed. Firm pressure with the stethoscope, or a powerful con- 
 traction of the uterus, will possibly lessen or even suppress the 
 sound. The souffle may possibly sometimes be due to the pres- 
 sure of the growth on the aorta ; but I believe it generally has 
 its seat in the vessels of the enlarged uterus. This murmur might 
 lead to the case being mistaken for pregnancy ; but unless this 
 condition coexist, we shall be unable to discover any sound re- 
 sembling the foetal heart, or anything which the practitioner can 
 mistake for foetal movements. When an}' solid body presses 
 upon the aorta, the growth will transmit the sounds of this 
 vessel; whether the solid be a foetus, or an enlarged scirrhous
 
 UTERINE FIBROIDS AVITH PREGNANCY. 179 
 
 uterus, or a fibroid tumor, or a solid ovarian tumor. The sound 
 may be single and systolic ; or it may be double and synchronous 
 with the double sounds of the heart. 
 
 Reference has already been made to the fact that these uterine 
 tumors may coexist with pregnancy. It therefore becomes an 
 important question how we may best discriminate such a com- 
 plication. The only chance of avoiding error is by submitting 
 the patient to a most careful examination, — by the abdomen as 
 well as by the vagina; by thoroughly sifting the history of her 
 symptoms ; and then by fairly weighing and comparing the evi- 
 dence obtained from these two sources. The details of the fol- 
 lowing case may perhaps serve as an example : 
 
 In October, 1855, a lady residing at Dalston consulted me about an ab- 
 dominal tumor from which she had suffered for some months. She was 
 thirty-tive years of age, had been married six years, and hud never been 
 pregnant. The catamenia were regular. On examination I found a fibroid 
 tumor, about the size of the foetal head at the full term, growing in the 
 anterior wall of the uterus. Under the use of the bromide of potassium and 
 cod-liver oil, the general health improved; but the growth remained un- 
 affected. On the l^th December, 1856, this lady again consulted me. The 
 tumor had apparently very much increased in size, and now extended to 
 midway between the ensiform cartilage and the umbilicus. But on exami- 
 nation, the growth struck me as presenting peculiarities which were not at 
 first noticed. It was hard at its upper part, but very elastic in the middle 
 and below; it was particularly even, and not at all nodulated; a loud uterine 
 souffle could be heard to the left, on a level with the umbilicus; while on 
 making a vaginal examination, the womb was found equably enlarged, the 
 cervix soft and congested, and the lips of the os hypertrophied and cushiony. 
 Moreover, the catamenia had not appeared since the month of July, though 
 they had previously been regular; there was a distinct areola round each 
 nipple, but no other very characteristic appearance; and none of the common 
 general symptoms of pregnancy were complained of. Hoping that pregnancy 
 existed, L was yet afraid to give an opinion ; and requested her to see me 
 again in a fortnight. On the 31st December, all doubts were set at rest by 
 my hearing the foetal heart. On the 19th April, 1857, I delivered her of a 
 live female child, after a lingering labor; from which, however, she recovered 
 without an unfavorable symptom. 
 
 The fear that these tumors may become greatly increased in 
 size as pregnancy advances, and that they must be compressed 
 and bruised during the process of parturition by the contractions 
 of the powerful uterine fibres, has leel some physicians to strongly 
 recommend the induction of premature labor in all such instances. 
 Tlie late Dr. Ash well was a great advocate for this proceeding, 
 lie believed that if such cases were left alone and the tumors
 
 180 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 escaped mechanical injury, yet that they were liable to become 
 softened during the latter months; that the increased supply of 
 blood which they received led to inflammation, unhealthy sup- 
 puration becoming subsequently established in them ; and tliat, 
 as a consequence, death occurred soon after delivery. But the 
 absolute correctness of Dr. Ashwell's views has not been con- 
 firmed by subsequent observers; although all practitioners allow 
 that these complicated cases are serious, and require great care 
 in their treatment. To lay down such a sweeping rule as that 
 just mentioned is therefore unnecessary. But at the same time 
 there can be no doubt that premature labor should be induced, 
 if the tumor, from its size or position, be likely to prove any 
 obstacle to delivery at the full term, or if there coexist any pel- 
 vic deformity. Moreover, it will always be advisable in every 
 case to consider carefully whether such an operation be neces- 
 sary; allowing the judgment free play, unoppressed by any bias 
 one way or the other. In manj^ instances these tumors have a 
 tendency to produce abortion; but I have more than once found 
 it advantageous to prevent this event rather than to encourage it. 
 
 5. Enlargements of the Liver, Kidneys, Spleen, &c. — 
 To those who do not consider how strangely a disease will 
 sometimes mimic a natural process, it must appear remarkable 
 that hypertrophy of the liver could ever give rise to symptoms 
 which would be attributed to pregnancy. Yet Mr. Ingleby 
 mentions the case of a woman wdio died under a suspicion that 
 she was pregnant; but in whom the great bulk of the liver, in 
 conjunction with an effusion of serum into the pelvic cavity, 
 gave the abdomen the appearance which led to error. The liver 
 was found to weigh nearly sixteen pounds ; the normal weight 
 of this gland being between three and four pounds. Smellie saw 
 a girl only twelve years of age, in the Marylebone workhouse, 
 who was supposed to be in the eighth month of pregnancy. 
 Several medical men had examined her, one of whom had 
 offered to deliver her gratis; while others had made interest to 
 be present at the accouchement. The case was even advertised, 
 and the matron obtained money from numbers who went to see 
 her; until the farce was concluded by the necessity for sending 
 the patient to an hospital to be cured of her enlarged liver — the
 
 ENLARGEMENT OF THE LIVER. 181 
 
 source of the mistake.^ — In 1841 Dr. Eobert Lee visited in con- 
 snltation, a married woman wlio was supposed to be not only 
 pregnant, but in labor at the full period. The uterus, however, 
 was in the unimpregnated state; the enlargement of the abdo- 
 men and the pain being due to hypertrophy and inflammation 
 of the liver,^ 
 
 Most of the hepatic diseases which present organic changes 
 cognizable to the senses during life, are accompanied by enlarge- 
 ment. This of course varies in degree, according to the nature 
 of the disease and its severity. In some disorders — such as con- 
 gestion, simple hypertrophy, and fatty liver — the enlargement 
 is seldom very great; and consequently there will merely be ob- 
 served increased fulness beneath the ribs on the right side. But 
 in other and more serious cases — as in the waxy or amyloid 
 liver, cirrhosis with effusion, tropical abscess, cancer and hydatid 
 tumor — the enlargement may be such that the gland will seem 
 to occupy the entire abdomen. In disease of the right side of 
 the chest, especially pleurisy with extensive effusion, the liver 
 has been found depressed for some inches ; thus causing an ap- 
 pearance as of abdominal tumor. Moreover, when in hepatic 
 disease the enlargement is only moderate, the gland may yet be 
 found much lower down than it ought to be in women who have 
 been in the habit of wearing tightly-laced stays. Even in health, 
 the compression thus exerted upon the lower part of the thorax 
 will often force the anterior edge of the liver quite as low as the 
 crest of the ilium ; while, at the same time, the upper convex 
 surface of the gland has been seen deeply indented by the pres- 
 sure of the ribs. 
 
 In cases of enlargement when the patient is emaciated, the 
 diagnosis will generally be found free from difliculty ; particularly 
 if the practitioner take note of the increased bulge of the lower 
 ribs on the right side, of the situation of the free margin of the 
 liver, of the persistence of dulness on percussion from the lower 
 edge of the gland over the whole enlargement, and of the dilated 
 veins on the exterior of the abdomen. But when the parietes 
 are loaded with adipose tissue, and the viscera are filled with 
 gas, it is not quite so easy to avoid error. Especial care must 
 
 1 A Collection of Cases and Observations in Midwifery, by William Smellie, M.D. 
 Fourth Edition. Vol. ii, p. 195. London, 1768. 
 
 2 Lectures on the Theory and Practice of Midwifery, by Robert Lee, M.D., F.RS., 
 &c. P. 168. London, 1S44.
 
 182 THE DISEASES W H I C H ; S I M U L A T E PREGNANCY. 
 
 then be taken to observe that none of the signs of pregnancy are 
 present. It will be ascertained that the measurements of the 
 right side of the abdomen exceed those of the left, unless the 
 spleen be also simultaneously e^darged ; that there is greater 
 resistance to the hand on pressing over the right side than over 
 the left, and that this increased resistance is continuous from the 
 margin of the right ribs; that there is defective abdominal re- 
 spiratory movement on the right side, owing to the impeded de- 
 scent of the diaphragm, while the motion on the left is exagger- 
 ated ; that the respiratory murmur on the left side of the chest 
 is generally puerile ; that the tumor has much less mobility than 
 the o-ravid uterus ; and that the enlaro;ed liver seldom descends 
 so very low but that some space exists between the edge of the 
 gland and the upper margin of the pelvis, where resonance on 
 percussion can be detected. In hepatitis which has gone on to 
 suppuration, the constitutional disturbance — fever, shivering, 
 pain, emaciation, &c. — will aftbrd a clue ; not to mention that 
 when the abscess is large there is almost always a bulging or 
 "pointing" in some situation corresponding with the situation 
 of the liver. Malignant disease not unfrequently produces great 
 general enlargement ; though perhaps more commonly it gives 
 rise to nodules or masses, which are numerous but small, and 
 the projections of which are perceptible to the touch. Encepha- 
 loid growths, more generally than scirrhous, extend to the pel- 
 vis; but the general j^henomena are such that the disease cannot 
 be mistaken. Hydatid tumors are mostly globular or oval in 
 shape, have an even and smooth surface, are very slow in their 
 growth, have a high degree of elasticity, sometimes fluctuate, 
 often transmit the aortic pulsations unless the patient be placed 
 on the hands and knees, and possibly furnish the hydatid fremitus 
 on practising auscultation. With respect to all the cases we have 
 been considering, it is worth recollecting that the examination 
 will be facilitated by taking care that the bladder is quite empty, 
 and that the colon has been thoroughly evacuated by an enema. 
 
 The kidneys may occupy positions different from their normal 
 ones, and this malposition is sometimes accompanied with great 
 increase in size. Or, one renal organ will be in its natural po- 
 sition, and the other far removed from its ordinary site. Andral 
 relates a case where one gland was in its natural situation, and
 
 ENLARGEMENT OF THE KIDNEYS AND SPLEEN. 183 
 
 the other in the hypogastric region immediately over the blad- 
 der. — The two organs are now and then found united so as to 
 form one body, giving rise to the so-called "horseshoe kidney." 
 Such a gland was shown to the Pathological Society by Dr. Bence 
 Jones. In this instance the crescent-shaped organ weighed 
 twenty ounces ; it was placed across the low^er lumbar vertebrae, 
 the inferior and convex margin being opposite the brim of the 
 pelvis ; it had two ureters, and the pelves with which the ureters 
 were connected did not communicate ; while on making ai'sec- 
 tion no indication could be found that the organ had originally 
 been formed by the fusion of two distinct kidneys.' — In rare cases 
 the gland on one side is wanting, and then the one present is 
 usually much enlarged. — Hydronephrosis, or dropsy of the kid- 
 ney, gives rise to a tumor which may attain considerable size. 
 The nature of such a tumor is often diagnosed with difficulty, 
 more especially if the right gland be the one affected. But I do 
 not know that such a tumor has been mistaken for the pregnant 
 uterus ; though it has certainly been diagnosed as a hydatid 
 tumor of the liver, disease of the cfecum, an ovarian cyst, and as 
 a tumor of the uterus. — Cancer of the kidney may proceed to 
 such an extent that a very large growth results. In one case 
 which I saw, the gland occupied the whole abdomen, was cen- 
 trally placed, and was raiistaken for an ovarian tumor. But in 
 this instance the diagnosis was complicated by the coexistence 
 of pregnancy, which ran its natural course. Three weeks after 
 labor the patient died, and the left kidney was then found to 
 w^eigh upwards of twenty-seven pounds. — Lastly, a movable kid- 
 ne}^ — the fact that one or both of the renal glands may be mov- 
 able has been proved by examination after death — might be mis- 
 taken for a morbid growth. It could scarcely, however, be con- 
 founded by any medical man with a case of normal, or even of 
 extra-uterine pregnancy ; the situation of the gland, chiefly in 
 one or other hypochondriac region, its form and size, and the 
 absence of all constitutional disturbance or even inconvenience, 
 sufficing to distinguish it. But that the movements of one of 
 these kidneys may lead a w^oman to believe that she is pregnant, 
 and that she feels the infant, is by no means impossible. In the 
 year 1864, a patient, the mother of one child, was admitted into 
 
 ^ Transactions of the Pathological Society of London. Vol. vii, p. '204. London, 
 1856.
 
 184 THE DISEASES AVHICH SIMULATE PREGNANCY. 
 
 King's College Hospital. She not only tlionght herself in the 
 family-way, but said she had distinctly felt the infant's move- 
 ments. As, however, nine months had passed since she believed 
 that pregnancy had commenced and there had been no delivery, 
 she became frightened. On examination, the uterus was found 
 empty; but both kidneys were movable, the right being more 
 so than the left. 
 
 The spleen may attain such a size as to almost fill the abdo- 
 men ; this condition occurring even in individuals who have 
 never been away from a temperate climate. It is not very diffi- 
 cult to make a mistake as to the nature of the swelling. Occa- 
 sionally, the combination of pregnancy with enlargement of the 
 spleen has been observed. The diseased conditions which in- 
 crease the volume of this organ are especial]}^ inflammation, 
 fibrinous deposits, simple hypertrophy, lardaceous or amyloid 
 degeneration, tubercular growths, cancer, and cysts of various 
 kinds. This gland may become so hypertrophied as to weigh 
 from two or three to eighteen pounds ; and instances are re- 
 corded where it has been found as heavy as forty pounds. In 
 the examination of these cases reliance must chiefly be placed on 
 the detection of the thin anterior edge of the organ, and its 
 notched condition ; on the smooth convex surface of the swell- 
 ing; on its mobility, and superficial character; on its seldom 
 occupying as much of the right side as of the left ; and possibly 
 on the presence of the " splenic murmur." Then the connection 
 of the tumor with special constitutional syn^ptoms — such as ague, 
 leucocythemia, or typhus fever — will usually show the exact 
 character of the disease. But in proof that erroneous opinions 
 may be formed, the following is quoted ; 
 
 Stella, an African slave, aged forty, the mother of four children, was led 
 to consider herself with child in April, 1881, in consequence of the interrup- 
 tion of the catamenia, and the presence of other indications of pregnancy. 
 She continued to follow her usual avocation as a field-hand until the close of 
 the. year; when the gradually increasing size of the abdomen, the oedema- 
 tous condition of the luwer extremities, and more especially the absence of 
 all internal motion, induced her master to look upon it as a dropsical aifec- 
 tion. In January, 18.32, she was examined by Dr. W. M. Lee, who found 
 the abdomen fully as large as at the expiration of the usual term of preg- 
 nancy; and who diagnosed the disease as scirrhus of the left ovary. In 
 April of the same year she died ; and it was then discovered at the autopsy 
 that the enlargement was due to the hypertrophied spleen. This organ, when 
 removed, was found to measure twenty-seven inches in its longitudinal cir-
 
 TUBERCULAR CONDITION OF THE PERITONEUM. 185 
 
 cumference, sixteen inches and three-quarters in its transverse circumference, 
 and to weigh five pounds and a half,^ 
 
 Mr. Ingleby also mentions tLat he once opened the body of a 
 woman who had been pronounced to be in a state of pregnancy ; 
 but the enlargement was ascertained to depend upon a diseased 
 spleen, which weighed nine pounds. 
 
 A tuhercular condition of the peritoneum might mislead if only 
 an imperfect examination were trusted to. Mr. Ingleby says 
 that he met two practitioners in consultation upon the case of a 
 middle-aged unmarried woman, whose abdomen had become very 
 evenly and progressively distended until it closely resembled the 
 gravid uterus at the seventh month. The body of the uterus was 
 found distinctly enlarged, and the woman believed herself to be 
 pregnant. Amenorrhoea had followed indulgence in sexual in- 
 tercourse. The general health had gradually declined. The 
 patient died. On examination, the enlargement was found to 
 consist of a tuberculated condition of the peritoneum at every 
 part, but particularly of that portion covering the uterus. Not- 
 withstanding the external evenness of the abdomen, the whole 
 serous membrane was studded with tubercles, varying in size 
 from mere granules to a large walnut. 
 
 Dr. Robert Lee records the following case : 
 
 A young- woman who resided in a family at Bayswater was attacked with 
 tuberculated disease of the peritoneum and omentum. The abdomen en- 
 larged so much, that pregnancy was suspected; and the medical attendant 
 of the family was requested to see her, and ascertain if such was the case. 
 He reported that she was in an advanced stage of pregnancy; and conse- 
 quently she was compelled immediately to quit her situation in disgrace. 
 She obtained, by some means, a letter of admis.sion into St. George's Hospi- 
 tal. There Dr. Robert Lee was requested to see her, to ascertain if the en- 
 largement of the abdomen arose from pregnancy. The abdomen was as large 
 as it usually is at the commencement of the ninth month : there were white 
 lines on its sides, and the r.avel protruded. No movements were felt indica- 
 tive of pregnancy, nor was any sound heard by auscultation. The mammae 
 were shrunk, and there were no areolae. The uterus was found on examina- 
 tion to be pressed down close to the outlet of the pelvis by a great mass of 
 disease above, which was thought to be probably of the nature of an ovarian 
 tumor. At all events. Dr. Lee seems to have convinced himself that there 
 was no pregnancy. 
 
 Even after this examination, Dr. Lee was requested a second time to look 
 
 1 The American Journal of the Medical Sciences, vol. xii, p. 383. Philadelphia, 
 1833.
 
 186 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 at the case, so as to be sure that there was no mistake. The diao-nosis was 
 correct. She died in the midst of great agony, in the course of a few weeks. 
 At the autopsy, the cause of enhirgement was revealed. There were im- 
 mense masses of tubercuhited accretions found occupying the whole sac of 
 the peritoneum and omentum.^ 
 
 Feeal accumulations occur at any portion of the colon, or they 
 may be distributed through the lower part of the small intestines 
 and the whole of the large gut. Generally, however, they are 
 found in the crecum, or in the sigmoid flexure of the colon, or in 
 the rectum. "When the accumulation is large and conjoined with 
 a flatulent state of the small intestines, the abdomen will be 
 found very greatly increased in all its measurements. An inor- 
 dinately large stercoral tumor has more than once given rise to a 
 suspicion of pregnancy. I have seen an instance of tliis kind in 
 which the woman was certainly as bulky as at the seventh month 
 of gestation ; the cause of the increase in size having been over- 
 looked by more than one practitioner, simply because on inquiry 
 the bow^els were stated to be relaxed. But the fact was, that the 
 rectum and a portion of the colon were completely choked by 
 hardened fgsces; a channel having been formed through the mass 
 to allow of a slight escape. The persevering use of warm purga- 
 tive enemata soon removed all doubt as to the nature of the 
 case ; but though the patient ultimately recovered, it was a long 
 time before the intestinal coats regained their normal tone. 
 
 The following aflbrds also a good example of a stercoral tumor 
 being mistaken for pregnancy : 
 
 Madame L., forty-eight years of age, in good health, with the menses 
 irregular and appearing only at long intervals, consulted her physician respect- 
 ing a swelling which had appeared and was increasing in the hypogastrium. 
 Pregnancy was dingnosed. But at the end of nine months nothing made 
 its appearance; while the tumor continued gradually, but slowly, to increase 
 in size. When M. Laronde was called in, the patient was despaired of by 
 her attendants. He found her condition as follows: Pulse small and weak, 
 decubitus dorsal ; prostration very great; face pale, emaciated, and charac- 
 teristic of a chronic affection of the intestinal canal; breath fetid; gums 
 soft and bleeding; while there was an abdominal tumor extending as high 
 as the umbilicus, hard and rounded, which instead of rising from the sides, 
 seemed intimately connected with them. The tumor felt like a mass of half 
 dried earth or clay. The patient went to stool once or twice daily, and occa- 
 sionally she was troubled with diarrhoea. Glauber's salts, &c , were adniin- 
 
 1 Lectures on tlie Theory and Practice of Midwifery, p. 108. London, 1841.
 
 FECAL ACCUMULATIONS. 187 
 
 istered ; an immense quantity of fecal matter was discliarged; and the tumor 
 disappeared.^ 
 
 A case of enteritis, with retention of faeces, simulating preg- 
 nancy and labor, has been put on record by M. Barbieri, a sur- 
 geon in Fifeshire: 
 
 The patient was thirty-two years of age, rather stout, and the mother of 
 two children. Pains like those of labor set in on the morning of the 16th 
 December, 1840, and recurred every five minutes. In answer to various 
 questions, she said that the catamenia had been absent for nine months and 
 two days; she had quickened at the end of lour months and a half; the 
 motions of the foetus had become progressively stronger every month ; she 
 had experienced morning sickness, heartburn, longings, dysuria, cramps, 
 frightful dreams ; and for the last two months had been troubled with vari- 
 cose veins, as well as anasarca of the legs. Just before the doctor's arrival 
 the liquor amnii — it was said — had been discharged ; and at the time there 
 was a slight sanguineous flow. After a careful examination it was found that 
 pregnancy did not exist; and the presence of enteritis, complicated perhaps 
 with Bright's disease of the kidney, was diagnosed. The treatment adopted 
 was rather active. A dose of castor oil prepared the way for more powerful 
 measures. Sixty-four ounces of blood were then abstracted from a large 
 orifice : in ten minutes ''profound syncope and collapse followed, which con- 
 tinued nearly a quarter of an hour, accompanied by an incredible amount of 
 liquid fseces," filling at least four large chamber urinals. Three grains of 
 opium and eight of calomel were next administered. " IShe was now neces- 
 sarily left for eight hours, owing to an obstetric engagement." At the end 
 of this time the treatment was renewed. As the urine was albuminous, she 
 was again bled to thirty-two ounces; forty leeches were applied to the ilio-caecal 
 region, and the hip-bath used when they fell of; a blister was put over the 
 whole abdomen, the sore being afterwards dressed with strong n)ercurial oint- 
 ment ; and she had two grains of calomel with a quarter of a grain of opium 
 every four hours. When the intestinal inflammation was subdued, on the 
 third day, acute gastritis set in, and " notwithstanding the most energetic local 
 treatment," the poor lady died on the sixth day "of the acute attack "^ 
 
 It is quite unnecessary, and might be injudicious, to weaken 
 the eft'ect of the foregoing facts — which are obviously published 
 for our instruction — by any comments ; for though we may agree 
 with the author that the case " is one of extreme interest," yet 
 it presents other features which it would be uncharitable to char- 
 acterize in words such as they deserve. 
 
 Mr. Roberton relates a case in which a very large ventral 
 omental hernia^ complicated with abdominal dropsy, was mistaken 
 
 ^ Journal de Medecine et deChirurgie Pratique. Paris, Novembre, 1840. 
 2 The London and Edinburgh Monthly Journal of Medical Science, vol. iv, p. 1S.5. 
 London and Edinburgh, 1844.
 
 188 THE DISEASES WHICp SIMULATE PREGNANCY. 
 
 by several medical men for extra-uterine pregnancy. Briefly 
 stated, the facts are as follows : 
 
 A patient with an enlargement of the abdomen consulted Mr. Roberton 
 in the year 1839. Twenty-two years previously, a suroeon had made an 
 exploratory opening into the tumor, and the skull of the foetus (as the op- 
 erator declared) had been felt. The tumor was situated on the left of the 
 median line; but as the patient was stout, it was not easy to determine its 
 size. The protuberance was firmer to the touch than the surrounding pari- 
 etes ; while from the most depending part, just above the pubes, hung a 
 pouch-like tumor, the size of a melon, which it was evident contained fluid. 
 A hard substance was also felt, which the imagination had regarded as the 
 cylindrical bones of a foetus. Five years afterwards the lady died. At the 
 post-mortem inspection the following was found : About two inches below 
 the umbilicus, and a little to the left side, was a loose shrivelled sac, ap- 
 parently empty. By making a semicircular incision into the abdomen, so 
 that, when the flap was turned down, the sac could be viewed from the in- 
 side, there was discovered an opening into it that would admit three fingers; 
 through which opening passed a longish protrusion of the omentum, about 
 the thickness of a finaer, and which adhered at its extremity to tl.e upper 
 fore-part of the sac. The sac itself would have contained an ordinary-sized 
 fist. The uterus with its appendages, the bladder, and all the pelvic viscera, 
 were quite healthy and in situ. It was clear that the substance which the 
 operator had mistaken for the foetal skull consisted of a mass of indurated 
 omentum.^ 
 
 Eneynted dropmy of the pentoneum, in which a cyst containing 
 fluid is formed between the parietes of the abdomen and this 
 serous membrane, could scarcely be mistaken for pregnancy. 
 Still the occasional occurrence of such a disease may be advan- 
 tageously remembered ; more especially as it would seem to be 
 more frequent in women than in men. Of twenty-six examples 
 referred to b}^ Lieutand, twenty-four occurred in females. The 
 disease with which it has generally been confounded, when in 
 an advanced stage, is ascites; but it may be usually distinguished 
 by noting the absence of constitutional disturbance, and the less 
 uniform enlargement of the abdomen. 
 
 Very large cysts occasionally, though rarely, form in the folds 
 of the omentum, or on the under surface of the liver, or under 
 the posterior part of the peritoneum; and though quite uncon- 
 nected with the ovaria, yet they have been found to contain the 
 products of certain ovarian tumors, viz., fat, hair, bone, &c. The 
 following very good example of a cystic tumor existing under the 
 
 ^ Essays and Notes on tlio Pliysiology and Diseases of Women, and on Practical Mid- 
 wifery, p. 431. London, 1851.
 
 ENCYSTED PERITONEAL DROPSY. 189 
 
 peritoneum, and presenting during life all the appearances of 
 ovarian dropsy, has been recorded by Mr. Lee : 
 
 Mrs. , aetat. 50, married, had been laboring under a tumor of the 
 
 abdomen for twentj-five years. She had had one child previously to its ap- 
 pearance, and three since ; and she suffered by the disease in nothing but 
 its bulk, up to the last being able to amuse herself with her household 
 duties. The tumor was of an enormous size, disturbing the breathing, and 
 at last producing fatal symptoms. On an examination after death, the cavity 
 of the abdomen was found almost entirely filled by an enormous tumor, which 
 pushed up the vivscera to the right side, and eonjpressed the spleen posteriorly. 
 It was seen to have commenced on the left side, just under the pancreas, hut 
 helow the peritoneum, so that it rested upon the posterior muscular walling 
 of the abdomen. A narrow pedicle, six inches long, of the size of a quill, 
 connected it with the uterus. It had also formed connections with the other 
 viscera of the abdomen. The cyst itself contained two pailfuls of a turbid 
 whitish-colored fluid, with an immense number of balls of hair mixed with 
 fat, in which was calcareous matter : no hairs were observed attached to the 
 cyst, but the balls of hair, fat and osseous deposit were as large as the closed 
 hand. On the left side of the cyst was attached a mass of bone, teeth, &c., 
 strongly resembling an imperfect foetus. This body was about four inches 
 long, and covered by a membrane resembling the true skin, but closely con- 
 nected with the sac. It presented at its upper portion an opening divided 
 into two parts, like the imperfect nostrils, immediately under which was a 
 large bone, like the lower maxilla, filled with teeth ; on each side of this 
 part projected a small appendage resembling the ear; and below this mass, 
 were two long appendages like abortive arms, the right one being the smallest, 
 and composed of skin, at the end of which were a few hairs. The left ap- 
 pendage was larger, still more closely resembled the arm, and was apparently 
 jointed at the shoulder and elbow; it contained one strong bone like the 
 humerus, and two small bones for the fore-arm. At the lower extremity of 
 the body of this mass was a large projecting bone, also jointed. This ap- 
 proached the form of a femur, at the lower extremity of which was an ir- 
 regular osseous deposit.^ 
 
 This case shows very strikingly that these formations of teeth, 
 bone, ^c, in certain tumors, are in no way connected with the 
 functions of generation in the individual presenting them ; but 
 proves that they are coeval with her in whose body they are 
 found, being due to the original inclusion of one germ within 
 another. In other words, two ova are impregnated, though only 
 one reaches maturity ; the other being arrested in its develop- 
 ment at an early stage, but becoming adherent to the body of 
 the healthy foetus, in which it is found after birth in the form of 
 a tumor. The same explanation applies to those cases where 
 
 ' On Tumors of the Uterus and its Appendages, by Thomas Safford Lee, M.R.C.S E., 
 &c., p. 124. London, 1847.
 
 190 THE DISEASES AY HIGH SIMULATE PREGNANCY. 
 
 hair, teeth, bones, &c., have been discovered within the one or 
 other of the ovaria of girls, where impregnation has not, and 
 could not have taken place ; as well as to those scarcely more 
 curious instances in which foetuses have been found in the 
 bodies of boys, examples of which have been recorded by 
 Messrs. Young, Higlimore, and Dupuytren.' 
 
 It is by no means an uncommon circumstance to find, in the 
 egg of the common fowl, two yolks, in one shell. But a remark- 
 able example of a perfect ovum in ovo has been described by Dr. 
 Barnes. In this case, a pullet, half-bred between a Cochin and a 
 Dorking, laid about one egg daily for six weeks ; during which 
 time nine eggs were found to be double. The specimen ex- 
 amined exhibited an inner perfect egg, of the size usually laid 
 by an ordinary pullet; this egg being contained in a larger one, 
 resembling that always produced by a Dorking fowl. The two 
 shells were not adherent; the inner one being surrounded by the 
 albumen of the larger egg, the yolk of which was in the big end 
 somewhat compressed.^ Two somewhat similar cases are also 
 reported; one having occurred in the egg of a Muscovy duck.^ 
 
 6. H^MATOMETRA, Hydrometra, AND Physometra. — Disten- 
 sion of the uterine cavity from retained menstrual blood — Jicema- 
 tometra, as it is technically called — may give rise to signs which 
 might lead to a suspicion of the existence of pregnancy, or of 
 some disease of the uterine or abdominal organs. This condition 
 may arise from either congenital or acquired obstruction of the 
 vulvo-uterine canal; such as a tough imperforate hymen, closure 
 of the orifice of the vulva owing to an attack of infiammation, 
 malformation of the vagina, or occlusion of the os uteri. Under 
 any of these circumstances the menstrual fluid gradually collects 
 
 1 Mpclico-Chinirgical Transartions, vol. i, p. 236. Third Edition. London, 1815. 
 Tlie pai»er was read before the t^ociety by Mr. Young, 16th March, IhDS. — bee also, The 
 Case ofa Fceiiis found in the Abdomen of a Young Man at Sherborne, Dorsetshire. By 
 Nathaniel Highmore, LL.D. London, 1815. The preparation described in this work 
 is in .the Museum of the Royal College of Surgeons of Englaml. — Also, Dissertation sur 
 le Foetus trouv6, a Verneinl, dans le Corps dun Enfant Mah^. Par Verdier-Heuriin. 
 Paris, 1804. This is the case generally referred to as Du|)iiytren's, who, however, only 
 made a report upon it. The report is publi?hed in the Bulletins de la Faculid de Mea- 
 ecine de Paris, et de la Society etablie dans son sein. Toine premier, p. 4. Paris, 1812. 
 And lastly, '■ Geburtsgeschichte und Untersuchung eines Fades von Foetus in foeiu." By 
 Dr Breslau and Dr. Eduard Rindfleisch. Virchow's Archiv fur Pathologische Anatomie 
 und Physiologie und fiir klinische Medicin. Band .'JD, p. 4nG. Berlin, IMiJ. 
 
 '^ Transactions of the Obstetrical Society of London. Vol. iv, p. 87. Lonilon, 1863. 
 
 3 Hardwicke'b Science Gossip. No. 2l>, pp. 46, 47. London, February, 1867.
 
 H^MATOMETRA. 191 
 
 in, and soon distends, the uterine cavity; the walls of which 
 generally become hypertrophied. In a case of imperforate os 
 uteri with retention of the menses, about which I was consulted, 
 the abdomen was quite as large as at the sixth month of gesta- 
 tion ; my opinion being sought for the purpose of determining 
 whether the enlargement was due to pregnancy or to an ovarian 
 tumor. As will appear, however, there was no difficulty in form- 
 ing a correct diagnosis. The chief points to which my attention 
 was directed were these : 
 
 A young woman, twenty years of age, had never menstruated. She had 
 been in very delicate health for nearly fuur years. The particular reason for 
 seeking' advice was on account of abdominal enlargenient, which had been 
 perceptibly increasing for nearly three years; during which time she had 
 suffered very frequently from nausea and constipation, from constant aching 
 in the back, and at intervals of about a month from severe bearing-down and 
 other dysmenorrhceic pains. A cai'eiul investigation was made. The oval 
 and even shape of the tumor seemed to show that it was the uterus ; there was 
 dulness on percussion over its surface ; and an indistinct sense of fluctuation 
 was communicated to the touch. Examining per vaginam, the body of the 
 uterus was found enlarged, and the cervix obliterated ; while there was also 
 a complete absence of the lips, and merely a slight depression where the os 
 should have been, but not the smallest opening. Subsequently, the passage 
 of a curved trocar into the cavity of the uteius confirmed the diagnosis which 
 was made, that the condition was one of retained menstrual fluid. The opera- 
 tion permitted the escape of about three pints of a thick viscid fluid, some- 
 what resembling treacle, which possessed a slightly fetid odor. The tumor 
 of course disappeared; and the subsequent careful dilatation of the opening 
 with small sponge tents effected a permanent cure. 
 
 It must be remembered that retention of the menses may not 
 only occur in women who have never had any external maniles- 
 tation of the catamenial flow, but also in those who have even 
 borne children. Thus, the lips of the os uteri have suffered from 
 adhesive inflammation, owing to the improper employment of 
 caustics; or to the careless use of instruments during labor; or to 
 some blow or accident ; or to the criminal introduction of probes, 
 pieces of whalebone, &c., to induce abortion. Instances are 
 known where attempts to destroy the product of conception in 
 the manner just mentioned have failed in their object, and yet 
 have produced so much mischief that ulceration and adhesion of 
 the labia uteri have followed. In such, when the pains of labor 
 have come on, there has been of course no outlet for the child ; 
 and unless an opening has been made at the site of the os, the 
 uterus has either ruptured, or the woman has died undelivered.
 
 192 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 It will very rarely happen that the opposite error to the one 
 just treated of can be committed — viz., the mistaking the enlarge- 
 ment of pregnancy for that due to the retention of the menses. 
 Yet the following history will show that such is possible : 
 
 Some years since, Professor Rossi was hurriedly sent for by a married 
 woman, who had been attacked with violent abdominal pains. On examina- 
 tion, he found that the external organs of generation were entirely wanting, 
 there being no hair upon the mons veneris, and no signs of puberty. He 
 dismissed the idea of pregnancy from his mind, and attributed the pains to 
 the absence of any passage for the discharge^ of the menses ; and therefore 
 determined at once to let out the catamenial fluid by making an incision three 
 inches long in the direction of the vagina. On introducing his finger, how- 
 ever, through the opening thus made, he ascertained that the woman was 
 really in labor; so that by enlarging the incision, she was delivered quickly 
 of a male foetus. On subsequently instituting a more careful examinatiun, 
 M. Rossi discovered near the sphincter ani a minute opening, which would 
 scarcely admit a very fine probe; and this orifice was found to communicate 
 with the passage made by the knife. ^ 
 
 The collection of a thin serous or watery fluid — hydrometra — 
 in the uterus, or of pus — pyometra — in the same situation, may 
 give rise to an erroneous diagnosis ; particularly if the accumu- 
 lation should amount to several ounces. The degree of enlarge- 
 ment of the uterus, and the fulness of the hypogastric region, 
 will of course vary according to the length of time that the cer- 
 vix has been blocked up, or the os completely closed ; as w^ell 
 as upon the circumstance of the mucous membrane of the body 
 of the uterus being healthy, or affected with a kind of chronic 
 catarrh causing its natural secretion to become much increased 
 in quantity. Moreover, unless the climacteric period has been 
 passed, or unless there is perfect amenorrhoea, hydrometra must 
 become complicated with h?ematometra ; and then the fluids re- 
 tained have amounted to many pints. A case is described by 
 Vesalius,^ in which the uterus was found to contain one hundred 
 and eighty pints of watery fluid, the edges of the os uteri being 
 firmly adherent, Ploucquet^ also gives references to several 
 other examples ; but the most recent characteristic instance which 
 I know of has been published by Dr. Anthony Todd Thomson. 
 The chief points of medical interest are as follows: 
 
 ^ Memorie (lella Reale Acad, (lelle Sc. di Torino. Tomo xxx. I am only acquainted 
 with this case from finding it quoted in The American Journal of the Medical Sciences, 
 vol. i, p. '1 34. Philadelphia, ISiS. 
 
 ^ De Humani Corporis Fabrica. Liber v, cap. 9, p. 627. Basil, 1543. 
 
 ' Literatura Medioa Digesta, sive Repertoriiim Medicinte Practicoe, Chirurgise, atque 
 rei Obstetricse. Tomus ii, p. 383. TubingsB, 1808.
 
 PHYSOMETRA. 193 
 
 A widow, sixty-five years of age, of intemperate habits, the mother of two 
 children, was admitted into the infirmary of the Chelsea workhouse in De- 
 cember, 1823. Nine or ten months previously she first noticed an enlarge- 
 ment of the lower part of the abdomen, but had no advice for it. On exami- 
 nation a tumor was found, rising as it were out of the pelvis, and occupying 
 the iliac, hypogastric, and umbilical regions. She appeared as large as if six 
 months gone with child ; an indistinct fluctuation was perceptible, and the 
 least pressure on the tumor excited pain. The disease was regarded as a 
 dropsical ovarium. In January, 1824, the left foot was found to be affected 
 with dry gangrene ; and in the following month the limb was amputated. 
 On the third day afterwards the patient sank and died. At the post-mortem 
 examination, on dividing the abdominal parietes, a body resembling closely 
 the gravid uterus was seen occupying the whole of the pelvic cavity, and the 
 greater part of the abdon)inal. On its anterior surface, and firmly adhering 
 to it, was the urinary bladder, which was found to extend to within an inch 
 of the umbilicus ; so that it must have been perforated, if the trocar had been 
 employed under the supposition that the disease was ovarian dropsy. The 
 tumor was at once ascertained to be the uterus; which was greatly enlarged 
 and filled with eight quarts of a dark brown-colored albuminous fluid. The 
 existence of a large hydatid was suspected; but this opinion was incorrect, 
 for the sac consisted merely of the uterus, in the cavity of which the fluid 
 was contained. The internal surface of the organ was not more irregular 
 nor more spongy than in its natural state, but none of the orifices could be 
 found, for even the os uteri was interiorly as completely obliterated as if it 
 had never existed ; and although its situation could be traced in the vagina, 
 yet even there it was very faintly marked.' 
 
 There is a peculiar disease of the follicles of the cervix, which 
 has been described as hydrorrhoea uteri ; and which, if unknown, 
 is not unlikely to be mistaken for hydronietra. The distinction, 
 however, is easy ; for in the former, as there is no obstruction, 
 so no tumor is formed. Indeed, the only symptoms consist in 
 the continual escape of a thin serous fluid, often in considerable 
 quantity; and a depressing feverish condition of the system, with 
 more or less pain in the loins. Hydrorrhoea uteri is not a com- 
 mon affection ; it afiects both the unimpregtiated and the gravid 
 uterus ; and it depends upon a sort of catarrh, or excessive ac- 
 tivity of the follicular structure of the cervix. In cancer of the 
 uterus there is also very generally an abundant watery discharge ; 
 but the cause of this is at once made, apparent on instituting an 
 examination by the vagina. 
 
 The accumulation of gas in the uterus — pliysometra — although 
 a very rare aflection, and one that not a few eminent obstetricians 
 have thought impossible, is still no fictitious disease. In exten- 
 
 ' Medico-Cliirurgical Transactions. Vol. xiii, p. 170. London, 1827. 
 
 13
 
 194 THE DISEASES WHICH SIMULATE PREGNANCY. 
 
 sive tympanites of the uterus the abdomen is found rather en- 
 larged. Just above the pubes, and extending upwards through 
 the hypogastric region to a slight degree, an ovoid and non-fluc- 
 tuating tumor may be discovered ; on percussing over which 
 uniform resonance is elicited. Then, on making a vaginal ex- 
 amination, the uterus will be detected dilated and elastic ; occa- 
 sionally it is retroflexed, or retro- or anteverted ; while sometimes 
 its lower orifice is closed. The passage of the uterine sound will 
 open the os uteri, permit of the escape of the gas, and so cause 
 a subsidence of the tumor. Sometimes the gas is expelled in- 
 voluntarily, much to the patient's discomfort ; the air evacuations 
 taking place rapidly and frequently, with violence, and with a 
 peculiar explosive noise. The gas is inodorous, unless it has 
 been generated in utero by the decomposition of a portion of re- 
 tained placenta, or by a putrefying ovum or clot of blood. 
 
 The accumulation of air in the vagina is a much more com- 
 mon occurrence than the foregoing. In not a few cases the air 
 rushes into the vaginal cavity directly the labia are separated 
 for making an examination; so that on passing the finger on- 
 wards, it seems as if it were in the centre of a hollow ball. It is 
 easy to imagine, that with a patulous os and a relaxed condition 
 of the uterine walls, the air may be sucked up into the cavity of 
 the womb from the vagina, and thus constitute a case of phy- 
 sometra. 
 
 At a meeting of the Obstetrical Society of Edinburgh, in 1856, 
 Dr. Keiller stated that he had seen several cases of physometra. 
 His conviction was, that although the gas might be in some 
 instances directly exhaled from morbid uterine or vaginal secre- 
 tions, and then afterwards become suddenly expelled, yet that 
 this explanation would not apply generally. On the contrary, 
 he believed that the air was not evolved in the uterus or vagina 
 previous to its expulsion, but that it was first received from with- 
 out, and then subsequently expelled ; the ingress, retention, and 
 subsequent explosive egress of atmospheric air constituting the 
 essential character of the infirmity. The suction-like action of 
 the levatores ani and abdominal muscles on the walls of the 
 vagina, thus occasionally leads to the presence of air in the 
 uterine passages; whci'C the gas quietly accumulates, until the 
 parts become distended, and cause its involuntary expulsion.
 
 THE DURATION OF PREGNANCY. 195 
 
 CHAPTER IV. 
 
 THE DURATION OF PREGNANCY. 
 
 Contradictory views entertained on the subject — Ordinary duration of preg- 
 nancy TEN LUNAR MONTHS — ThE EXCITING CAUSE OF PARTURITION — OUR IGNORANCE 
 OF THE INTERVAL WHICH ELAPSES BETWEEN INTERCOURSE AND THE ACTUAL VIVIFI- 
 CATION OF THE OVULE — TABLES OP CASES BY DrS. MeRRIMAN, ReID, MuRl'HY, AND 
 
 THE Author — Forty-five cases of conception, the dates being calculated 
 
 FROM A SINGLE COITUS — M. TeSSEIR'S RESEARCHES ON COWS, MARES, ETC. — EaRL 
 
 Spencer's observations on the time of gestation in 764 cows — To what 
 
 EXTENT may PREGNANCY BE PROLONGED BEYOND THE NORMAL PERIOD? — PRO- 
 TRACTED PARTURITION SAID TO BE SOMETIMES MISTAKEN FOB PROTRACTED GESTA- 
 TION — Very scanty satisfactory evidence that pregnancy, in the human 
 
 SUBJECT, has ever BEEN PROLONGED BEYOND TEN CALENDAR MONTHS — MoDE OP 
 calculating the DATE OF LABOR. 
 
 A PERUSAL of the medical evidence which has been given in 
 various courts of law, as to the duration of pregnancy, can only 
 excite the reader's astonishment. For not only are the very 
 positive statements of different physicians in different countries 
 quite contradictory, but in no one kingdom does it seem possible 
 to bring together a score of practitioners whose views on this 
 subject shall be in exact accordance. It might almost have been 
 thought that the subject was one which the most ancient fathers 
 of medicine would have discussed, and finally agreed upon ; and 
 that writers in succeeding ages would have had nought to do but 
 to quote from black-letter volumes. This is far from being the 
 case, however; though the question has been the theme of many 
 an interesting essay, and the matter of frequent discussion, par- 
 ticularly since the occurrence of the Gardner Peerage Cause, in 
 1825.^ But society at large is so deeply interested in the correct 
 
 1 The chief mecUcal interest in this trial was owin^ to the following points : In 1802, 
 Lord Alan Hyde Gardner, captain of H. M. ship Resolntion. arrived otf Portsmouth, and 
 was joineit by his wife, Mrs. Gardner. She remained on board for three weeks, leaving 
 for London on the .Sdth Jaiinary ; but the Resolution did not sail for the We^t Indies until 
 the 7tli February, antl in the meantime comnumicaiions were kept up between the ship 
 and the shore. Loril Gardner returned home on the llth July, of the same year. Mrs. 
 Gardner bore a son on the Sth Deeernber, 1802, which a[)peared to be the fruit of an 
 illicit intercourse between her and Mr. Henry Jadis. Lord Gardner succeeded in obtain- 
 ing one thousand pounds damages, and a divorce; whereupon he married again, and
 
 196 THE DURATION OF PREGNANCY. 
 
 settlement of this questio vexata, that it would certainly long since 
 have been decided, and the truth extracted from the mass of con- 
 flicting evidence surrounding it, were it not that the opportunities 
 for obtaining correct data are really much fewer than might seem 
 to be the case at first sight. It has been aptly observed, that "as 
 it is difficult to conceal the termination of pregnancy, so is it 
 equally difficult to ascertain its commencement ;" and with regard 
 to civilized life, at least, this is no exaggeration. From married 
 women the information required can seldom be obtained ; while 
 in the case of single females so many motives for the practice of 
 deception exist, that their testimony has to be received with the 
 greatest caution. 
 
 It is on all hands admitted as certain, that the ordinary dura- 
 tion of pregnancy in the human subject is ten lunar months, or 
 about nine calendar months, or forty weeks, or from two hun- 
 dred and seventy-four to two hundred and eighty days. But 
 the point which has to be solved is this, — may not gestation be 
 protracted beyond this time, without the infringement of any 
 law ? It must be summarily replied, that from all which can be 
 ascertained on the subject by the study of recorded cases; from 
 all reasoning by analogy, for it has never been denied that the 
 periods of dentition, puberty, the cessation of the catamenia, &c., 
 are each liable to vary within certain limits; and from all argu- 
 ments adduced from comparative parturition — for we know that, 
 to a certain extent, the period of gestation is not precise among 
 
 on the 29th January, 1810, had a son born. The trial was caused by this son's claim 
 to tlie barony being opposed by the youth born on the 8th December, lb0"2. Hence the 
 main questions put to eacli medical witness were three: 
 
 1. Is it your opinion, that a cliild born on the Sth December could have been the 
 result of sexual intercourse either on the 30th January (being 311 days), or anterior 
 to if? 
 
 2. Is it your opinion that a child born on the Sth December could have been the result 
 of sexual intercourse on the 7th February (304 days), or anterior to it? 
 
 3. Do you think that a child born on the Sth December, who has lived to manhood, 
 could be the result of sexual intercourse on or after the llih July; a period short, at 
 least by two or three days, of five calendar months? 
 
 The two extremes of lime alluded to in these questions are 311 (or at least 3U4 days) 
 and ITiO days. Hence, if Henry Fenton Jadis, «/«ias Gardner, were the son of Lord 
 Alan Hyde Gardner, he must either have been a five months or nearly a ten months 
 and a half child. 
 
 Seventeen medical men were examined. Of these, five supported the view that the 
 period of human utero-gestation was limited to about nine calendar months, or from 
 270 to 280 days. The remaining twelve seemed to maintain the possibility that preg- 
 nancy might be protracted to nine and a half, ten, or even eleven calendar months; 
 and so, of course, to 311 days, the alleged term of gestation. The committee was not 
 convinced, however, by the majority; the decision being against the claim of Mr. Jadis's 
 son.
 
 EXCITING CAUSE OF PARTURITION. 197 
 
 cattle — I say that all these circumstances seem to prove that the 
 period effort}^ weeks is certainly not invariable. Hence the old 
 argument of Nature being certain in all her laws, which in any 
 case has but little meaning, clearly cannot be applied to the 
 present question. 
 
 Legislators have been so persuaded of the truth of this princi- 
 ple, that in many countries they have acted upon it in framing 
 the laws. By the Romans the time of gestation was fixed at ten 
 lunar months. The Code Napoleon ordains three hundred days 
 as the duration of pregnancy, and allows legitimacy to be con- 
 tested after this period. In Prussia the term ordained is three 
 hundred and two days, thus permitting a latitude of three weeks. 
 The Scotch enactments account a child a bastard who is born 
 after the tenth solar month. While the English statutes — on 
 which the American are founded — do not prescribe any precise 
 number of days, but remain as when Blackstone wrote in the 
 year 1765 : " From what has been said it appears that all chil- 
 dren born before matrimony are bastards by our law ; and so it is 
 of all children born so long after the death of the husband, that 
 by the usual course of gestation they could not be begotten by him. 
 But this being a matter of some uncertainty, the law is not exact . 
 as to a few days."^ 
 
 One great difiiculty which arises in discussing this question is, 
 the fact that we are really unacquainted with the exciting cause 
 of parturition. As it is a step in advance to appreciate the full 
 extent of our ignorance, a few remarks may be premised on this 
 head ; since it is impossible for us to remain contented with the 
 devout remark of the Arabian physician, Avicenna — that at the 
 appointed season labor comes on by the command of God. The ob- 
 servation is very generally admitted as correct, that by far the 
 greatest number of women complete the period of gestation in 
 the fortieth week after the cessation of the menses : or in other 
 words, that the duration of human pregnancy is commonly a 
 multiple of a catamenial period, i. e., 280 days. It must not be 
 inferred, however, that it is equally clear that parturition neces- 
 sarily occurs at what would otherwise be a menstrual period. 
 Two hundred years have elapsed since this latter suggestion was 
 first published by the illustrious Harvey ; who, after making 
 
 ' Commentaries on the Laws of England. Fifth edition, vol. i, p. 456. Dublin, 
 177.3.
 
 198 THE DURATION OF PKEGNANCY. 
 
 some observations on the way in which prudent matrons calcu- 
 late, says that they, " after ten lunar months have elapsed, fall 
 in labor, and reap the fruit of tlieirwomb the very day on which 
 the cataraenia would have appeared, had impregnation not taken 
 place. "^ Dr. Rigby clearly entertained the opinion that this view 
 is a correct one, for he made this remark : "It is now ten years 
 ago since we first surmised that the reason why labor usually ter- 
 minates pregnancy at the fortieth week is, from the recurrence 
 of a menstrual period at a time during pregnancy when the uterus, 
 from its distension and weight of contents, is no longer able to 
 bear that increase of irritability, which accompanies these periods 
 without being excited to throw off the ovum."- To Dr. Tyler 
 Smith, however, is due the credit of verj- plausibly attempting to 
 show that the ovaria are the special organs which excite the uterus 
 to the act of parturition. This gentleman endeavors to prove 
 that not only is parturition essentially a menstrual period, and 
 the mucous discharge tinged with blood — technically the " show" 
 — which accompanies it, as well as the lochial discharge which 
 follows, analogous to the catamenial flow ; but also that the re- 
 lation of the ovarian nerves to parturition is the same as the 
 bearing of the pneumogastric nerves on respiration. In fact, 
 that the periodical stimulation of the ovary is the exciting cause 
 of parturition, acting by reflex action on the uterus through the 
 spinal system of nerves ; the ovarian nerves being the excitois, 
 and the uterine the motors. It is also urged that when utero- 
 gestation is prolonged beyond the ten menstrual periods, partu- 
 rition is deferred until the following catamenial period ; and on 
 the contrary, when it is brought to a premature termination, it 
 is at what would have been a menstrual period that abortion 
 usually takes place. Indeed, according to Dr. Tyler Smith, there 
 is in all women a tendency to abortion at the times represented 
 by the recurrence of what, but for pregnancy, would have been 
 a catamenial period.^ The physiologists who oppose these views 
 chiefly rely upon the following arguments : 
 
 (1) That Dr. Tyler Smith assigns no valid cause why the action at the 
 
 1 Tlie Works of William Harvey, M.D. Translated for the Sydenham Society by 
 Dr. Willis, p. 529. London, 1817. 
 
 2 A System of Midwifery, p !S.5. London, 1844. 
 
 3 Parturition and the Principles and Practice of Obstetrics. Lecture VIII. London, 
 1840. Also, Lectures on the Tiieory and Practice of Obstetrics. "The Lancet." vols. 
 i null ii London, 18-56.
 
 IMPEDIMENTS TO EXACTITUDE. 199 
 
 tenth period — at the eleventh, if the period prior to suppression be included 
 — should be so much more potent than at any other, except that by this time 
 there is a much greater aptitude to contraction in the uterus itself, and an 
 increased readiness to be thrown oif on the part of the placenta; conditions 
 which the objectors consider adequate in themselves to account for the result. 
 — (*2) That the period of gestation, although commonly a multiple of the men- 
 strual interval, is by no means constantly so ; the former often remaining nor- 
 mal, when the latter is shorter or longer than usual. — (3) Parturient efforts 
 take place in the uterus, notwithstanding tlie previous removal of the lower 
 part of the spinal cord. — (4) The removal of the ovaries in the later part of 
 gestation does not interpose the least check to the parturient action, as Sir 
 James Simpson has experimentally ascertained.' — (5) That when the dura- 
 tion of pregnancy exceeds the ten menstrual periods, parturition is not deferred 
 till the following period ; and that the evidence given on the Gardner Peerage 
 Case before the House of Lords in 1825-6, which Dr. Smith cites as favor- 
 ing his views, is strongly against them. Dr Samuel Merriman, who was one 
 of the witnesses at the trial, has published a table showing that of 84 women, 
 38 were delivered in the fortieth week, 22 in the forty-first. 15 in the forty- 
 second, 10 in the forty-third, and only four in the forty-fourth. — (6) The 
 evidence of comparative gestation is against Dr. Smith ; inasmuch as experi- 
 ments carried on under the direction of the late Earl Spencer, on 76-1 cows, 
 each impregnated by a single coitus, show that although 284 or 285 days is 
 the average term of gestation in this animal, yet an excess of a few days is 
 not uncommon ; gestation having been prolonged from 5 to 10 days in 111 out 
 of the 764, and for 28 days in only one of this number.^ Moreover, it has 
 been proved that in the mare, sow, sheep, goat, bitch, cat, &c., the usual 
 period of gestation may be occasionally exceeded by as much as two or three 
 weeks. 
 
 These objections have not been satisfactorily overcome by any 
 arguments which I have read of Dr. Tyler Smith's; and it must 
 be allowed that they seem to be fatal to his very ingenious theory. 
 In fairness to this physician, however, it ought to be stated, firsts 
 that in some experiments on gravid rabbits, at the middle period 
 of gestation, irritation of the ovaria by galvanism, or pinching 
 with the forceps, brought on contractions of the uterus and vagina ; 
 which contractions continued, after the irritation was left off", until 
 the foetuses were expelled. Secondly, that one of the best facts in 
 favor of his views is derived from the circumstance that in many 
 of the lower animals ovulation and oestruation are going on at 
 the very time of parturition. Thus, in the guinea-pig, for ex- 
 ample, immediately that the young are dropped, the female ad- 
 mits the male, conception takes place, and a new^ utero-gestation 
 
 1 Dr. Carpenter's Human Physiology. Fifth edition, p. 819. London, 1855. Also, 
 The British and Foreign Medico-Chinirglcal Review. Vol. iv. p. 1. Lonclon, 1849. 
 
 2 Journal of the Royal Agricultural Society of England. Vol. j, p. 165. London, 
 1 S40.
 
 200 THE DURATION OF PREGNANCY. 
 
 commences, dating from the very hour of parturition. Never- 
 theless, that the hypothesis which has now been considered cannot 
 be supported, is, I believe, the opinion of most physiologists. 
 This fact is the more to be regretted since no perfectly satisfac- 
 tory explanation can be substituted. And therefore we must at 
 present rest content with surniising that the cause of parturition is 
 to be found in the maturity of the ovum ; or in the placenta, which 
 — having attained its full evolution as an organ of temporary 
 function — begins to degenerate, while its attachment to the uterus 
 loosens. The author of the essay on Tli^ Physiology of Parturition, 
 in the review from which I have quoted, well observes : " The 
 act of parturition was likened by Buftbn to the dropping of ripe 
 fruit ; and we believe that, in seeking for its cause partly (to say 
 the least) in that condition of the uterus and its contents which 
 may be designated as maturation, we are justified by all the facts 
 at present known to us." 
 
 Another obstacle to a satisfactory settlement of this question 
 is owing to the circumstance that many physicians who have con- 
 structed statistical tables from the observation of a large number 
 of cases, have commenced their calculations from different epochs. 
 Thus the reckoning of some is calculated from the date of the 
 cessation of the catamenia; of others, from the time of a single 
 coitus; of a third class, from the day of quickening ; and of a 
 fourth, from the hour of conception, which they assert is known 
 to many females by certain peculiar sensations experienced at the 
 moment of conception. It is almost unnecessary to say that the 
 observations of the first and second classes are alone deserving 
 of any attention ; while the most trustworthy views, probably, 
 are those derived from calculating the duration of pregnancy 
 from a single coitus. 
 
 A third impediment to our making exact calculations is the 
 impossibility of fixing the date of conception or impregnation, 
 even when that of insemination is known. In other words, the 
 interval which elapses between a fruitful intercourse and the 
 actual vivification of the ovule by the semen is uncertain ; but 
 that the period is not insignificant, and that it ma}' be interfered 
 with by a variety of physical and moral causes, is highly proba- 
 ble. For obvious reasons, but little exact evidence on this subject 
 derived from observations on the human female can be brought 
 forward. Hence we are driven to make such deductions as are
 
 IMPEDIMENTS TO EXACTITUDE. 201 
 
 possible from analogy — from the results of experiments on ani- 
 mals. Now pbj'siologists have long since proved that for im- 
 pregnation to take place it is not necessary that the semen should 
 be newly expelled by the male. Valentin states that, " On opening 
 the body of a female mammal one or more days after it has re- 
 ceived the male, semen may be found not only in the body and 
 horns of the uterus, but also in the oviducts, and on the surface 
 of the ovary. The spermatozoa are in vigorous movement. 
 These may retain their activity for a week or more in the female 
 organs."^ More than sixty years ago Haighton showed that con- 
 ception does not generally take place in the rabbit till about fifty 
 hours after insemination ; a long period, considering that the 
 ordinary interval between insemination and parturition is only 
 thirty days. He found that division of the Fallopian tube before 
 the expiration of two days prevented conception ; while, by wait- 
 ing longer, impregnation was not impeded by the mutilation.^ 
 Dr. Samuel R. Percy, of New York, found living spermatozoa 
 in a mass of muco purulent-looking matter projecting from the 
 OS uteri of a lady, eight and a half days after the last intercourse 
 with her husband.^ Consequently it may be looked upon as 
 proved, that the spermatozoa retain vitality when in the female 
 genital passages, and especially when in the uterus, for several 
 days ; although we cannot say exactly for how many. And this 
 circumstance probably gives the key to the fact, that notwith- 
 standing the Jewish people of the present time act up to the law 
 as expressed in the book of Leviticus,^ yet they are as fruitful as 
 their Christian neighbors. It is certain, that intercourse shortly 
 before a menstrual period is very likely to cause conception ; and 
 not only so, but that when conception happens it may possibly 
 prevent the catamenia from making their appearance, although 
 I believe that more commonly such a result only makes the dis- 
 charge very scanty at that period. Whether then the ovule finds 
 
 1 A Text-Book of Physiology. Translated from the German by Dr. Brinton, p. 641. 
 London, 1S53. 
 
 2 The Philosophical Transactions of the Royal Society. Vol, Ixxxvii, p. 159. Lon- 
 don, 1797. 
 
 ^ The American Medical Times, p. IfiO. New York, 9th March, 1861. 
 
 * " And if a woman have an issue, and her issne in her fle.<h he blood, she shall be 
 put apart seven days: and whosoever toiicheth her shall be unclean until the even. 
 
 " And if a woman have an issue cf her blood many days out of the time of her sepa- 
 ration, or if it run beyond the time of her separation ; all the days of the issue of her 
 uncleanness shall be as the days of her separation: she shall be unclean. 
 
 "But if she be cleansed of her issue, then she shall number to herself seven days, 
 and after that she shall be clean." Leviticus xv, 19, 25 and 28.
 
 202 
 
 THE DURATION OF PREGNANCY. 
 
 the spermatozoa in the uterine cavity, or the spermatozoa have 
 to wait the arrival of the ovule, is a matter of no consequence, 
 within certain limits. The question is, as to the time of contact. 
 And it seems therefore not altogether improhahle, that by here- 
 after making a distinction between the date of insemination and 
 that of fecundation, less discordant views as to the duration of* 
 pregnancy may be entertained. 
 
 Three highly esteemed authors — Drs. Samuel Merriman, James 
 Reid, and Edward W. Murphy — have published useful tables of 
 cases derived from their own practice, to show the date of delivery, 
 as reckoned from the last day of the last catamenial period. Dr. 
 Merriman's data were obtained from the births of 114 mature 
 children ; the dates being calculated from, but not including, the 
 day on which the catamenia were last distinguishable.^ Dr. 
 Murphy's similar cases number 168;^ while Dr. Reid's amount to 
 500.^ In addition I now give the results in 1U3 cases of my own; 
 premising, that those only have been selected from my note-book 
 where the patients' statements could be relied on, and where I 
 attended her in labor. In the two following tables, a compara- 
 tive view can be taken of these 885 cases: 
 
 Date or Delivery, Calculatp:© from Last Day of Catamenia. 
 
 Weeks. 
 
 Days. 
 
 Menim.an. 
 
 Reid. 
 
 Murphy. 
 
 Author. 
 
 37th, 
 
 From 252d to 2.59th, 
 
 3 
 
 23 
 
 12 
 
 4 
 
 38th, 
 
 " 2f;0th to 266th, 
 
 13 
 
 48 
 
 14 
 
 7 
 
 39th, 
 
 " 2<.7th to 273d, 
 
 14 
 
 81 
 
 27 
 
 18 
 
 40th, 
 
 " 274th to 280th, 
 
 33 
 
 131 
 
 28 
 
 37 
 
 41st, 
 
 " 281st to 287th, 
 
 22 
 
 112 
 
 39 
 
 16 
 
 4'2d, 
 
 " 288th to 294th, 
 
 15 
 
 63 
 
 21 
 
 12 
 
 4M, 
 
 " 29.5th to 301st, 
 
 10 
 
 28 
 
 25 
 
 6 
 
 44th, 
 and upwards, 
 
 \ " 3(l2d to 324th 1 
 j and upwards, J 
 
 4 
 
 14 
 
 2 
 
 3 
 
 114 
 
 500 
 
 168 
 
 103 
 
 To exhibit these facts more clearl}^ they may be reduced into 
 another form, and the weekly percentage of deliveries shown: 
 
 1 Tho Medico-Chirurfrical Transaotions. Vol. xiii, p. -3.38. London, 1827. 
 
 2 A Report of the Obstetric Practice of University College Hospital. London, p. 9. 
 Dublin, 18^4. 
 
 3 The Lancet, 13th April. IS.'-iO, p. 438; 18th May, 18-50, p. 596; 20th July 1850, p. 
 77 ; 3d September, 1853, \i. 205 ; and 10th September, 1853, p. 235.
 
 TABLE OF DATES OF DELIVERY. 
 
 203 
 
 Percentage of Weekly Deliveries from Last Day of Catamenia. 
 
 Weeks. 
 
 Days. 
 
 Merrimaii. 
 
 Reid. 
 
 Murphy. 
 
 Author. 
 
 37th, 
 
 From 252d to 2r)nth, 
 
 2.65 
 
 4.60 
 
 7.14 
 
 3.88 
 
 3Sth, 
 
 " 260th to 26()th, 
 
 11.40 
 
 9.60 
 
 8.33 
 
 6.79 
 
 89lh, 
 
 " 267th to 278d, 
 
 12.28 
 
 16.20 
 
 16.07 
 
 17.47 
 
 40th, 
 
 " 274th to 280th, 
 
 29.00 
 
 26.20 
 
 16.66 
 
 35.92 
 
 41st, 
 
 " 281st to 287th, 
 
 19.30 
 
 22.40 
 
 23.21 
 
 1.5. .58 
 
 4:^d, 
 
 " 288th to 294th, 
 
 13.16 
 
 12.60 
 
 12.. 50 
 
 11.65 
 
 43d, 
 
 " 295th to 301st, 
 
 8.77 
 
 5.60 
 
 14.86 
 
 5.82 
 
 44th, 
 and upwards, 
 
 \ " 302d to 824th \ 
 J and upwards, J 
 
 3.50 
 
 2.80 
 
 1.20 
 
 2.91 
 
 100. 
 
 100. 
 
 100. 
 
 100. 
 
 From the examination' of these tables it clearly appears that 
 considerable variations occur in the duration of pregnancy when 
 the calculations are made from the last day of the last menstrual 
 period. This irregularity may be partly accounted for by the 
 circumstance, that although in most instances impregnation 
 doubtless takes place within two or three days of the cessation 
 of the catamenia, yet it need not necessarily do so. There can 
 be no doubt, as has already been mentioned, but that a fruitful 
 intercourse may take place just before a catamenial period ; while 
 in consequence of such impregnation, the expected flow may not 
 occur. Now by applying this explanation to the most protracted 
 cases of Drs. Merriman and Reid, we reduce their extraordinary 
 to very ordinary cases. Thus, Dr. Merriman's most prolonged 
 gestation was 306 days : but 306 — 28 = 278. So again, Dr. 
 Reid's longest case was 316 days : 316 — 28 := 288. In my own 
 practice, the longest interval between the cessation of the cata- 
 menia and parturition was 317 days ; and 317 — 28 = 289. "With 
 regard to Dr. Murphy's two patients, however, we are deprived 
 of this explanation, inasmuch as he applies it himself. The fact 
 is, that of the two instances which went over the 302d day, one 
 is said to have had gestation prolonged to 342 and the other to 
 352 days; these figures being reduced to 314 and 324 respectively 
 by subtracting 28. For my own part, however, I attribute very 
 little importance to either of these cases. The reports were 
 drawn up simply from the statements of the patients themselves, 
 there being no corroborative evidence of any kind ; and as such
 
 204 THE DURATION OF PREGNANCY. 
 
 statements would not be admitted in proof of any other anomal- 
 ous occurrence, I cannot see why they should be accepted here. 
 If, however, the difficulty of fixing the time after the men- 
 strual period at which impregnation can occur were the only 
 cause for the irregularities brought out by the foregoing tables, 
 we should of course obtain undeviating results by reckoning the 
 date of the occurrence of labor from the time of a single coitus. 
 The following table by Dr. Reid, formed from the largest num- 
 ber of cases of conception from a single intercourse which has 
 been yet collected by one author, may suffice as an answer to the 
 question, whether the results so obtained are variable or not. 
 It consists of forty-three — with two exceptions — trustworthy cases 
 of conception, the dates being calculated from a single coitus : 
 
 260 days after a single coitus, delivery occurred in 1 
 
 263 " " " " 1 
 
 264 '' " " " 2 
 
 265 " " " " 1 
 
 266 " " " " 2 
 
 270 " " " " 1 
 
 271 " " " " 2 
 
 272 " " " " 3 
 
 273 " " " " I 
 
 274 11 " " " 7 
 
 275 " " " " 2 
 
 276 " " " " 5 
 278 " " " " I 
 280 " " " " 3 
 
 283 " " " " 1 
 
 284 « " " " 1 
 
 286 " " " '■ 1 ■ 
 
 287 " " " " 3 
 291 " " " " 1 
 293 « « » « 2 
 
 296 " " " " 1 
 
 300 " " •' " 1 
 
 43 
 
 This table shows that the duration of pregnancy, reckonins from a single 
 intercourse, varied between 270 and 280 days in 25 out of 48 cases; or 
 taking the whole of the latter number, that the time ranged from 260 to oOO 
 days In my own note-books, I find only two cases in which it is certain that 
 pregnancy resulted from a single coitus; and in one of these delivery took 
 place 270 days subsequently, and in the other on the 275th day. Now by 
 comparing the results in these 45 cases with those shown in the two preceding 
 tables, it ii seen at once that the variations from established rule are much 
 more numerous in the latter than in the former. And even with regard to 
 the last two of the 43 cases by Dr. Reid it should be stated that the evidence 
 derived from them is rather of a doubtful character. The Jirxf of these oc- 
 curred in the practice of Dr. !McIlvain, of Charlotte, North Carolina : Mrs. 
 S., a lady, was visited by her husband from a distance, on 1st July, 1847 : he
 
 EXPERIMENTS ON ANIMALS. 205 
 
 remained until the morning of the 6th, and did not again see his wife for 
 nine months. Intercourse took place on the 1st, 2d, 3d, and 4th July. 
 Shortly afterwards symptoms of pregnancy appeared ; but parturition did not 
 take place until 23d April, 1848, being 293 days after the 4th July, or 296 
 after the 1st. — The second history was communicated by Dr. Ashwell : The 
 catamenia terminated on the 25th January, the husband leaving a few days 
 after, and being absent six weeks. The lady was confined on the 27th Novem- 
 ber ; being 30U days after the supposed fruitful intercourse, or 258 days 
 after the husband's return. Dr. Ashwell imagines that the infant was not 
 prematurely born, inasmuch as it was much larger than the patient's other 
 children. Excluding these two cases from our calculations, it a[tpears that 
 293 days was the longest period to which gestation extended in 43 instances, 
 where a single intercourse took place. 
 
 To make this subject more clear and certain, we may compare 
 the results now obtained with those which have been gathered 
 from observations upon the lower animals; for although some of 
 my readers may think that facts so derived are not applicable to 
 the human subject, yet a little consideration seems to me to show 
 that the argument from analogy is to a certain extent trustworthy. 
 M. Tessier's researches — conducted with unusual care through a 
 period of forty years — on the time of gestation in 575 cows, from 
 a single coitus, gave the following results '} 
 
 21 cows calved between the 260th and 270th days. 
 213 " 270th " 280th " 
 
 321 " 280th " 297th " 
 
 6 " at 29S days. 
 
 4 " at 299 •' 
 
 10 between tlie 300th and 321st " 
 
 575 
 
 Experiments on mares by the same writer proved that similar 
 deviations occur. Of 447 mares, whose natural period of gesta- 
 tion is eleven calendar months, or about 335 days, — 
 
 51 foaled from the 290th day to the 329th. 
 
 96 
 
 " 
 
 329th 
 
 " 
 
 335th. 
 
 258 
 
 u 
 
 335th 
 
 (( 
 
 359th. 
 
 35 
 
 " 
 
 359th 
 
 « 
 
 377th. 
 
 7 
 
 (1 
 
 377th 
 
 " 
 
 419th. 
 
 447 
 
 The observations on asses, buffaloes, sheep, sows, rabbits, and 
 bitches, showed that variations similar in degree occurred. Earl 
 
 ^ Memoires de TAcad^mie Royale des Sciences de j'institut de France. Tome ii, 
 p. 1. Paris, 1819.
 
 206 
 
 THE DURATION OF PREGNANCY. 
 
 Spencer's experiments on 764 cows have been already alluded 
 to ; but it seems advisable to quote tbem here more fully, as 
 they serve to corroborate the opinions advanced at the com- 
 mencement of this chapter. The results obtained by this noble- 
 man may be thus tabulated : 
 
 220tli and 259th days. 
 
 25 Cows calved 
 between the 
 35 " 262d and 275th days. 
 
 15 Cows calved on the 27()tli day 
 
 14 
 
 18 
 
 32 
 
 35 
 
 39 
 
 47 
 
 54 
 
 (i6 
 
 74 
 
 60 
 
 52 
 
 42 
 
 45 
 
 23 
 
 31 
 
 16 
 
 lU 
 
 8 
 
 7 
 
 6 
 
 2 
 
 1 
 
 1 
 
 1 
 
 3 
 
 1 
 
 1 
 
 764 
 
 277th ■' 
 
 27sth " 
 
 279ih " 
 
 2f>0th " 
 
 281st " 
 
 2&2d " 
 
 283d " 
 
 284th " 
 
 285th " 
 
 286th " 
 
 287th " 
 
 288th " 
 
 280th " 
 
 29Uth " 
 
 291st " 
 
 2»:2d " 
 
 293d " 
 
 294 th " 
 
 295th « 
 
 296th " 
 
 297th « 
 
 299th " 
 
 3U4th " 
 
 305th " 
 
 306th " 
 
 307th " 
 
 313th " 
 
 
 Cow- 
 
 Bull- „ 
 
 
 
 cahes. 
 
 calves. ""' 
 
 The pro-} 
 
 10 
 
 15 
 
 
 duce was | 
 
 
 
 
 u 
 
 14 
 
 15 
 
 6 
 
 " 
 
 7 
 
 6 
 
 2 
 
 " 
 
 10 
 
 2 
 
 2 
 
 " 
 
 11 
 
 4 
 
 3 
 
 " 
 
 16 
 
 11 
 
 5 
 
 It 
 
 15 
 
 20 
 
 
 " 
 
 20 
 
 18 
 
 1 
 
 " 
 
 26 
 
 20 
 
 1 
 
 " 
 
 30 
 
 24 
 
 
 " 
 
 33 
 
 33 
 
 
 l( 
 
 29 
 
 43 
 
 
 (( 
 
 22 
 
 38 
 
 
 " 
 
 25 
 
 27 
 
 
 (1 
 
 13 
 
 28 
 
 
 (( 
 
 20 
 
 25 
 
 
 u 
 
 10 
 
 13 
 
 
 (1 
 
 9 
 
 22 
 
 
 " 
 
 5 
 
 11 
 
 
 u 
 
 1 
 
 9 
 
 
 " 
 
 1 
 
 7 
 
 
 " 
 
 3 
 
 4 
 
 
 u 
 
 2 
 
 4 
 
 
 11 
 
 1 
 1 
 
 1 
 1 
 
 
 11 
 
 1 
 3 
 
 
 
 It 
 
 1 
 
 
 
 It 
 
 1 
 
 
 
 
 340 
 
 401 
 
 23 
 
 This table, like that of M. Tes.sier, proves without a doubt that in the 
 cow, when the date of impregnation was positively certain, yet the day of 
 parturition was far from being precise and determinate. Tiie average term 
 of gestation in this animal seems to be 28-1 or 285 days; 314 of the cows 
 having calved before the two hundred and eighty-fourth day, and 310 after 
 the two hundred and eighty-fifth. None of those calves which were born 
 before the two hundred and forty-second day were reared. 
 
 If, then, we are forced to admit that in the human subject, as 
 in animals, the period of gestation is liable to considerable varia- 
 tions, the question naturally arises, — "What is the greatest extent 
 to which pregnancy may be prolonged beyond the common 
 period of gestation ? A reply cannot very readily be given to 
 thrs inquiry. In fact, the subject has been so complicated by
 
 PROTRACTED PREGNANCY. 207 
 
 the concoction of extravagant fable, the promulgation of erro- 
 neous and rash hypotheses, as well as by the narratives of im- 
 perfectly observed cases, that it is difficult to sift the true from 
 the false. 
 
 The obstetricians of the Celestial Empire allow a very wide 
 margin. In a modern work on Chinese midwifery it is noted : 
 "The great pharmacopoeia says that pregnancy generally con- 
 tinues for seven or eight months, and sometimes for one or two 
 years, and in some rare cases even for four years, and this should 
 be made known. "^ According to the Hindu medical Shdstras, 
 ten calendar months are allowed for the perfection of the foetus 
 in utero. The expulsion of the child is thus explained : " At 
 the tenth month the foetus acquires knowledge, and prays to 
 God, and sees the seven heavens, the earth, and the inferior re- 
 gions. By the air of the pelvis {opana bayu) the foetus is then 
 expelled, as an arrow is shot from a bow, and the child falls in- 
 sensible to the ground. All his former knowledge is imme- 
 diately forgotten, and on losing so many pleasing illusions, he 
 cries. "^ M. Hamont, for some years the director of the School 
 of Veterinary Medicine of Abou-Zabel, states that in Egypt the 
 judges gravely decided that, — " Children may remain in the 
 mother's womb for four years. After five years this cannot be.'"^ 
 
 Mons. A. Petit believed that gestation might be prolonged to 
 the end of the eleventh or twelfth month, or even far beyond 
 this time ; and asserted that cases proving this had occurred 
 many times. In one instance, a woman was pregnant for three 
 years and then gave birth to a stout live boy. About the tenth 
 month she had suffered from pains, and had lost about three 
 quarts of water; but this flow was checked by bleeding. The 
 truth of this history was testified by the signatures of the bur- 
 gomaster of the town, one notary, and two surgeons. Such re- 
 markable corroborative evidence appears to have quite removed 
 all feeling of incredulity on the part of Mons. Petit. And not 
 only so, but twenty-three of the most eminent physicians of the 
 
 ' A Treatise on Midwifery. A New Edition, published in the fifth year of Taou 
 Kwong, IbJ.'). Translated from the Chinese by Dr. W. Lockhart. Published in 'J'he 
 Dublin Journal of Medical Science, vol xx, p. 357. Dublin, 1842. 
 
 ^ A Cotninentary on the Hindu System of Medicine. By T. A. Wise, M.D.. &c., p. 
 .37. Calcutta, lb4.J. 
 
 ■^ Annales d'Hygifene Publique, et de M^decine Legale. Tome x, p. 204. Paris, 1833.
 
 208 THE DURATION OF PKEGNANCY. 
 
 day agreed with liim that the report was correct, and signed a 
 certificate to that effect.^ 
 
 Velpeau, in addition to eight cases published in 1829, has re- 
 corded another in which he distinctly felt the active and passive 
 movements of the foetus at the fourth month. Symptoms of 
 labor set in at the end of the ninth month ; but they were soon 
 suspended, and did not return for thirty days. He believes that 
 the gestation lasted for 810 days.^ 
 
 Dr. Ryan attended a delicate woman, who menstruated the 
 last week in February, 1826, and quickened in July. She had 
 spurious pains in ISTovember and Decen>ber and January; and 
 was delivered on the 28th February, 1827, nearly twelve months 
 from her previous menstruation. Such is the evidence, and here 
 is the corollary : " I most solemnly declare that the case is a true 
 one, and not fabricated to support any particular opinion. This 
 is the longest instance of protracted pregnancy which has hith- 
 erto been recorded in British medicine."^ 
 
 The majority of the medical men examined in the Gardner 
 Peerage Cause were in favor of protracted pregnancy ; and Dr. 
 Granville asserted that in his own wife gestation lasted at least 
 30G, and perhaps 318 days. The only evidence that it did so is, 
 that this lady missed her menstruation on the 7th April, on the 
 15th August she quickened, on the 7th February she was de- 
 livered ; and the accoucheur, the patient, Dr. Granville, and 
 "every one," on examining the large infant, agreed that it was 
 a ten months' child. Mr. John Sabine gave equally valuable 
 evidence as to his own wife, whose last period of menstruation 
 took place about the 14th September, quickening occurred dur- 
 ing the second week of Januarj^, but delivery w^as delayed until 
 the 14th of the August following. 
 
 Three examples of protracted pregnancy have been reported by 
 Mr. Robert Annan. As, however, they were not published until 
 several years after they occurred, and even then were only given 
 "as nearly as my notes and recollections permit," the histories 
 would have to be received with caution though they were much 
 
 1 Reciieil de Pieces concernant les Nnissances Tardives. Une Consultation, &c., 
 (leliljere a Paris, '2"Jd Janvier, neS. Amsterdam, 1760. 
 
 2 Traitfe Complet des Aceoucliemens, ou Tocologie tlitoriqiie et pratique. Tome i, 
 p. .18,'}. Paris, \K',b. 
 
 ' A Manual of Midwifery; or Compendium of Gynaecology and Paidonosology. 
 Third Eilition, p. 133. London, 1831.
 
 PROTRACTED PREGNANCY. 209 
 
 more satisfactory than they really are. But in fact, the first two 
 cases only prove that a couple of women were not delivered at the 
 
 time they expected. In the third instance, Mrs. , menstruated 
 
 for the last time on the 1st April, 1836. After an interval of 327 
 days, labor supervened; and at the end of twenty-four hours she 
 was delivered, on 15th February, 1837, of a male child weighing 
 10 lbs. 14 ozs. The husband was quite convinced that the period 
 of* pregnancy had been protracted, because " during nearly the 
 whole period above mentioned, he had not approached the nuptial 
 bed."^ Mr. Annan thinks this case affords "almost decisive evi- 
 dence of protracted pregnancy ;" but it is to be hoped that he 
 will "nearly" or "almost" stand alone in this conclusion. 
 
 The opinion of the American court regarding the possible pro- 
 traction of pregnancy, as elicited during a lawsuit for bastardy at 
 the Lancaster Quarter Sessions, is deserving of our notice. In 
 this case the ];)rosecutrix swore that her child was begotten on 
 the 28d March, 1845, and was born on the 30th January, 1846, 
 making tlie period of gestation 313 days. At the trial six Ameri- 
 can physicians and surgeons testified against the possibility of 
 the protraction of pregnancy. On the other side, five practi- 
 tioners of medicine declared their belief in the occasional exten- 
 sion of gestation beyond the normal period, and in the possibility 
 of its protraction to 313 days. Dr. Atlee, in particular, asserted 
 that two cases " had occurred in his own practice, in which, by 
 all the usual methods of calculation, the patients must have gone 
 at least ten calendar months."^ In charging the jury, the presi- 
 dent of the court held that protracted gestation for a period of 
 313 days, " although unusual and improbable, was not impossi- 
 ble ;" and in accordance with this charge the jury found a verdict 
 against the defendant. 
 
 Dr. Meigs says he has " reason to believe that pregnancy may 
 endure even beyond twelve months." In proof, he relates a 
 case — which seems chiefly to have been believed on account of 
 the woman's appearance of perfect candor and sincerity in all 
 that she said — where impregnation was deemed to have taken 
 place in July, 1839, and in which delivery was not accomplished 
 
 1 Edinburgh Medical Journal, vol. ii, p. 716. February, 1857. 
 
 2 Tlie American .Tournal of Medical Sciences. New Series, vol. xii, p. 536. 
 Philadelphia, 1846. 
 
 *14
 
 210 THE DURATION OF PREGNANCY. 
 
 until the 13tli September, 1840, a term of 420 clays.^ The well- 
 authenticated case of Albert Kranz, quoted by Schenk, is scarcel}^ 
 more extraordinary. In this instance the wife of Count Baruch 
 de Vandal became pregnant, and carried the child for two years ; 
 so that when it was born, it could walk and speak ! 
 
 Many more examples, both from ancient and modern literature, 
 miglit be quoted to prove that the narrators were convinced of 
 the occasional occurrence of very protracted gestation. It is quite 
 unnecessary to do this, however, since the histories are most un- 
 satisfactory, and destitute of any facts approaching to proof. 
 When we remember how easily women become the dupes of their 
 own fertile imaginations ; how necessary it often is, for the sake 
 of reputation, that they should endeavor to deceive medical 
 men ;- how difficult it is to be accurate when the calculation is 
 commenced from the cessation of the catamenia ; and, in short, 
 how varied and numerous are the sources of error that may vitiate 
 the first impressions produced by examining these cases, — we 
 shall hardly be surprised at some of the extraordinary statements 
 which have just been quoted. 
 
 To show that even the strictly medical evidence, derived from 
 a physical examination, must be received with great caution, in 
 cases of assumed protracted gestation, I quote the following case 
 from Dr. Reid's essay : 
 
 1 Obstetrics; the Science and the Art. Fifth Edition, p. 235, Philadelphia. 1867. ^^ 
 
 2 The following anecdotes may serve as a guide to the explaiiatiou of not a few of 
 the cases which have been from time to time brought forward : 
 
 The widow of a bookseller at Wolffenbuttel was delivered of a child thirteen months 
 after her hu.sband"s decease. The cliild, if begotten by him, was heir to his property; 
 but otherwise, the goods and ir)oney went to distant relations. The child was declared 
 legitimate, owing to the excellent character of the mother, and to its being thought 
 probable that her delivery was delayed by the deep grief into which she was plunged 
 by the loss of her husband. Shortly after this decision the lady was n)arried to Chris- 
 topher Misnerus, who acted as shopkeeper in the business during her widowhood! 
 
 Victor Ratier relates the following romance of Mary of England, the tliinl wife of 
 Loiiis XII, who was left a widow shortly after her marriage. After the death of this 
 king, who had no male issue, the throne was to revert to the young Comte d'Angouleme, 
 who afterwards became Francis the First. Tlie widowed queen had retired to the 
 Hotel de Climy, and, in order to secure the regency, spread a report that she was 
 l)regnant; a .sn|jpc)sition (which as we shall see hereafter) she ho[)ed to carry out suc- 
 cessfnlly. But Francis's mother, Louisa of Savoy, who saw (says Brantome) how 
 much was at stake for herself and her son, ca#fidly watched the movements of One 
 who wished to play the part of queen mother so much to her disadvantage. One day 
 she was informed by her spies that xMary, as tender as she was ambitious, had made 
 an assignation for that night with Charles Brandon, Duke of Sutiblk. The mother and 
 son, accompanied by four gentlemen of the highest rank at court, surprised the lovers 
 at a moment which generally allows of little solemnity; and required that the Abbot 
 of Chmy should forthwith celelirate the nuptials in the adjoining chapel. This cere- 
 mony took place accordingly in ttie night of the 31st of May, 1515. 'J"he fruit of tiiis 
 impromptu marriage was the unfortunate Lady Jane Grey.
 
 ASSUMED PROTRACTED GESTATION. 211 
 
 Mrs. F., married on the 8th May, had her catamenial period unexpectedly 
 on that day. Shortly afterwards she was attacked by inornin<!; sickness : the 
 abdomen gradually enlarged, and other symptoms of pregriancy followed. 
 In the fifth month decided movements were felt; and everything apparently 
 progressed favorably until the 18th December, which was thought to be the 
 seventh month. There had been, however, an irregular uterine discharge 
 every four or five weeks during the above period. At the date mentioned, 
 pains came on at intervals, accompanied by a very free discharge, almost 
 amounting to flooding, but no substance was passed. The monthly nurse 
 arrived, and the practitioner who had been engaged to attend the lady was 
 sumnioned. On his arrival, he exaa)ined the abdomen, and pronounced the 
 patient advanced to the seventh month ; remarking also that he could feel 
 the limbs of the foetus through the parietes of the abdomen. Simple reme- 
 dies were prescribed, and the pains subsided by the next morning. The 
 patient was kept in the recumbent position, the size of the abdomen now 
 remained stationary, and the nurse — after waiting three months in the house — 
 took her leave. The movements had continued as strong as before, but for 
 the last three months there had been no return of the menstrual function; 
 and the morning sickness was much more intense than formerly. The abdo- 
 men still further increased in size, and she was delivered on the 1st September 
 of a moderately-sized child, eight and a half months after she had been pro- 
 nounced by medical authority fully seven months advanced in pregnancy. 
 
 " Kow here," says Dr. Reid, witli great justice, " is a yevy fair 
 sample of the usual case of very protracted gestation, which we 
 meet with in the older authors. A surgeon, after making a cur- 
 sory examination of the ahdomen, decides that the lady is seven 
 months advanced in pregnancy on the 18th Decetnber, and there- 
 fore by his evidence, the lady must have retained the foetus in 
 utero during a space of nearly sixteen months. But the arrested 
 catamenia, and the intense sickness in December, much more 
 probably point at the real commencement of pregnane}^ ; the 
 reasonable conclusion is, that this state lasted for about eight 
 months and a half only, and that the medical attendant had de- 
 ceived himself." To these remarks let me add the suggestion 
 that this case might have assumed all the importance of one of 
 the " Causes Celebres," had this lady become a widow only a few 
 weeks prior to her spurious parturition ; and then lancying her- 
 self pregnant, and hence safe from detection, allowed sexual in- 
 tercourse with a favored admirer about the month of December. 
 In some court of law the lady's immaculate virtue would have 
 been appealed to in glowing terms, the impossibility of the " emi- 
 nent" surgeon's opinion being erroneous would have been in- 
 sisted on, the child would have been declared legitimate, and an 
 undoubted instance of very protracted gestation would have
 
 212 THE DURATION OF PREGNANCY. 
 
 been added to those examples which have been already credited 
 by judges and juries. 
 
 The following case is of a different character. It is justly 
 adduced by Desormeaux, as proving that the term may be 
 slightly prolonged beyond the usual period : 
 
 A lady, the mother of three children, became deranged after a severe fever 
 Her physician thou<>ht that pregnancy n)ight have a beneficial effect on the 
 mental disease, and permitted her husband to visit her; 43ut with this re- 
 striction, that there should be an interval of three months between each visit, 
 in order that if conception occurred the rifk of abortion from further inter- 
 course might be avoided. The physician and attendants made an exact note 
 of the time when the husband's visits took phice ; and as soon as symptoms 
 of pregnancy began to appear, the visits were discontinued. The lady was 
 closely watched by her female attendants all the time. She was delivered 
 at the end of nine calendar months and a fortnight by Desormeaux. The 
 number of days is not given, but taking the shortest nine months we shall 
 have 273 + 14 = 2^7 ; or if other nine months were those meant we might 
 have 276 + U = 290 days.i 
 
 Dr. William Hunter is said to have replied to a question as to 
 the duration of pregnancy, in these words : " The usual period 
 is nine calendar months, but there is very commonly a difterence 
 of one, two, or three weeks. I have known a woman bear a living 
 child, in a perfectly natural wa}^ fourteen days later than nine 
 calendar months; and believe two women to have been delivered 
 of a cliild alive, in a natural way, above ten calendar months 
 from the hour of conception." 
 
 The proposition that the time of parturition is dependent upon 
 a cycle of ten catamenial periods has been already referred to. 
 Regarding this as a physiological fact, Cederschjold has tried to 
 show that the duration of gestation is influenced by the length 
 of the intervals between the catamenial periods. Thus, these 
 intervals, though usually consisting of twenty-eight days, need 
 not invariably do so ; and he asserts that it is by no means rare 
 to meet witli variations. Hence, in a woman whose menses 
 recur every twenty-nine days, we shall have 10 X 29 = 290 days = 
 the duration of her gestation. Or, again, in one who menstruates 
 every thirty days, 10 x 30 = 300 = the length of her pregnancy. 
 These ingenious views have been commentated on by Schuster, 
 who has related the case of his own wife in confirmation of 
 
 1 Dictionnaire de M(5ilcciiie, 2me edition, tome xiv, p. Ki?. Paris, 1836.
 
 GESTATION MAY BE PROLONGED. 213 
 
 them. This lady's menses recurred every twenty-nine or thirty 
 days. Her first pregnancy ended on the 296th day : her second 
 histed exactly 300 days. 
 
 Dr. Jorg fixes the duration of gestation as 280 days from the 
 time of conception, and will not allow that this period is liable 
 to fluctuation, as in the females of many classes of animals. He 
 seems to think that instances o^ protracted 'parturition have been 
 mistaken ioY protracted gestation. A case in point is detailed, in 
 which labor commenced on the 280th day ; but owing to the 
 weakness of the pains and the length of the remissions, the 
 child was not born until after the lapse of fourteen days.^ No 
 doubt many medical men would have set down such a case as 
 one of gestation prolonged to 294 days. I am acquainted with 
 the history of a more extraordinary case, which may be briefly 
 related, as there is no doubt in my mind that it is perfectly au- 
 thentic. The chief facts as they were detailed to me by my 
 patient are these : 
 
 Mrs. F., a lady of delicate health, forty-one years old. was delivered of her 
 third child, in Manilla, on the lUth March, 1847. When the infant was 
 fourteen days old it was weaned ; the climate, it is said, being too hot to 
 allow of European ladies suckling their offspring At the end of the next 
 month the catamenia came on, and after continuing for four days ceased on 
 the oOth April. The courses did not again return, but my patient believes 
 that she did not become pregnant until the 20t.h May; while she is certain 
 that intercourse never took phice after that date, on account of the serious 
 illness of her husband. This gentleman died on the olst August, and Mrs. 
 F. soon afterwards returned to England. She calculated that her labor 
 would come on about the middle of February, 1848; as it ought to have 
 done, supposing her opinion as to the day of fecundation correct. If we 
 reckon in the usual manner, and say that labor should have supervened 280 
 days after the last catamenial period, it will be seen that delivery ought cer- 
 tainly to have taken place on the 4th February; but if we adopt the better 
 plan — so seldom possible, however — and calculate 275 days from the time 
 of the fruitful coitus, then the accouchement was to be expected on the 19th 
 February Now it is remarkable that labor pains first manifested themselves 
 on the 18th February, so that everything was prepared for the immediate 
 birth of the infant. But at the end of a couple of hours the pains went off, 
 and did not return till the next day. Again they ceased for twenty-four hours, 
 and again returned ; and this happened every day for three weeks. Some- 
 times only two or three pains were experienced, sometimes the parturient 
 efforts came on frequently for half-an-hour or a little longer and then sub- 
 sided. She was delivered of a live girl, remarkable for its size, on the 11th 
 March; being twenty two days — for it was leap-year — from the 19th Feb- 
 ruary, or 297 days from the last coitus. 
 
 1 Die Zurechnungsfahigkeit der Schwangern unci Gebarenden belenchtet. P. 238.
 
 214 THE DURATION OF PREGNANCY. 
 
 Now, it must not be imagined from the foregoing, that I agree 
 with Dr. Jorg and believe that all the cases in which gestation 
 continues beyond 280 days are merely examples of tardy labor. 
 On the contrary, it seems to me that such a position is quite 
 untenable; independently of its being at best merely the same 
 thing under a different name, a specious distinction of little, if 
 any, value. I would therefore rather say, that we are in a posi- 
 tion to assert positively that gestation may be prolonged beyond 
 the usual or normal period ; although no case has occurred so 
 far as my own personal experience goes, in which the time has 
 been extended for more than three weeks and one day, calculat- 
 ing 275 days as the natural interval from a successful coitus. I 
 believe further, that all recorded exporience of any value, as well 
 as the few trustworthy experiments which have been performed, 
 teach us that the cases in which utero-gestation in the human 
 subject have been prolonged beyond ten calendar months are 
 exceedingly rare. But that such departures from the common 
 law may possibly occur, seems to me proved by an example 
 which has been very clearly related by ])r. Joynt. I have ven- 
 tured to abbreviate this gentleman's report, though I would rec- 
 ommend a careful perusal of his essay to all who are interested 
 in this subject. The following is an outline of the case : 
 
 A lady, aged about 30, became a patient of Dr. Joynt's in November, 
 1863. She had been pregnant six times; but on two of these occasions had 
 miscarried, — the last time in the previous April. She complained of exces- 
 sive menstruation, and of ovarian pain. Was also the subject of hystero- 
 epileptic fits. Caustics had frequently been applied to the lips of the uterus. 
 The uterus and ovaries were found free from any organic lesion on an exami- 
 nation being made by Dr. Joynt. 
 
 On the 28th December, 18(38, the catamenia occurred ; they ceased on the 
 2d January, 1864. About the middle of this month, intractable morning 
 sickness set in ; of the same character as had signalized the commencement 
 of former pregnancies. At the next expected period, menstruation did not 
 occur. The sickness continued until the last week in 3Iarch ; and on the 
 28th of this month she quickened, foetal movements being di.stinctly felt. 
 On the 12th May, she was threatened with miscarriage, but the symptoms 
 yielded to treatment. 
 
 On the evening of the 3d October, having arrived at her full time, as sbe 
 believed, labor pains set in. They increased in force till the following morn- 
 ing, when they went off. Exactly simihir phenomena occurred on the evening 
 of the 4th, and again and again on successive days, for some six times in 
 all. During an intermission a vaginal examination was made; the cervix 
 uteri was quite obliterated, and the os uteri patulous. On three separate 
 occasions there was a discharge of about a pint of water from the vagina.
 
 GESTATION MAY BE PROLONGED. 215 
 
 Uterine pains, observinir nearly the order and duration of the first set, con- 
 tinued to recur at uncertain intervals until the 21st November. Labor then 
 actually set in, and on the followinir tnornin<r, precisely seven weeks f'ron: the 
 first occurrence of pains, she was delivered of a mature male child. The 
 infant had no other peculiarity than a tolerably good head of hair; the 
 former children having had no hair at birth. The period of convalescence 
 was very favorable. 
 
 It is probable, that in this case the minimum duration of pregnancy was 
 317 days, or nearly six weeks more than the average. The patient's hu.'^band 
 was absent from 26th December to the 6th or 7th January. He remained 
 with her until the 10th January. Before he again visited her, the charac- 
 teristic morning sickness had convinced Dr. Joynt that pregnancy had 
 commenced.^ 
 
 Every obstetrician is expected to be able to predict, witli some 
 slight approach to accuracy, the day when labor may be expected. 
 The only certain data for reckoning the time of this event are 
 those depending on the known time of a successful or fertilizing 
 coitus. It has been proved that the average duration of preg- 
 nancy when computed from this occurrence is about 275 days. 
 But it is obvious that reliable and exact information on this head 
 can only very rarely be obtained ; and hence the period must be 
 calculated from the date of the cessation of the catamenia. To 
 effect this readily we cannot do better tban follow the plan of 
 most German obstetricians, who foretell the probable clay of 
 delivery thus: The date of the last menstruation being given, it 
 is merely necessary to calculate three months backwards and add 
 seven days. For example, suppose the 20th of January to be 
 the last, day of the last menstrual period ; then labor will be due 
 about the 27th October, — i. e., on the 280th day. 
 
 Dr. Charles Clay has attempted to prove that the term of 
 utero-gestation is regulated by the ages of the parents ; and he 
 endeavors to establish this proposition by the examination of 
 recorded experiments on animals, as well as by the investigation 
 of some twenty authentic instances of pregnancy resulting from 
 a single act of coition in the human subject. In these latter 
 cases, one prominent fact is said to be undeniably illustrated, 
 viz., " that the younger the parties concerned, the shorter the term of 
 utero-gestation ; and, vice versa as age increases, the term of gesta- 
 
 ' Dublin Quarterly Journal of Medical Science. Vol. xlii, p. 377. August and 
 November, 1866.
 
 216 THE DURATION OF PREGNANCY. 
 
 tion if< proportionably lengthened."^ By placing in juxtaposition 
 tlie few cases on which full reliance can be placed, it will be seen 
 that this statement seems to be correct : 
 
 At 12^ years, the term of gestation was 264 days. 
 
 15 
 
 " 
 
 
 267 
 
 1ft to 15^ 
 
 " 
 
 
 267 
 
 16 to 17 
 
 " 
 
 
 270 
 
 19 
 
 u 
 
 
 272 
 
 25 
 
 l( 
 
 
 274 
 
 30 
 
 " 
 
 
 276 
 
 35 
 
 '< 
 
 ' , " 
 
 278 
 
 44 
 
 " 
 
 
 284 
 
 52 
 
 u 
 
 
 290 
 
 In the preceding examples the mother's age alone is given ; 
 although when Dr. Clay maintains that the duration of utero- 
 gestation is definite and regulated by age, he means that in order 
 to arrive at accurate conclusions it is necessary to take into the 
 calculation the age of both parents, and to strike a mean between 
 the two. For example, suppose a female of 20 to cohabit with 
 a male 30 years old, a result may be expected nearly equal to an 
 age of 25. To be still more exact, it is thought that a slight al- 
 lowance should be made for the well-known fact, that the female 
 arrives at maturity earlier than the male; and hence, taking the 
 same figures, a female at 20 and a male at 30, we should fix upon 
 24 instead of 25; or vice versa, a female at 30 and a male at 20, 
 the result would be, not 25 or 24, but 26. Before the truth or 
 fallacy of these propositions can be substantiated, however, a large 
 number of careful observations by independent observers must 
 be collected ; though it may be justifiably conceded, even at the 
 present stage of the inquiry, that Dr. Clay's views are not only 
 rather ingenious, but so far sufficiently supported to merit further 
 investigation. 
 
 In conclusion it may be mentioned that there is a popular 
 belief, especially prevalent in fishing towns, where the date of a 
 fruitful intercourse is often more positively known than in other 
 places, that when the time of gestation is longer than usual the 
 produce will very probably be a male child. This opinion is 
 slightly corroborated by Earl Spencer's observations on cows. 
 
 ' Observations on the Term of Utero-Gestation. By Charles Clay, M.D., Manchester, 
 p. 9. London, 1855.
 
 CAUSE OF PROLONGED GESTATION. 217 
 
 In examining these experiments we ought to exclude from our 
 calculation those cows which calved before the 260th day, and 
 after the 300th, as being anomalous cases. "We shall then find 
 that 233 cow-calves and 234 bull-calves were produced by those 
 489 cows whose period of gestation did not exceed 286 days; 
 while the 243 cows whose period exceeded 286 days, gave 90 
 cow-calves, and 152 bull-calves. A patient of my own, a farmer 
 in Derbyshire, tells me that it is a common opinion which he 
 regards as well-founded, that when the cow goes over her time 
 by a week or ten days, the produce of her labor will be a bull- 
 calf. And so with the mare, when her gestation exceeds the 
 usual term of eleven months, she more frequently gives birth to 
 a horse- colt than a filly. 
 
 Moreover, it may be mentioned that in my record of midwifery 
 cases I find that children of much greater weight than ordinary 
 have almost invariably been males; and this increase in size has 
 very commonly been attributed by the mothers to their having 
 gone a longer time than their calculations had led them to ex- 
 pect. On examining Dr. Murphy's cases it appears that out of 
 90 instances in which the mothers were not delivered until after 
 280 days from menstruation, 43 per cent, of the children born 
 were girls, and 57 per cent, were boys. On the other hand, we 
 have the statement of Tessier, that he ascertained beyond any 
 doubt that the protraction of gestation in the cow and mare was 
 neither influenced by the age, constitution, or food of the animal ; 
 nor by the size, sex, or strength of the fcetus. 
 
 The objection has been made to this kind of evidence by Dr. 
 Matthews Duncan, that the reasoning from analogy between the 
 cow and woman has been much overstretched ; and he attempts 
 to show, that many of the cases of protracted gestation which 
 have been reported are untrustworthy, because the infants when 
 born did not exceed the usual size. Indeed, he says that two 
 cases had been under his own care, in which gestation was, with 
 some reason, supposed to be prolonged ; but that he refused to 
 place them in this category, "because, although the ladies were 
 in good health at the time of falling in the familj'-way, yet the 
 infants born were not at all larger than their former children."^ 
 And he further adds, that he does not knoAV of " an individual 
 
 ^ Fecundity, Fertility, Sterility, and Allied Topics, p. 346. Edinburgh, 1866.
 
 218 THE DURATION OF PREGNANCY. 
 
 instance of certainly protracted gestation in which the produc- 
 tion was small and light in weight," 
 
 Now at first sight this opinion of Dr. Duncan's seems only- 
 consonant with what might roasonahly be expected. For cer- 
 tainly as an infant's life gets lengthened, whether it be born or 
 not, so day by day does it increase in size. But when we come 
 to apply this law to any special case, it is seen that certain other 
 conditions besides duration of life have possibly been brought 
 into action and must claim consideration. Thus disease, with- 
 out destroying life or mutilating the body, may doubtless retard 
 development. Or, to take extreme instances, the assertion of 
 Dr. Graves may be cited, — that " dwarfs generally come into the 
 world after the ordinary term of gestation."^ Remembering that 
 the normal foetus at maturity has an average length of from 
 eighteen to twenty inches, there can be no objection to the in- 
 ference that dwarfs are much below this size at birth ; although, 
 of course, their growth may only be checked subsequently. Still 
 we know that Jeffrey Hudson was only eighteen inches high at 
 the age of eight years ; Borwilaski at twenty-two was twenty- 
 eight inches; while Bebe — a seven months child — was only be- 
 tween seven and eight inches long, and weighed a pound, when 
 born. Moreover, the case published by Dr. Joynt, and already 
 quoted, tells against Dr. Duncan's views. At all events, I think 
 sufficient has been said to show that all statements on this ques- 
 tion should be received with considerable caution ; for the subject 
 undoubtedly requires further investigation. 
 
 1 Stndips in Pliysiolos^y and Medicine, by tlie late Robert James Graves, F.R.S. 
 Edited by William Stokes, p. 241. London, 18G3.
 
 INTRODUCTION. 219 
 
 CHAPTER V. 
 
 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 1. Introduction — Definition of the terms abortion, miscarriage, and premature 
 LABOR — Characteristics of the embryo at different ages — Earliest period 
 at which the f(etus can reach maturity. — 2. Causes of abortion — As they 
 
 are accidental — As THEY ARE DUE TO SOME DERANGED STATE OP THE MATERNAL 
 HEALTH — As THEY CAN BE TRACED TO SOME MORBID CONDITION OF THE UTERUS OR 
 ITS APPENDAGES — AS THEY ARISE PROM DISEASE OF THE EMBRYO OR ITS MEM- 
 BRANES. — .S. Symptoms — In early days op gestation — At an advanced stage 
 
 OF PREGNANCY — INVERSION OF UTERUS AFTER ABORTION. — 4. DIAGNOSIS — DISTINC- 
 TION between THE MENSTRUAL FLOW AND THE HEMORRHAGE OF AN EARLY ABORTION. 
 
 5. Prognosis — In first or second months, the danger slight — Hemorrhage 
 
 THE CHIEF source OF DANGER. — 6. TREATMENT — PROPHYLACTIC OR PREVENTIVE 
 MEASURES — Plan to be pursued when expulsion APPEARS UNAVOIDABLE. 
 
 1. Introduction. — The abrupt termination of pregnancy by 
 the premature expulsion of the foetus is of frequent occurrence; 
 the number of mothers who pass through the childbearing epoch 
 of life without aborting once, or even much oftener, being small. 
 Although this accident may be the cause of alarming symptoms 
 as well as of much suffering at the time of its occurrence, and 
 although it not uncommonly proves the source of many months 
 of ill-health subsequently, yet it is seldom directly destructive to 
 the life of the parent. Indeed, the very large quantity of blood 
 vi^hich a woman may lose under these circumstances is quite sur- 
 prising; and no less astonishing is it to witness the rapid way in 
 vi^hich, under skilful treatment, she frequently will recover from 
 the immediate effects of the loss. 
 
 The expulsion of the ovum may take place at any period of 
 gestation. When it occurs during the first sixteen weeks, it is 
 often spoken of as abortion; when between the end of this period 
 and the twenty-eighth week, as miscarriage ; and when after the 
 latter period, but before the completion of the full term, as prem- 
 ature labor. The most simple subdivision, however, and there- 
 fore the best, is into abortion and premature labor: the former 
 comprising all cases which occur before the twenty-eighth week,
 
 220 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 or seventh lunar month, inasmuch as the expulsjon is invariably 
 fatal to the offspring either previous to or just after birth; the 
 latter including the cases which occur after the twenty-eighth 
 week, when it is possible that the foetus may, with care, be reared. 
 The terms, "abortion" and "miscarriage" may be conveniently 
 employed as synonymous expressions. Until the present reign, 
 the law discriminated between the crime of producing abortion 
 at an early period of pregnancy, and of doing so in a woman 
 quick with child. Fortunately no such subtle distinction now 
 exists ; for, as I have before said, the expulsion of the foetus or 
 infant by criminal violence, at any period of pregnancy, is re- 
 garded as an abortion, and is punishable as a felony.^ 
 
 It is commonly believed that early, especially first gestations, 
 have more frequently a premature termination than subsequent 
 pregnancies. According to the experience of Mr. Whitehead — 
 who, as surgeon to the Manchester Lying-in Hospital, has had 
 valuable opportunities for investigating such questions — this is 
 not the case. On the contrary, he is inclined to believe that 
 "the third and fourth, and subsequent pregnancies, and one or 
 two of the last, — those, namely, which occur near the termination 
 of the fruitful period — are most commonly unsuccessful."^ Al- 
 though abortion may occur at any period of utero-gestation, yet 
 it is more frequent at some stages of the process than at others ; 
 and, as might be expected, it happens more commonl}- during 
 the early months than subsequently. This is partly due to the 
 comparatively slight causes which about this time suflice to induce 
 hemorrhage, and consequently^ expulsion. The uterine mucous 
 membrane, then transformed into the decidua, is very vascular; 
 and blood is readily efiused into the space which originally exists 
 between the chorion and tlie decidua reflexa. Moreover, it seems 
 to me probable that the uterus is more irritable during the first 
 three months than it is afterwards. The following table by Mr. 
 Whitehead shows the respective periods of 602 cases of abortion 
 whicli occurred under his own immediate observation. It must 
 be stated that each figure in the first column embraces a period 
 of four weeks, extending from a fortnight before to the same 
 length of time after the month indicated. Moreover, as abortions 
 happening earlier than the seventh week of utero-gestation are 
 
 ^ See note, chapter ii, section 6, p. 98. 
 
 * On the Causes and Treatment of Abortion and Sterility, &c., p. '247. London, 1847.
 
 EVIDENCE OF LIVE BIRTH. 
 
 221 
 
 so frequently and closely simulated, both in married and un- 
 married females, by certain uterine discharges, the result of dis- 
 ordered menstruation ; therefore, events said to have taken place 
 at this early period — except those where the escape of an ovum 
 was undoubtedly proved — have not been included in the report. 
 
 A Table showing the Period of Pregnancy at which Abortion 
 OCCURRED in 602 Cases, etc. * 
 
 Period of Prpgnancy at 
 
 which Abortion 
 
 occurred. 
 
 Numher of 
 
 Births at each 
 
 period. 
 
 Number 
 Stillborn. 
 
 Number 
 
 Living; at 
 
 Birth. 
 
 Number 
 Livin;; at the 
 
 end of a 
 
 Month after 
 
 Birth. 
 
 2 months, 
 
 3 " 
 4 
 
 5 
 
 6 " 
 
 7 
 
 8 " 
 
 
 35 
 
 275 
 147 
 30 
 32 
 55 
 28 
 
 24 
 
 38 
 23 
 
 8 
 
 17 
 
 5 
 
 
 3 
 1 
 
 Total, . . 
 
 602 
 
 85 
 
 30 4 
 
 Of the eight children indicated in this table as having been born alive at 
 six months, seven perished within six hours after birth, and only one attained 
 to the age of ten days. Of the seventeen born alive at seven months, the 
 majority lived over several days, a few to the end of the third and fourth 
 week, and three were alive at the end of nineteen months. Eleven of those 
 born alive at seven months, and three of the five born alive at eight months, 
 perished from disease of a specific nature inherited from the mother. In 
 three of the cases the event was attended with fatal consequences to the 
 mother:, one, in which delivery occurred at the seventh month, being a case 
 of placenta pr?svia, where the expulsion had been preceded for several days 
 by a constant and profuse hemorrhage; one was a case of malignant degen- 
 eration of the uterus; while the third was a case of twins, at about the sev- 
 enth month of their uterine growth, in which delivery was followed by 
 alarming prostration, symptoms of uterine phlebitis setting in, and death 
 taking place on the sixth day. 
 
 In cases of premature delivery it is sometimes a matter of con- 
 siderable importance to determine whether a child was born alive, 
 even though it may certainly have perished very shortly after- 
 wards. This may particularly be the case in contested lawsuits 
 relating to the inheritance of, or succession to, property. The 
 question as to what constitutes a live birth might also be raised. 
 At a meeting of the Obstetrical Society of Edinburgh in 1854, 
 Dr. Keiller exhibited a premature foetus which was born alive in
 
 222 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 the fourth month ; and at the same time referred to some recent 
 cases in civil jurisprudence in which tlie question of live birth was 
 held to he established without any evidence of that which was 
 formerly demanded — respiration or crying. The mere muscular 
 movements of the limbs or the features, independent of any signs 
 of respiration, having been ruled as sufficient evidence of a child 
 being born alive, is therefore now held to be ample enough proof 
 of what is ternied^n such investigations " live birth." The fol- 
 lowing are the chief points of interest in Dr. Keiller's case : 
 
 On 17th June, 1854, this gentleman was called to Mrs. R., who was 
 about to abort. A miscarriage had occurred a year previously, when seven 
 months pregnant. She now considered lierstdf in the fourth month; having 
 last menstruated on the 8th February, while she quickened on the 8th June. 
 The foetus was soon born; and as the heart was beating vigorously, together 
 with the vessels of the cord, the foetal circulation through the attached pla- 
 centa was allowed to continue some time, in order to observe the reflex move- 
 ments of the limbs and fjice and respiratory muscles which took place. At 
 first the muscular reflex contractions were very marked: so that on touching 
 the feet and hands, the limbs were immediately drawn up and moved about. 
 On blowing upon the face, the lower part of it was tremulously moved, and 
 the mouth opened; and three or four times an attempt to respire or gasp, 
 acconipatiied by an apparently respiratory movement of the chest, took place. 
 On cutting the cord, and allowing about a drachm of blood to ooze from its 
 foetal extremity, the heart's action immediately became quicker, and one or 
 two thoracic convulsions afterwards followed. The heart's action gradually 
 became more feeble, although pulsations occurred for nearly an hour. The 
 foetus weighed 9 J oz. ; in length it measured 8 inches j and the placenta with 
 attached cord weighed about 6 oz The eyelids were adherent, the nose and 
 ears closed, and the njouth open; the membrana pupillaris was entire ; while 
 on opening the chest, the situation and appearance of the lungs and other 
 organs were characteristic of the apparent age. 
 
 It has been already remarked that when the foetus is expelled 
 before the twenty-eighth week of utero-gestation, it either dies 
 immediately or very soon after birth. Possibly some few re- 
 markable exceptions to this rule can be found ; and the follow- 
 ing would seem to be one : 
 
 In the year 1748 a woman was delivered of a male foetus, precisely six 
 months after her previous accouchement. The child was puny and weak to 
 excess ; it did not cry, and it seemed hardly able to breathe ; the eyes were 
 closed ; the limbs were flabby and relaxed ; and some slight movement, with 
 a warm surface, were the only signs of life exhibited. It was carefully pre- 
 served from cold, and fed with a little lukewarm milk; but it uttered no cry, 
 and voided no excrements. At the end of four months the child began to 
 cry, to void excrements, to move its body, to suck, and to grow like other
 
 DETERMINATION OF AGE OF FGETUS. 223 
 
 children. So steady was the improvement, that in about sixteen months 
 after its birth, it surpassed other children of the same age in strength.^ 
 
 The data by whicli the age of the embrjo can be ascertained 
 are deserving of notice ; inasmuch as the accoucheur is always 
 expected to give an opinion as to the period to which the intra- 
 uterine life has advanced. The following statements are, how- 
 ever, to be regarded as affording an approximation to the truth, 
 rather than as being unconditionally exact. Hence, in any given 
 case, the physician must form his opinion not from one sign alone, 
 but from a consideration of the majority of the characters which 
 the foetus presents. The chief points to which I would direct 
 attention are as follows : 
 
 From the time of impregnation until the fifteenth daj, the embryo is seen 
 only as a minute, semi-transparent, gelatinous, grayish-colored mass ; pre- 
 senting no distinct formation, even when examined by the microscope ; and 
 only detected at all with very great difficulty by a lens. Indeed, if the ovum 
 be expelled within six weeks from conception, it is scarcely possible to find 
 the embryo in the great majority of cases, owing to its minuteness, and the 
 coagula of blood in which it is enveloped. Burns examined three uteri 
 within the first month of gestation, where expulsion had not occurred; and 
 yet, under these favorable circumstances, he could not discover the embryo. 
 Probably the earliest embryo which has been seen is that mentioned by Von 
 Baer, in an ovum of about fourteen days. 
 
 All embryo of one calendar month weighs about twelve grains, and is six 
 or eight lines long. It has been roughly compared to a grain of barley, or 
 to the common house-fly, or to a small worm curved upon itself. The head 
 is distinguishable, constituting half of the entire embryo; the eyes are placed 
 laterally, and consist of two black points, surrounded by a membranous circle, 
 representing the lids; while the mouth is triangular and wide open, the ru- 
 dimentary tongue being discernible. The bronchial clefts have not quite 
 disappeared. A quadrangular mark behind and below the upper jaw indi- 
 cates the situation of the external auditory canal. The brain is represented 
 by a little gray mass; and the rudimentary spinal cord is evident. The 
 extremities are to be distinguished as little leaf-like appendages. The ora- 
 phalo-meseraic are the first bloodvessels developed; and from these the vena 
 portae is formed, the heait first appearing as a dilatation of the latter. This 
 dilatation is separated by two contractions into three portions; two parts 
 forming an auricle and a ventricle, and one the bulbus arteriosus — the rudi- 
 mentary aorta. It has been stated that the pulsations of the heart have been 
 recognized as early as the fifth week at the upper part of the left side of the 
 abdomen. The circulating fluid is at this time colorless. The chorion is 
 smooth internally, and covered externally with small villi ; while the um- 
 bilical vesicle is large, and connected with the intestine by the ductus om- 
 phalo-entericus. This duct, with the vasa omphalo-meseraica which accom- 
 
 1 Essai sur I'Edncation Medicinale des Enfans, et sur leurs Maladies. Par M. 
 Brouzet. Tome Premier, Note p. 37. Paris, 1754.
 
 224 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 pany it, and the pedicle of the allantois, forms part of the umbilical cord, 
 which begins to be developed at about the fifth week. A double sheath, 
 fornjed by the chorion and amnion, incloses these structures. 'J'he urachus, 
 with the umbilical vein and two arteries, constitutes the chief portion of the 
 cord at a later period of gestation. 
 
 Alt embryo of hDO months weighs from six to eight drachms, is about 
 eighteen lines in length, and somewhat resembles a large kidney-bean. The 
 head is very large. The brain is represented by a series of vesicles : the an- 
 terior, small and double, being the cerebrum ; the posterior, larger, repre- 
 senting the cerebellum, while in front of this is the vesicle of the corpora 
 quadrigemina, and that of the third ventricle. The eyes are prominent, and 
 partly closed. The lungs, liver, and Wolffian bodies exist. The heart is 
 covered in, and its septum developed. The extremities are quite visible. 
 The first centres of ossification have appeared in the clavicle and lower jaw. 
 These ossific points can be very clearly seen by soaking the embryo for a few 
 days in a solution of caustic soda and alcohol (from five to ten giains of 
 caustic soda dissolved in a little water, to one fluid ounce of alcohol); a 
 mixture which renders the soft tissues transparent; without affecting the 
 earthy particles. The foetus can afterwards be perm.anently mounted in 
 glycerine or in diluted alcohol. — By this time the villi of the chorion have 
 become accumulated at one spot, to form the placenta ; while the uuibilical 
 cord is thick, and the vessels straight, though they now begin to assume a 
 spii'al direction. Development henceforth goes on rapidly; the features be- 
 coming in part well-marked, and the extremities well-formed. Hence we 
 find that, — 
 
 All embryo of tliree months weighs from one and a half to rather over two 
 ounces, and when stretched out measures between three and four inches. Os- 
 sification has progressed at several points; and some of the deposits are of 
 considerable size. The rudiments of the muscles are formed. The head is 
 heavier than the rest of the body. The anterior lobes of the cerebral hemi- 
 spheres have much increased in size, but there are no convolutions visible. 
 The dental sacs make their appearance in the upper and lower jaws. Each 
 pupil is closed by the n)embrana pupillaris, and the eyelids coalesce, or nearly 
 so. The mouth is large, with the lips well-formed. The heart is large as 
 compared with the body, the proportion being as 1 to 50, whereas at birth it 
 is as 1 to I'iO, and in the adult about 1 to 150. Tlie thymus, spleen, pan- 
 creas, and salivary glands are visible. The external genital organs are also 
 of considerable size in proportion to the rest of the body, though the sex is 
 not discriminative, the clitoris not being distinguishable from the penis ; 
 while the rudimentary kidneys, with the testicles or ovaries are in course of 
 development. The membranes are larger than the egg of a goose; the meni- 
 branro deciduae are in close contact; the umbilical vesicle, allantois, and the 
 omphalo-meseraic vessels have collapsed ; and the placenta is distinctly 
 isolated. 
 
 A foetus of four months varies from three to five ounces in weight, and is 
 five to six Indies long. The skin is slightly red, and rather dense. The 
 brain is smooth on its surface, there being no appearance of convolution ; 
 but the middle and posterior lobes of the cerebrum can be seen. The small 
 ossicula auditus are ossified. The supra-renal capsules are as large as, or 
 even larger, than the kidneys, the latter being voluminous. The sex is just 
 distinguishable; the retrocession of the clitoris, or the increased devek)pment 
 of the penis with the formation of the raphe of the scrotum, beginning to be
 
 DETERMINATION OF AGE OF FCETUS. 225 
 
 apparent. There is meconium in the larpe intestines. Ossification has much 
 advanced : the shafts of the long bones, rudiments of the vertebrae, and plates 
 of several flat bones are distinct. Moreover, the umbilicus is situated near 
 the pubes ; and the chorion and amnion are in close contact all round. Mons. 
 Cazeaux states that while he was Interne at the Hotel Dieu, he received a 
 foetus that had scarcely reached the fourth calendar month ; but which lived 
 for four hours after its birth. 
 
 A foe fits of five months weighs about one pound avoirdupois, and is some 
 ten or eleven inches in length. Its head is in size one-third of the whule 
 body, and has short scattered hair upon it, of a silvery lustre; the eyelids 
 are adherent, and the pupils closed by the membranae pupillares ; while the 
 brain' presents slight interlobular depressions. The germs of the permanent 
 teeth may be perceived. The nails are slightly formed. The lungs are small 
 and solid; the heart is still voluminous and beginning to assume an oblique 
 direction instead of being vertical as before, the auricles are larger than the 
 ventricles, and the ductus arteriosus and pulmonary artery are equal in 
 development The liver is large, while the gall-bladder is perceptible. The 
 muscles are becoming fibrous. There is a slight appearance of fat in the 
 connective tissue. During this month the foetal movements have become 
 appreciable to the mother. 
 
 A foetus of six months has a weight of two pounds, and is twelve or thir- 
 teen inches long. The head is to the body as I to 4. The brain is a grayish 
 mass, the posterior lobes of the cerebrum overlapping the cerebellum. The 
 hair loses its silvery lustre, and becomes darker. The eyelids are still ag- 
 glutinated. Ossification has proceeded to a considerable extent. The lungs 
 are small, solid, and of a reddish color; the heart is rather smaller than 
 before, and the foramen ovale at the lower and back part of the septum 
 auricularum is now at its greatest size. Meconium of a deeper color and 
 more viscous than hitherto, is found in the cjecum. In the male the testi- 
 cles are just apparent in the abdomen, lying on the psose muscles, and grad- 
 ually withdrawing from the kidneys. 
 
 A foetus of seven months weighs from three to four pounds, and measures 
 between fourteen and fifteen inches in length. The skin is thick, and be- 
 ginning to be covered with a white unctuous matter; the body is round and 
 plump, from the deposition of fat in the connective tissue ; ossification is 
 rapidly advancing throughout the skeleton ; and the nails are tolerably firm, 
 but do not reach to the extremities of the fingers. Vulvula3 conniventes 
 appear in the small intestines, and meconium is found in the colon as well 
 as in the caecum. The eyelids are no longer closed, and the membranas 
 pupillares are less apparent. The liver is of considerable size, the left lobe 
 being almost as large as the right; while the gall-bladder contains bile. The 
 testicles are drawn almost in contact with the abdominal rings. The ancients 
 entertained a conceit that an infant born at seven months could live, while 
 one at eight months was almost spre to die. It is hardly necessary to observe 
 that the capability of living in a foetus increases in proportion as it advances 
 towards the natural period of delivery ; and the propagation of the opposite 
 opinion could only have arisen from the prevalent belief in the harmony and 
 powers of certain numbers with which philosophers were formerly infected. 
 As Haller points out, the Pythagorean number Seven was regarded with 
 great favor. 
 
 The foetus of eight months weighs from four to five pounds, and is from 
 sixteen to seventeen inches in length. The quantity of fat beneath the skin 
 
 15
 
 226 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 has increased ; the hair and nails are well developed ; and the sebaceous 
 matter on the skin is more distinct. The membranEe pupillares have disap- 
 peared. The surface of the brain is grooved, but the convolutions are 
 shallow or rudimentary. The testicles are found in the inguinal canal or in 
 the scrotum, or the left gland is in the scrotum, while the right is found 
 about the external ring; or the clitoris can be seen through the open vulva. 
 The foe,tii.!i of nine calendar months, i.e., of maturifj/, has an average 
 weight of seven pounds avoirdupois, and an average length of nineteen 
 inches. The breadth across the shoulders is five inches; across the hips, 
 three. The male infant is usually rather longer and heavier than the female.^ 
 Great deviations in weight and length are sometimes met with. The heaviest 
 child I have noted in the register of my own practice was a male, and weighed 
 twelve pounds four ounces; labor set in at the expected time, at the end of 
 the ninth calendar month; and delivery of the head was accomplished by the 
 natural efforts alone, though there was so much difficulty with the shoulders, 
 that the infant died during the birth. Dr. John Ramsbothaui has delivered a 
 woman of a child weighing sixteen and a half pounds.'^ Dr. Bloxam, with Mr. 
 Owens, had a case of difficult delivery, in which the child weighed seventeen 
 pounds twelve ounces, while its length was twenty-four inches.^ Dr. AV. P. 
 Johnson, of the National Medical College, Washington, delivered a patient, 38 
 years of age, of her fourteenth child, on the JJGth November, 1848. The in- 
 fant, a male, weighed twenty pounds; was 25| inches long, 8 J inches broad 
 across the shoulders, and 7t inches across the hips. The placetita weighed 3 
 pounds. The child was alive when the head escaped, but death occurred 
 before delivery was completed, owing to the pressure on the cord from the 
 difficulty experienced in getting the shoulders and breech into the world* 
 Dr. Waller relates an instance where he effected delivery by the long forceps, 
 after the woman had been thirty-six hours in labor, of a male infant which 
 weighed fifteen pounds fifteen ounces, and the circumference of whose head, 
 measured at the orbital processes, was sixteen and a quarter inches.^ Dr. 
 Meadows has met with an instance in which a male child weighed eighteen 
 pounds three ounces, and was thirty-two inches long. The infant presented 
 by the breech, and lived for five hours after its birth. ^ While lastly, Mr. 
 
 1 Tliis difference in weight and lieiglit between the two sexes continues — except for 
 three or four years — during life. The following table, drawn up by jM. Quetelet, well 
 shows the comparative weights of the two sexes : 
 
 lb. avoir. lb. avoir. 
 
 At birth the male weighs, . . 7.05 The female weighs, . . 6.41 
 
 At one year of age, .... 20 «4 " " . . 1 '.).:<8 
 
 At five years of age, .... 34.78 " " . . 31. (i7 
 
 At twelve years of age, . . . 65.76 " " . . 65 76 
 
 At fifteen years of age, . . . 8^.69 " " . . 89 03 
 
 At thirty years of age, . . . 140.37 •" " . . 121.80 
 
 And so on, in a corresponding ratio, up to the age of ninety. This exhibits also the 
 effect of the earlier accession of puberty in (he female, giving her the advantage between 
 the ages of twelve and fifteen. 
 
 2 Practical Observations in Midwifery. Second Edition, p. 174. London, 1842. 
 
 3 Lancet, p. 477, J'id December, 1838. The sex of the child is not mentioneil in the 
 report; but Dr. Bloxiun inlbrnied ine that he believed it was a male. 
 
 * The American Journal of Medical Sciences. New Series, vol. xxi, p. 340. Phila- 
 delpliia, 1851. 
 
 ^ Transactions of the Obstetrical Society of London, vol. i, p. 310. London, 1860. 
 6 Medical Times and GazeUe, p. 105, 4th August, 1800.
 
 DETERMINATION OF AGE OF F(ETUS. 227 
 
 Davies of Pershore, delivered a woman safely with the forceps, after a linger- 
 ing labor lasting six days, of a live child weighitig nineteen pounds two 
 ounces ^ On the other hand, souie children burn alive at the full time, have 
 been known to weigh less than five pounds. In a twin pregnancy the 
 weight of each individual foetus is less than that of a foetus not a twin, 
 though tiie combined weight is greater. Dr. Clarke found that the average 
 of twelve twins was eleven pounds avoirdupois each pair; the heaviest couple 
 being thirteen pounds, and the lightest eight pounds and a half. 
 
 The head of the mature child is large and well covered with fine hair; the 
 great fontanelle is about three-quarters of an inch in length; the features 
 are perfect; and the limbs plump and firm. The skin is of a clear red color, 
 firm and ten.se ; while it is usually thickly covered with vernix caseosa, which 
 consists of desquumated cells of epiderniis and fatty matter. The scrotum 
 is corrugated : or the vulva is closed by the apposition of the labia niajora, 
 and there is a hymen. The nails reach to the ends of the fingers, but not 
 to the extremities of the toes. The surface of the brain presents convolu- 
 tions, though the organ is pulpy, and the diff'erence between the white and 
 gray matter is not very distinct. Ossification has also advanced considerably 
 throughout the whole skeleton; and the muscles, nerves, &c., are firm and 
 well developed. The placenta at maturity weighs from eighteen to twenty- 
 four ounces, the average being one pound five ounces avoirdupois ; while it is 
 commonly some eight inches in diameter, and one inch in thickness at its 
 centre. Cases are recorded by Wrisberg and Stein, where this organ has 
 been so greatly hypertrophied as to weigh in one instance three pounds, and 
 in another six. The average length of the umbilical cord is now about 
 twenty inches, though it has been found as short as four, or even shorter; 
 while Baudtilocque has seen it measure fifty-seven inches, Gardien refers to 
 an instance where it was five feet, and I)r G. Thomson, of Boston, U. S., 
 once found it to be five feet nine inches. The greater the quantity of gelat- 
 inous matter in the interspaces of its fibrous tissue, the thicker will the cord 
 be. The funis has been found attached to other parts of the body besides 
 the umbilicus : Meckel says he saw a preparation in the Anatomical Museum 
 at Brussels where it arose from the head of the foetus. It may also be found 
 knotted in one or more places, and coiled round the foetal body; or so tightly 
 wound round one of the extremities as to cause atrophy, or perhaps even am- 
 putation of the limb. 
 
 The new and painful sensations experienced by the child on passing into 
 the world from the warm body of the mother, cause it to make certain etl'orts, 
 which end in inspiration and crying. The lungs thus become thoroughly 
 inflated, and the circulation of the blood through the pulmonary vessels su- 
 persedes the use of the foramen ovale and ductus arteriosus. So also, the 
 blood from the lower extremities being unable to force its way along the 
 umbilical arteries, passes through the ascending vena cava into the right 
 auricle and ventricle, and so into the lungs, to be purified and redistributed. 
 By degrees the foramen ovale closes ; the ductus arteriosus, ductus venosus, 
 and umbilical arteries are obliterated; and the normal circulation is perma- 
 nently established. 
 
 * Medical Times and Gazette, p. 249, 8th September, 1S60. The child's sex is not 
 mentioned in this report; but by a note from Mr. Davies I learn that it' was a male. 
 The patient thought she had gone a little over her time, tliough nothing exact can be 
 gathered from her statements.
 
 228 THE PREMATURE EXPULSION OF THE FCETUS. . 
 
 Granting that an infant — as a general rule — is not destined to 
 reach maturity before the end of nine calendar months, the 
 question has sometimes been raised as to the shortest period at 
 which a perfect, full-grown infant may possibly be born. Leuret 
 and a few other writers have maintained that infants occasionally 
 reach maturity of development as early as the end of the seventh 
 month ; but I know of no experienced modern author who in any 
 way supports this opinion. Were it true, it might not unreason- 
 ably be supposed that a child so prematurely developed could by 
 accident be sometimes brought into the world at the fifth calen- 
 dar month; and it ought then to have an equal chance of life 
 with an ordinary seven months' infant. But is there any prac- 
 titioner living who has ever met witli an instance where a foetus 
 born at the fifth month has been reared ? It is true that the fol- 
 lowing case has been recorded by Professor John W. Francis, of 
 New York; but it is far from satisfactory, inasmuch as the scien- 
 tific reasons for believing the age of the foetus to be only twenty- 
 three weeks are not given. The particulars are these : 
 
 Mrs. B. was delivered, after protracted snfFerings, of a dead male child. 
 Twenty months afterwards, in the year 1832, she aborted. By one powerful 
 effort the entire ovum was expelled. Mr. Francis fortunately arrived at this 
 crisis, and had the whole mass immersed in a vessel of tepid water, while he 
 attended to the mother. On afterwards rupturing the membranes, he per- 
 ceived a foetus, " apparently of souie five months and upwards of tirowth. 
 The curd was divided, and more than usual care taken with the child; a 
 fillet or ribbon was applied round its head, which seemed unusually large, and 
 the body wrapped in cotton. By unremitting attention on the part of a com- 
 petent nurse, the fondest wishes of the parents were ultimately realized; 
 and the daughter, in the enjoyment of excellent health, has at the present 
 writing completed her seventh year. Subset|uent inquiry with the parents 
 concerned, made the age of this premature offspring at birth a ftjetus of the 
 twenty-third week of pregnancy."^ 
 
 I^otwithstanding this history, I believe if we allow that thirty- 
 five weeks, or 245 days, is a period at which maturity of devel- 
 opment may be reached, we shall be making a statement diflicult 
 of proof. But I entertain no doubt that mature infants have 
 been born at 259 days, or thirty-seven weeks. There is, indeed, 
 no sound reason why some few foetuses should not grow at a 
 greater rate than others. And just as the time of utero-gesta- 
 
 1 A Treatise on the Diseases of Infants. By C. M. Billard. Translated from the 
 tliird French Edition by Dr. James Stewart. A|)[)endix. p. 612. London, ItJo'J.
 
 CAUSES OF ABORTION. 229 
 
 tion may sometimes be prolonged perhaps to allow of increased 
 foetal development, so doubtless it can occasionally be shortened 
 when maturity has been reached in a rather shorter time than 
 ordinarily. 
 
 Morgagni and Desormeaux entertained the opinion that abor- 
 tions with female foetuses were more common than with males. 
 If this were so, it could only be because the boys born at the 
 full term exceed the girls in number. I can quote no fact, how- 
 ever, in support of the observation ; and I do not think, from 
 my own experience, that it is true. 
 
 2. The Causes of Abortion. — These are very numerous. By 
 one author or another, almost every action of daily life has been 
 said to be likely to induce it. Hence it is better for the sake of 
 clearness to resort to some classification, arbitrary though such 
 may be. Some writers treat of the predisposing or exciting, 
 and the immediate causes ; but there are many objections to 
 this subdivision. Others speak of the causes which act indi- 
 rectly by destroying the foetus, and such as have a direct in- 
 fluence by inducing uterine contractions. As the most simple 
 plan, it seems useful to consider the causes under four heads, 
 viz. : (1) As they are accidental. (2) As they are due to some 
 deranged state of the mother's health. (3) As they can be 
 traced to some morbid condition of the uterus or its append- 
 ages. And (4) as they arise from disease of the embryo or its 
 membranes. 
 
 (1) The Accidental Causes. — The most common of these are 
 violent mental emotion, sudden agitation from fright, great 
 bodily fatigue coupled with mental anxiety, and severe pain. 
 Then we find abortion resulting sometimes from the effect of 
 hysteric convulsions, from immoderate laughter, from the 
 straining produced by dysentery and diarrhoea, and from blows 
 and falls ; as well as from occurrences generally which suddenly 
 disturb the equilibrium of the circulation, or strongly affect the 
 nervous system, or have a direct tendency to separate the ovum 
 from its uterine connections. Although the uterus is suspended 
 in the maternal pelvis in the way best calculated to prevent its 
 being aftected by sudden shocks, yet the connection of the thin 
 and fibrous decidua — this tissue having lost the spongy characters 
 it presented before impregnation — with the uterine walls is so 
 fragile, that slight accidents will sometimes effect a partial sepa-
 
 230 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 ration and give rise to the effusion of blood. Should the clot be 
 large, its presence between the uterus and decidua must interfere 
 with the nutrition of the ovum ; and hence will soon lead to the 
 death of the foetus and abortion. 
 
 The uterus being in reflex relation with many important 
 organs, it can readily be understood that diseases of the latter 
 are not unlikely to induce uterine contractions. Dr. Tyler Smith 
 has shown that irritation of the mammary nerves may be a cause 
 of the latter; as when abortion occurs during lactation, from the 
 excitation produced by constant suckling. Acting on this prin- 
 ciple, Scanzoni has recommended the induction of premature 
 labor to be effected by the application of an exhausting appa- 
 ratus to the breasts. So again, irritation of the gastric nerves 
 must be cited as a cause of abortion; though it is often astonish- 
 ing to what an extent — even to such a degree as to cause death 
 — nausea and vomiting may proceed without exciting the uterus 
 to expel its contents. Indeed, some authors go so far as to say 
 that a sick pregnancy never ends prematurely ; but for the word 
 "never" it is better to substitute "rarely." Then we must men- 
 tion irritation of the trifacial nerve produced by cutting one of 
 the late molars, or by the extraction of a tooth ; irritation of the 
 renal nerves from gravel, or the employment of cantharides; 
 irritation of the bladder from a calculus, or of the ovaries from 
 congestion and inflammation; and excitement of the nerves of 
 the rectum from hemorrhoids, ascarides, or the injudicious use 
 of such drastic purgatives as aloes and gamboge and senna, &c. 
 Lastly, irritation of the vagina and uterus will occasionally excite 
 abortion : whether the irritation be due to the violent jolting of 
 horse exercise, riding over rough roads, railway travelling, danc- 
 ing, &c. ; or to excessive sexual intercourse, the employment of 
 a vaginal plug or pessary, the growtli of malignant or non-ma- 
 lignant tumors from the cervix, or the implantation of the pla- 
 centa over the os — placenta prsevia : or to the administration of 
 certain drugs which act specially on the uterine organs, such as 
 ergot of rye, savin, certain preparations of iron, rue, iodine, 
 iodide of potassium, iodide of mercury, cinnamon, borax, &c. 
 
 It is very remarkable to what an amount of injury, from me- 
 chanical causes, the body may be subjected without disturbing 
 the functions of the uterus. Thus ISIauriceau relates, in astonish- 
 ment, the history of a woman, advanced to the seventh month
 
 ACCIDENTAL CAUSES OF ABORTION. 231 
 
 of pregnancy, who fell from a window on the third floor, broke 
 her arm, had great pain and distress from a dislocation, and was 
 severely bruised ; and yet gestation continued to the fall period, 
 at the completion of which she was delivered of a healthy child. 
 In the present day, almost every hospital surgeon has seen the 
 most frightful injuries recovered from during pregnancy, without 
 causing premature expulsion of the foetus. "Women have suffered 
 from fracture of the skull, extensive abdominal wounds, falls 
 from horses, &;c. ; they have nearly killed themselves, uninten- 
 tionally or otherwise, with violent poisons, or with powerful 
 drugs supposed to act specifically upon the uterus ; they have 
 undergone all the horrors of shipwreck, with immersion in the 
 water for very many hours ; and yet a few weeks afterwards have 
 been delivered of healthy mature children, without more suffer- 
 ing than usual. 
 
 Under this head must also be included those cases in which 
 abortion or premature labor is voluntarily excited; either for 
 criminal purposes by some knave, or for some good end by the 
 physician. The appliances adopted by the former for committing 
 intra-uterine murder very frequently endanger the life of the 
 pregnant woman, and sometimes destroy it altogether; while 
 those skilfully employed by the latter, at the call of duty, are not 
 uncommonly the means of saving two lives. It is, however, 
 unnecessar}^ to mention here the different methods which can be 
 employed for causing the premature expulsion of the foetus, with 
 comparative safety to the mother; since the object of this chapter 
 is to show how abortion may be prevented, not how it should be 
 provoked. 
 
 (2) Causes due to a Deranged State of the Mother s Health. — It 
 is generally believed that women of a nervous and irritable tem- 
 perament, who may be prone to great excitement from slight 
 impressions, are more liable to abort than such of their sex as 
 are favored with more equable temperaments. So again, plethoric 
 females, who have the catamenial flow unusually abundant, are 
 likely to miscarry frequently. Women who reside in bleak 
 mountainous countries are said to have tlieir health so aflected 
 that they frequently suffer from repeated miscarriages ; those 
 inhabiting the summit of the Yosges in the northeastern district 
 of France being so subject to abortion, that — according to Sauce-
 
 232 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 rotte — they are in the constant habit of descending into the ad- 
 jacent plains to avoid this accident. 
 
 Acute thoracic and abdominal diseases occurring during the 
 progress of utero-gestation, have a tendency to interrupt it. So 
 likewise epileptic and especially ursemic convulsions have a sim- 
 ilar influence. Pregnant women attacked with measles, scarlatina, 
 erysipelas, and typhus or typhoid fever, &c., very frequently abort 
 during the progress of the disorder; either from the direct effect 
 upon the maternal system, or from the foetus becoming affected 
 with the disease. The occurrence of small-pox during pregnancy 
 is almost certain to produce abortion or premature labor; while 
 in all probability the foetus will be found covered with the erup- 
 tion.^ In chronic pulmonary, cardiac, renal, and liver affections, 
 pregnancy often progresses uninterruptedly until an advanced 
 period. It is especially interesting to notice the fact pointed out 
 by Dr. Montgomery, that when a pregnant woman labors under 
 an organic disease which is to end fatally before the natural com- 
 pletion of her gestation, it almost invariably happens that partu- 
 rition is delayed until the child has acquired such a degree of 
 development as to be capable of living when born ; labor being 
 established, and delivery safely accomplished, a day or two before 
 the mother's death. 
 
 I have seen a few cases which appear to prove, that certain 
 cutaneous diseases may occasionally act as the provokers of 
 uterine contractions. A remarkable instance, in which abortion 
 was induced in eight successive pregnancies by the irritation of 
 excessive itching of the skin, has been reported by M. Maslieurat. 
 The details abbreviated are these : 
 
 A lady thirty-two years of a<>;e, became pregnant for the first time when 
 twenty-one years old. She suflFered but little from the disorders incidental 
 to her condition, until the sixth month; when, without any apparent cause, 
 she was seized with intense pruritus of the whole surface of the body. The 
 legs, thighs, and genital organs were first attacked; but towards the eighth 
 month the itching extended even to the palms of the hands and the soles of 
 the feet. The rubbing and scratching which she was compelled to have re- 
 course to caused premature labor; immediately after which the cutaneous 
 
 ^ Although there is a marked difference between some of the symptoms presented by 
 sm;ill-|)ox in the liuman subject as compared with ovine variola, yet in not a few points 
 there may be found a curious accordance. The parallelism is especially seen in the 
 case of the pregnant ewe. For not only is she very apt to abort when under the influ- 
 ence of the small-pox poison, but the dropped lamb is also commonly covered with vario- 
 lous pustules.
 
 CAUSES DUE TO HEALTH OF MOTHER. 233 
 
 irritation ceased. The patient a,e;ain became pregnant; and, as before, ailed 
 nothing till the sixth month. Then the itching again returned, and con- 
 tinued until she miscarried at seven months. The same series of events re- 
 curred for six times ; making in all eight premature labors due to excessive 
 pruritus.^ 
 
 During the early months of pregnancy women are apt to suffer 
 from obstinate constipation, accompanied with tenderness and 
 flatulent distension of the abdomen. Very frequently, during 
 the iburth month, the pressure of the enlarged uterus upon the 
 pelvic viscera gives rise to a mechanical impediment to the 
 evacuation of the bowels; and hence a daily increasing accu- 
 mulation of fecal matter takes place in the descending portion 
 of the colon. The more liquid parts of the collection tlius 
 formed pass away ; a dry indurated mass, often of great size, 
 being left. In many cases, a channel gets formed through the 
 centre of this mass; and as fluid excrement mixed with mucus 
 passes down tins, and is evacuated in small quantities, at short 
 intervals, the patient fancies and alleges that she suffers froni 
 diarrhoea. A proper investigation of the history and symptoms, 
 together with a manual examination, will, however, enable the 
 practitioner to dispel the delusion ; for if a hard and lobulated 
 and slightly movable tumor, tender on pressure, cannot be felt 
 about the left inguinal region, still an exploration per rectum 
 will detect the hardened fseces blocking up the passage. The 
 congestion of the pelvic viscera produced by the pressure of the 
 accumulation ; the distressing tenesmus, and the violent strain- 
 ing employed to pass the substance ; together with the nervous 
 excitement, the vitiation of the secretions generally, and the 
 impediment to the free circulation of the blood in the uterine 
 organs, may very often produce abortion. A poor woman at- 
 tended by me under circumstances similar to those just detailed, 
 aborted at the end of the fourth calendar month ; and very 
 nearly lost her life from the extreme difficulty which was ex- 
 perienced in controlling the profuse hemorrhage that ensued. 
 The hardened faeces, which were subsequently removed from 
 the rectum by the use of enemata and a scoop, were at least 
 sufl&cient in quantity to fill a quart measure. 
 
 The effects of chronic lead poisoning seem to be especially un- 
 favorable to foetal life. Whether the system of the mother or of 
 
 1 Gazette Medicale tie Paris, 15tli March, 1848.
 
 234 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 the father be tainted with this pernicious metal, tlie pregnancy 
 is very apt to terminate before the close of the sixth month ; the 
 labor being often accompanied with severe hemorrhage. Even 
 when premature delivery does not take place, there is consider- 
 able fear of the child being born dead, or with such a feeble 
 constitution that it can only be reared with great difficulty. 
 
 But of all the causes of abortion arising from an abnormal 
 condition of the mother's health, I am inclined to think that 
 constitutional syphilis is one of the most common. There is 
 every reason to believe, that the blood of persons which has 
 once been contaminated by the poison of syphilis may be in a 
 depraved condition, even though there are no external signs 
 manifested by the individual. The precise nature of the abnor- 
 mal taint has not as yet been determined by any of the micro- 
 scopical or chemical examinations which have been made ; and 
 hence we can only judge of it from the effects produced at some 
 later period either on the victim herself, or on her offspring. 
 Females who once suffer from abortion arc liable to abort again, 
 and at about the same period of utero-gestation. These subse- 
 quent abortions are then said to be due to the habit which has 
 been acquired of aborting. Without absolutely denying that 
 this may sometimes be the correct explanation, yet I am con- 
 vinced that it is not often so. Certainly, most of the cases of 
 so-called abortion from habit which have come under my notice, 
 have really been instances of miscarriage from constitutional 
 syphilis; and they have only clearly proved that so long as the 
 cause remains, the same effects will be reproduced again and 
 again. 
 
 There are three principal modes in which a woman can become 
 infected with the venereal poison. The most obvious of these is 
 by contracting a primary sore. The ulcer may have its seat on 
 either of the labia majora, or on the nymphpe ; or it may attack 
 any part of the vaginal walls ; or it may be situated on the cervix 
 uteri, although this part is very rarely affected. A primary 
 syphilitic sore contracted during pregnancy is not necessarily 
 fatal to the foetus in utero ; but if a mercurial course of treatment 
 be neglected, the child is almost certain to perish and to be prema- 
 turely expelled. Some authors have thought that the adminis- 
 tration of mercury to a pregnant woman is calculated to produce 
 abortion : but I know of no observations which will bear a criti-
 
 EFFECTS OF THE SYPHILITIC POISON. ZoO 
 
 cal analysis in support of their views, notwithstanding that the 
 error has every now and then found advocates since it was origi- 
 nated hy De Blegny in 1673.^ In my opinion it is an important 
 fact which cannot be too strongly impressed on the practitioner, 
 that it is the syphihtic poison which causes the abortion, and not 
 the mercury. In the first edition of this volume I stated, that 
 out of thirty-seven women by whom I had been consulted, who 
 had contracted primary sores at some more or less remote period, 
 and who had been treated in different ways by other physicians, 
 twenty-three subsequently either aborted once or oftener, or 
 were prematurely delivered of dead children. Of the remaining 
 fourteen, one was delivered three times in succession, at the full 
 period, of dead children : seven gave birth to live children who 
 were afterwards affected with constitutional syphilis: five were 
 delivered of healthy children, who were apparently of sound 
 constitution wdien six months old: and one was delivered of a 
 dead child, by means of the forceps, after a tedious labor. Were 
 it necessary I might now add several cases to the foregoing, cor- 
 roborative of the inference which has been drawn as to the mis- 
 chievous effects of the syphilitic poison. But surely no advantage 
 can result from the multiplication of proofs of the truth of what 
 only a few will be found to dispute. 
 
 Another way in which it is highly probable that a woman may 
 receive the venereal taint is by direct secondary inoculation; the 
 individual contaminating her having been apparently cured of 
 the primary disease, or perhaps even having been himself only 
 infected by a person with secondary symptoms. Although this 
 method of contagion is denied by many authors, yet I have had 
 some few cases under my care which could only be explained by 
 admitting the truth of this hypothesis : unless indeed the pa- 
 tients practised very great and unnecessary deceit. Dr. White- 
 head may be cited as a believer in this theory ; and from his 
 waitings the following graphic illustration is quoted : 
 
 1 " Ydii are further to observe, that sometimes it happens, that some urgent occa- 
 sions oblige Women to be cured while they are with Child, a circumstance which renders 
 the cure very dangerous. But, w hen tliis happens, you must take care to treat them 
 with all possible gentleness, and make choice of that time when they are pretty far 
 gone. For a Foetus is too weak to endure the commotions caus'd by Mercury and other 
 Kennedies: Besides, that it runs the greatest Eisk of being render'd abortive." The Art 
 of Curing Venereal Diseases, explained by Natural and Mechanical Principles By 
 Nicholas de Blegny, Chirurgeon to the French king. Done into English from the last 
 edition of the French, by J. H., M.D., p. 286. London, 1707.
 
 236 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 " A young wife, in her twenty-fifth year, having been married upwards of 
 four years, came under my notice in September, 1850, complaining of de- 
 ranged general health. She had had five pregnancies, of which the first 
 ended at seven and a half months, the second at three months, the third at 
 seven and a half, the fourth at eight and a half, the fifth at eight and a 
 quarter months, all stillborn and in a state of decay. She was a member of 
 a robust, unailing family, and had never been out of health, to her knowl- 
 edge, before marriage ; but since, had constantly had yellow leucorrhoea, 
 painful menstruation, with all the sympathetic disturbances usually attendant 
 thereon. The whole body of the uterus, and especially its lower section, 
 was enlarged and painful under pressure; the circle around the orifice was a 
 suppurating surface extending apparently within the cervix; and external to 
 this, which was bounded by a defined margin, the cervix was irregularly 
 patched with aphthae. These appearances led me to suspect that the patient 
 labored under constitutional syphilis, and in delivering the necessary instruc- 
 tions in reference to treatment, I expressed a wish to see her husband. This 
 request led her to guess at my object, and to infer also what my suspicions 
 were respecting the nature of her case, as she began voluntarily to assure me 
 that her husband possessed a strong and healthy constitution, that he be- 
 longed to a remarkably healthy family, and that, moreover, he was a man of 
 the strictest moral integrity, and could not be suspected of infidelity. The 
 husband, however, paid me a visit shortly afterwards. He had never suffered 
 from either venereal disease or gonorrhoea in the primary form. He frankly 
 confessed, however, that he had incurred the risk of infection some months he- 
 fore marriage. A few weeks after the occurrence alluded to by him, he had 
 an ulcer on the lower lip, near the right angle of the mouth : it was broad 
 and deep, and the surrounding parts were extensively inflamed, hard, and 
 painful. The sore proved refractory, and on being shown to a late eminent 
 surgeon, Mr. R. Thorpe, it was pronounced venereal, and was prescribed for 
 accordingly. When presented to my inspection, the peculiar aspect of the cica- 
 trix, with its adjoining brown, wavy margin, together with a suspicious-looking 
 scaly tubercle on the outside of the left commissure, with the assurance also 
 that he had been frequently troubled with spots of that kind during several 
 years past, induced me, unknowing at the time all the preceding details, to 
 say that it looked extremely like the remains of an old venereal sore. The 
 patient's medical attendant, dissatisfied with my opinion, took him to one 
 deservedly celebrated for his knowledge in these complaints, who likewise 
 pronounced it the remains of a venereal sore. In this case the disease, un- 
 doubtedly imbibed by secondary inoculation, and in thesameform continued, 
 had existed at least five years : its virulence was no way weakened by time, 
 as the constitution of the wife was greatly enfeebled, and the evil in her 
 seemed to be increasing daily. Both patients were several months under my 
 care ; they appear to have recovered perfectly under the anti-venereal treat- 
 ment adopted." — The wife has since borne four living children.^ 
 
 The third means by which the maternal system gets infected 
 consists in the propagation of the poison from the foetus to the 
 parent. Thus a father begets sypliilitic children, who while in 
 utero contaminate the mother. It has been clearly shown by 
 
 1 On the Transmission from Parent to Offspring, of some forms of Disease, and of 
 Morbid Taints and Tendencies. Second Edition, p. 24."}. London, 1857.
 
 EFFECTS OF THE SYPHILITIC POISON. 237 
 
 ^Ir. McGillivray, of Huntly,^ and has been proved to demonstra- 
 tion by Mr. Savory,^ that while, as all allow, a portion of tlie 
 mother's blood is continually passing by absorption (and assimi- 
 lation) into the body of the tbetus, in order to effect its nutrition 
 and development; so also a portion of the blood of the foetus 
 is as constantly passing, in like manner, into the body of the 
 mother. Thus as the foetal blood commingles with the general 
 mass of the maternal blood, it inoculates the mother's system 
 with the constitutional qualities and peculiarities of the embryo; 
 and as these qualities are in part derived by the foetus from its 
 male progenitor, the peculiarities of the latter are thereby so 
 engrafted on the system of the female, as to be communicated 
 by her to any offspring she may subsequently have even by 
 other males. Of course with each successive fecundation by the 
 impure father, the mother's health deteriorates ; for on each oc- 
 casion she receives, as it were a fresh charge of the poison from 
 the ovum, which is added to that already accumulated in her 
 system. I have recorded elsewhere a rather striking example 
 of this means of contamination. The chief points in the history 
 are briefly as follows: 
 
 In 1851, a healthy ladj was delivered of her first child : the infant wms 
 strong and heartj, has never since had any particular illness, and is now alive 
 and well. During the puerperal period, the husband contracted a sore from 
 a prostitute, for which he was profusely salivated. The ulcer quickly healed : 
 but two months afterwards secondary symptoms appeared, and mercury was 
 again freely taken. Being nervous as to the conse<juences, he did not have 
 connection with his wife tor nearly seven months from the date of his last 
 cure ; at the time of intercourse he was perfectly free from the slightest in- 
 dication of any taint. The wife then became pregnant, and was prematurely 
 delivered of a dead child. Again and again this happened, until she had 
 been delivered of five premature still-born infants. With each pregnancy 
 her mental and bodily health deteriorated in a marked degree, and at length 
 she applied to me on account of her wretched condition. Under the influence 
 of mercury she very much improved; and then becoming pregnant, was de- 
 livered at about the close of eight calendar months of a healthy-looking child. 
 At the end of a fortnight thi.s baby was attacked with all the symptoms of 
 constitutional syphilis; and though apparently cured by mercurial inunction, 
 yet it died suddenly in the mother's arms some weeks afterwards.^ 
 
 1 See a series of papers On the Fcetus in Utero, as Inoculating tlie Mnternal with the 
 Peculiarities of the Paternal Organism ; and on Mental States in either Parent, as In- 
 fluencing the Nutrition and Development of the Offspring. By Alexander Harvey, 
 M.D., Physician to the Aberdeen Royal Intirnjary. Monthly .lournal of Medical ^ciel)ce. 
 Edinburgh, October, 1849, October and November, 1850. 
 
 " An Experimental Inquiry into the Etfect upon the Mother of Poisoning the Fcetus. 
 Pamphlet. No date. 
 
 ^ The Transactions of the Obstetrical Society of London, vol. i, p. 1.32. London, 1860.
 
 238 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 When the venereal taint in the father is slight, the mother 
 may not become affected for a considerable time. In Jannarj, 
 1859, I was consulted by a ladj' about her own and her young 
 infant's health. The history given to me was this : 
 
 She was thirty-seven years of ase, and had been married three and a half 
 years. Her health had been uniformly good until two months previously, 
 while her husband was strong and hearty. She was delivered of her first 
 child in July, 1857 : it was small and thin at birth, and died of wasting and 
 an eruption about the buttocks, three months afterwards. The second child 
 was born in March, 1858 : though premature, it was then healthy, but it 
 soon became much emaciated, and died in the following July. The third 
 child was born on the 23d December, 1858 : it remained healthy for four- 
 teen days, when it began to suck with difficulty, and a scaly eruption ap- 
 peared around the anus. When brought to me on the 21st January, 1859, 
 it had all the symptoms of constitutional syphilis ; but a cure was soon effected 
 by mercurial inunction. The infint was weaned at the same time, and was 
 reared on cow's milk alone, which always agreed remarkably well with it, so 
 that by December, 1859, he was a tine and well-grown child. The mother 
 was pale and thin; she complained chiefly of languor, loss of appetite, great 
 restlessness at night, and of an abundant yellow leucorrhceal discharge. The 
 cervix uteri was found hypertrophied and tender, while the labia were in- 
 durated and marked with patches of aphthous excoriation. The treatment 
 was nut commenced for some weeks, owing to objections on the part of the 
 husband; but ultimately it consisted in the prolonged administration of the 
 solution of perchluride of mercury, and the "occasional application of the 
 nitrate of silver to the excoriated surf;ice of the lips of the uterus. Although 
 she was thus cured, still it was feared that the relief would not be permanent; 
 inasmuch as the husband believed himself to be in sound health, and there- 
 fore reiused to undergo any treatment. 
 
 The sub.sefiuent progress of this case bore out the foregoing unfavorable 
 prognosis. On the 21st April, 1860, I delivered Mrs. H. of her fourth 
 child. On the 1st May, the infant exhibited the usual proofs of contami- 
 nated blood. The little creature had " the snuffles;" there was an erythema- 
 tous eruption around the anus, and on the buttocks; the skin was harsh and 
 dry; and the breast was refused. By treating the child with mercurial 
 ointment applied over the abdomen, and by getting it suckled by a healthy 
 woman, a cure was eflfected. The mother, 1 believe, has not since been 
 pregnant. 
 
 (3) A Morbid Condition of the Uterus or its Ajjpendages the cause 
 of Abortion. — The ovum and the uterus being developed simul- 
 taneously by forces peculiar to each, any inequality in the growth 
 of the two must be mischievous to the former. 
 
 The existence of old inflammatory adhesions between the 
 uterus or its appendages and the other pelvic viscera is often a 
 cause of persistent sterility by producing some uterine or ovarian 
 displacement. But when pregnancy occurs, perhaps long alter
 
 UTERINE DISEASE AS A CAUSE. 239 
 
 an attack of inflammation of the pelvic serous membrane has 
 been cured, it is not unlikely to terminate prematurely. If the 
 peritoneal adhesions be slight, they may perhaps get ruptured 
 as the uterus enlarges; the patient will sufl'er from severe hypo- 
 gastric pains, especially during the second and third months, 
 and there is sure to be very troublesome sickness. These dan- 
 gers surmounted, however, the course of gestation will proceed 
 favorably after the uterus has risen out of the pelvis. It is only 
 in those instances where the adhesions are firm, or where the 
 uterus is immovably fixed, that abortion is to be feared ; the ad- 
 hesions preventing the development of the pregnant uterus be- 
 yond a limited point. In such cases the miscarriage often takes 
 place about the end of the second, or some time during the third 
 month. The expulsion of the embryo is preceded frequently 
 by copious hemorrhage ; while it is apt to be folloAved by acute 
 metritis, or renewed pelvi-peritonitis, or pelvic cellulitis. The 
 inflammation thus lighted up seldom ends fatally ; although the 
 symptoms are alarming at the time, and often enfeeble the sys- 
 tem considerably. When the constitution is bad, an abortion 
 with these complications is liable to be followed by months of 
 bad health, which may even terminate in phthisis. 
 
 There are many reasons for believing that an excessive rigidity 
 or an unusual sensibility of the uterine fibres, may prevent ges- 
 tation progressing to the full term ; these causes being most likely 
 to have this untoward effect in primiparse. Congestions and 
 acute inflammatory diseases of the uterus or ovaries may also 
 cause the death of the foetal germ soon after conception ; and so 
 perhaps will inflammation and ulceration of the mucous mem- 
 brane covering the cervix uteri, or of that lining the cervical 
 canal. Ulcerative lesions of the uterine neck, whether simple 
 or specific, are sometimes a cause of sterility; but when they do 
 not prevent conception, the ulcerations are apt to be rendered 
 more severe and irritable by pregnancy. In about one-third of 
 the cases of cancer of the uterus the child dies and is prema- 
 turely expelled at the sixth or seventh month. When the abor- 
 tion is due to chronic inflammatory induration and hypertrophy 
 of the cervix, the expulsion of the ovum is generally preceded 
 by very copious and intractable hemorrhage ; owing to the diffi- 
 culty with which the thickened os uteri dilates to allow the ovum 
 to pass.
 
 240 THE PREMATURE EXPULSION OF THE F(ETUS. 
 
 Retroversion of the uterus sometimes occasions abortion ; 
 owing to the great congestion of the uterine veins, as well as of 
 all the neighboring viscera, which results from the pressure of 
 the organ on the unyielding walls of the pelvic cavity. This 
 displacement is very likely to happen prior to the timeof quick- 
 e'ling from the straining exerted to expel hardened f?eces, espe- 
 cially if any great accumulation has been allowed to take place. 
 The mass in its descent is violently impelled against the fundus 
 of the uterus, thus forcing this part into the hollow of the sacrum ; 
 while the lower part of the body and "cervix is tilted up directly 
 under the arch of the pubes. When the accident occurs sud- 
 denly, the patient experiences great pain from her immediate 
 inability to void urine owing to the pressure of the womb upon 
 the neck of the bladder ; but if the change in position be more 
 gradual the bladder can be partially emptied, and the inconveni- 
 ence from the retention is much less urgent. Unless the uterus 
 be replaced, however, and the bladder relieved by the catheter, 
 inflammation and sloughing and ursemia are very likely to ensue, 
 and to end fatally. 
 
 Prolapsus of the uterus, by impeding the circulation of the 
 blood through the pelvis, and irritating the rectum and bladder, 
 may give rise to venous congestion of the uterine walls, the effu- 
 sion of serum, and the consequent separation and expulsion of 
 the ovum. So also fibroid tumors of the uterus, by opposing the 
 due development of this organ, have caused abortion ; and large 
 abdominal growths of every kind have had a like eft'ect. And 
 lastly, all chronic diseases of the uterine appendages which can, 
 either directly or indirectly, induce irritability of the muscular 
 fibres of the uterus, or impede their free growth, may prema- 
 turely determine the arrest of gestation. Hence ovarian tumors, 
 dropsy of the Fallopian tubes, follicular ulceration of the vagina, 
 gonorrhoea, &c., may act as causes of abortion. 
 
 (4) Disease of the Ftvtus and Placenta the cause of Abortion. — 
 It is now a recognized fact, that the foetus is liable to almost 
 every form of disease which may attack the new-born child; and 
 it is remarkable that many of these morbid states, as well as such 
 as invade the placenta, are apt to recur in the same woman in 
 successive pregnancies. These affections, though not necessarily 
 fatal to the foetus, are always more disastrous in proportion to the 
 early period of gestation at which they occur. Whatever cir-
 
 FCETAL DISEASE AS A CAUSE. 241 
 
 cumstance causes the death of the ovum, will almost inevitably 
 produce abortion ; although the latter very seldom takes place 
 immediately upon the supervention of the former. When dis- 
 ease ends fatally at an early period of foetal life, it may either do 
 so without leaving any anatomical changes by which its nature 
 can be recognized, or the process of putrefaction will perhaps 
 have masked the morbid appearance ; and even at a later period 
 the immediate efiect will possibly have been such upon the whole 
 organism, that there has not been sufficient time for any appre- 
 ciable circumscribed lesion to take place. During the early 
 months of intra-uterine life, the liver and intestines sufter most 
 frequently from disease : at a later period, hydrocephalus, hydro- 
 thorax, pulmonary lesions, peritonitis, ascites, syphilitic eruptions, 
 and strumous deposits, are the prevalent affections; whilst during 
 the last two months of gestation there is scarcely a disorder with 
 which the unborn infant may not be afflicted. 
 
 Hereditary diseases can be transmitted by the father or by the 
 mother. With regard to the father, it was formerly doubted if 
 his disorders were communicable to the offspring ; but repeated 
 observations have decided this question in the affirmative A 
 vitiated spermatic fluid, such as that derived from a man whose 
 health has been broken down by a long course of dissipation ; or 
 a secretion corrupted by a syphilitic, or strumous, or tuberculous 
 taint, undoubtedly communicates a morbid principle to the new 
 being, which is almost sure, sooner or later, to destroy it. Many 
 physicians have also thought that intoxication, great fatigue, or 
 mental depression at the time of coition, have a very injurious 
 effect on the physical development of the emljryo. — The maternal 
 diseases which may affect the child in utero are very numerous. 
 The most remarkable of these are typhus and typhoid fever; the 
 exanthemata ; phthisis and scrofula ; syphilis, &c. When the 
 mother suffers from cholera, the fcetus seldom escapes ; but 
 whether the latter dies from the direct influence of the epidemic, 
 or from the pressure exerted on the uterus by the cramps and 
 contractions of the abdominal muscles, or from the nutritious 
 materials afforded by the mother becoming dried up in conse- 
 quence of the excessive evacuation, is uncertain. The mother 
 and foetus sometimes suffer contemporaneously from variola ; or 
 the former may experience an attack of modified, while the 
 latter has natural small-pox. The foetus may also recover from 
 
 16
 
 242 THE PREMATURE EXPULSION OF THE FffiTUS. 
 
 the disease, and be born with the pits alone remaining. In other 
 cases, the body of the mother seems but to serve as the conductor 
 of the morbid agent, slie herself being unaffected by it. Thus 
 women who have been years before affected with small-pox, or 
 been well vaccinated, have — shortly after exposure to contagion 
 — given birth to infents marked with variolous pustules ; the 
 maternal system having remained quite healthy. Dr. Jenner 
 has recorded many cases of this kind. So, again, a few writers 
 have asserted that during the prevalence of cholera, infants in 
 utero have perished from its influence,-without the mothers being 
 attacked at all ; and though the proofs brought forward to sup- 
 port this opinion are not very convincing, yet the observation is 
 not to be rashly rejected. Numerous examples of congenital 
 measles and scarlet fever are recorded ; while two or three writers 
 have described instances in which the poison of malaria has 
 reached tlie fcetus and given rise to intra-uterine ague. In one 
 striking case, the foetal rigors were perceptible both to the mother 
 and others during the fit ; but it was remarkable that the periodic 
 attacks of shivering did not occur at the same time as those of 
 the mother, who also labored under the disease. 
 
 One of the most fatal of foetal diseases, without any doubt, is 
 syphilis. The observations already made upon this head render 
 further comment almost needless. Still it may be said that the 
 following are the chief morbid appearances found after birth in 
 these cases : A copper colored cutaneous eruption, generally most 
 marked about the perineum, or upon the palms of the hands and 
 soles of the feet ; abscesses in the lungs, or indurations of portions 
 of the pulmonary tissue; diffused or circumscribed suppuration 
 of the thymus gland ; the infiltration of an albuminous fluid into 
 the parenchyma of the liver, disconnecting and deranging its 
 proper secreting structure ; and lastly, the presence of numerous 
 pemphigoid vesicles, having a blue or violet tinge, and being 
 seated on the palmar or plantar regions, is stated to be a veritable 
 indication of syphilis, though one of its most rare phenomena. 
 
 The various serous membranes of the foetus would appear to 
 be particularly susceptible to attacks of acute iufiammation ; 
 which attacks very frequently terminate fatally. Pleurisy, peri- 
 carditis, and acute or chronic inflammation of the arachnoid 
 leading to hydrocephalus, are not uncommon diseases of intra- 
 uterine life. But the peritoneum seems to be the membrane
 
 FCETAL DISEASE AS A CAUSE. 243 
 
 most frequently affected ; and in stillborn infants, expelled prem- 
 aturely, we can often detect evidences of the severity of the 
 inflammatory action in the patches of coagulable lymph, the ad- 
 hesions between the convolutions of the intestines, the effusion 
 of serum or pus, or the marks of ulceration, to either or all of 
 which it may have given rise. Very rarely, morbid appearances 
 are found indicating that pleurisy and peritonitis have both been 
 present; or the latter may have existed with pericarditis, or with 
 hepatitis, or with pneumonia, or with ascites. The inflammatory 
 process may have been confined to one or more spots of the peri- 
 toneum, or the whole surface of this membrane may have been 
 invaded; it is also remarkable that in most of these cases the 
 mesenteric glands are found liypertrophied, though free from any 
 morbid degeneration. It is difficult to say what are the causes 
 of inflammation in the foetus. Sometimes, no doubt, it is due to 
 a special morbid state of the mother's health; but frequently it 
 originates in, and is confined to, the organs or tissues of the 
 foetus itself, being quite independent of any peculiar condition of 
 the maternal system. Several instances are known Avhere an 
 imperforate urethra has given rise to such excessive distension 
 of the foetal bladder, that the latter has ruptured; the urine be- 
 coming extravasated into the abdominal cavity, and setting up 
 intense inflammatory action in the peritoneum. So again, peri- 
 toneal inflammation seems sometimes to have been due to an 
 internal strangulation of the intestines. Sir James Sim[>son re- 
 lates two instances where coagula of blood in the abdominal 
 cavity, from a partial laceration of the substance of the liver, 
 appeared to have excited it; while occasionally it has been con- 
 nected with some malformation of the abdominal viscera or 
 parietes. Our knowledge of the symptomatology of all intra- 
 uterine diseases is most imperfect; but with regard to peritonitis 
 in particular, I know of no signs by which its existence can be 
 diagnosed. One combination of symptoms seems to attend most 
 severe foetal diseases ; viz., a great increase in the strength and 
 frequency of the child's movements, appreciable to the mother. 
 They are attended sometimes with spurious pains. And they 
 have this peculiarity — that they generally cease suddenly and 
 permanently. Beyond this we really know nothing. Peritonitis 
 is believed with reason to aftect the foetus most frequently during
 
 244 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 the two latter months of gestation ; and it is commonly Fatal, 
 though children have been born alive while suffering from it. 
 
 In twin pregnancies, when one foetus happens to be acephalous, 
 the progress of gestation is often interrupted. Of forty-seven 
 cases referred to by Tiedemann, the laborwas premature in thirty- 
 three. Of eleven examples mentioned by Dr. Plohl, of the Uni- 
 versity of Ilalle, in three parturition took place at the full period; 
 in one, at the sixth month ; in four, at the seventh ; in one at 
 the eighth ; in one, at the ninth ; while in one it is only said that 
 the woman did not go to the full term. The most perfect child 
 is born first, the foot being often the presenting part; and the 
 aceplialous monster generally follows in from half an hour to 
 ten or twelve hours. 
 
 Organic alterations of the membranes, especially vesicular or 
 hydatidiform disease of the chorion, and inflammatory affections 
 of the amnion, may destroy the foetus ; the effusion of blood into 
 the parenchymatous substance of the decidua will perliaps have 
 the same effect ; knotting of the funis, or compression of it from 
 torsion, by impeding the circuhation, can produce a like result ; 
 and so also may diseases of the placenta. The latter organ, which 
 Lobstein called a physiological lung, and which Harvey termed 
 the nutrient organ of the embryo, as the mammary gland is of 
 the infant, performs the most important offices in the vital func- 
 tion of sanguification. Literally a mass of bloodvessels, there is 
 — as Dr. Robert Barnes remarks — no other organ in which such 
 active and diversified j^rocesses of hpematosis are carried on ; not 
 even perhaps excepting the lungs, spleen, and liver. All the 
 blood of the foetus is successively brought by the umbilical ar- 
 teries to the placenta; where it exchanges, with the maternal 
 blood, its waste materials for fresh alimentary matter. Tliese 
 changes are wrought through the apposed walls of the utero- 
 placental arteries' and veins or maternal portion of the organ, and 
 the branches of the umbilical arteries and vein or foetal portion. 
 By such changes the placenta is made the final emunctory chan- 
 nel, as well as the prime restorative source ; and hence its phys- 
 iological and pathological conditions must exercise the most im- 
 portant effects upon the economy both of the mother and foetus. 
 
 The morbid conditions to which the placenta is liable, during 
 its stages of formation and growth and maturity, are numerous 
 and important. Tlius it may become hypertrophied, or indurated,
 
 EFFECTS OF DISEASE OF PLACENTA. 245 
 
 or partially calcified, or ossified ; while in other eases its textures 
 undergo the opposite processes of atrophy, or of softening. Then, 
 this temporary organ occasionally gets afiected with inflamma- 
 tion, a condition technically known as placentitis ; it ma}^ l)e the 
 seat of partial congestions and extravasations of blood, the so- 
 called placental apoplexy ; or crude tubercles may be deposited 
 on its surface. All of these conditions have to a greater or lesser 
 degree the like eftect of interrupting or vitiating its functions ; 
 for unless the structure of the placenta l)e uniformly soft and 
 spongy, and its adhesion to the uterus perfect, hemorrhage must 
 usually result. Then, the partial disruption will extend, uterine 
 contractions will be excited by the effusion of blood, and the ovum 
 will be expelled. Dr. Robert Barnes has elucidated by means 
 of the microscope, and has ably described in some important 
 papers,^ an abnormal condition of the placenta — fatty degenera- 
 tion — which is not unfrequently connected with the death of the 
 foetus, both in the earlier and later months of gestation. The 
 fatty matter is found chiefly in the cells of the foetal villi, and in 
 the coats of their bloodvessels. In some instances, the morbid 
 change seems to invade the entire decidual surface of the placenta 
 with great uniformity ; but in others, only portions are affected, 
 some parts being far gone towards disorganization, whilst in the 
 remaining portions the villi continue comparatively healthy. 
 The cases observed by Dr. Barnes furnish illustrations of the in- 
 fluence of fatty degeneration in causing abortion and hemor- 
 rhage : the first being produced by the disease rendering the villi 
 unfitted for their office of maintaining the nutrition of the em- 
 bryo; the second, by the affected portionsof the placenta ceasing 
 to be spongy and yielding, by the vascular channels between the 
 placenta and uterus becoming more or less obliterated, and by 
 there resulting in consequence a disposition to detachment at the 
 diseased points. If the detachment were strictly limited to these 
 points where little or no vascular connection with the uterus re- 
 mains, there would be no flooding ; but this can seldom be the 
 case, for the detachment of the diseased lobes is almost sure to 
 entail partial separation of portions still maintaining a freer vas- 
 
 ' Medico-Chirurtjical Transactions, vol. xxxiv, p. 1S2 ; and vol. xxxvi, p 143. Lon- 
 don, 1851 and 1853. See also some valuable articles on Diseases of the Placenta, by 
 Dr. Barnes, in the British and Foreijjn Medico Cliiriirgical Review, vol. xiv, p. 21 ; vol 
 XV, p. 156; and vol. xvii, p. 138. London, 1854, "55, and "56.
 
 246 THE PREMATURE EXPULSION OF THE F(ETUS. 
 
 cular connection, and thus hemorrhage cannot be prevented. 
 The loss of blood also may be the immediate occasion of the ex- 
 pulsion of the ovum: or the death of the embryo will give rise 
 to irritation similar to that produced by any other foreign body, 
 and so excite contractions of the uterus. 
 
 "When, from any diseased action the fcetus pe-rishes, an interval 
 varying from five or six to twenty or more days usually elapses 
 before it is expelled. During this time, slight symptoms of im- 
 pending abortion are generally present ; and in order that our 
 treatment of these may not be altogether empirical, it is very im- 
 portant that we should know whether the fcetus be alive or dead. 
 To the medical jurist such knowledge is not unfrequently quite 
 indispensable ; as when a pregnant woman has been maltreated, 
 and her unborn infant is thought to have died from the injury. 
 Moreover, in many cases of difficult labor it is very desirable that 
 we should be able to decide this question. To take merely one 
 example : Where the choice has to be made between the per- 
 formance of craniotomy, the application of the forceps, or the 
 operation of turning, it can be taken for granted that most 
 practitioners would resort to the first proceeding, as being the 
 least painful and dangerous to the mother, were it only quite 
 certain that the child was dead. Hence the following observa- 
 tions on the Signs of the Death of the i^ceiits will hardly be deemed 
 out of place. 
 
 The signs generally enumerated as indicating death before 
 labor are these : A complete cessation of the fcetal movements ; 
 a diminution in the size of the abdomen, and a loss of its firm 
 rounded appearance ; an absence of that tense elasticity of the 
 uterus, so peculiar to healthy pregnancy ; a sensation of coldness 
 and dead weight in the abdomen ; the impression as of a heavy 
 mass rolling about the uterus, or the falling of the uterine tumor 
 from side to side in the abdomen, as the patient changes her 
 position ; the breasts losing their firmness and becoming flabby; 
 and occasionally the occurrence of a slimy, whitish-yellow, or 
 slightly sanguinolent discharge from the vagina. The escape of 
 a fetid discharge is very frequently said to be a common sign of 
 the child's death ; but the absence of such a flow is no proof that 
 there is vitality, for a lifeless fcetus may remain in the mother's 
 womb for many weeks wnthout the putrefactive process setting 
 in, provided the membranes remain entire. In the case of twins,
 
 SIGNS OF DEATH OF THE FCETUS. 247 
 
 where one infant dies at an early period of gestation, it is often 
 retained and expelled undecayed when its fellow is born at ma- 
 turity. None of the foregoing symptoms alone can do more 
 than give rise to slight suspicion. But taken collectively they 
 are valuable ; more especially if corroborated by the existence of 
 languor and debility, nervous irritability and mental depression, 
 loss of appetite, disordered bowels, and sunken eyes with the 
 formation of a deep leaden color beneath them. At the same 
 time it must be remembered, that women have been known to 
 carry a dead child for weeks without presenting any one of the 
 foregoing symptoms ; while their general health has become 
 much improved, owing to the cessation of some of the sympa- 
 thetic disorders of pregnancy. As the detection of the double 
 sounds of the foetal heart affords the surest sign of pregnancy, so 
 the inability of an experienced auscultator to hear them, after a 
 thorough or repeated examination, is the most valuable proof of 
 the child's death ; a proof which maybe regarded as almost con- 
 clusive during the last few weeks of pregnancy, when I believe 
 that careful auscultation can otherwise scarcely fail to discover 
 the comparatively strong tictac of health. 
 
 The symptoms during labor which may be regarded by the 
 physician as diagnostic of the child's death are various ; but 
 none have the same importance as the inability to detect the 
 sounds caused by the action of the heart. In head presenta- 
 tions the scalp is found loose and flabby, the great fontanelle is 
 depressed and lax, and the bones of the skull overlap each other 
 more than during life ; while when the foetus has been dead some 
 time and is putrid, the cranial bones are felt to be movable within 
 the scalp, something like loose shells in a bag. Where there is 
 a face presentation the lips are flabby, the jaws do not close if 
 the finger be insinuated within the mouth, and the tongue is felt 
 flaccid and motionless. If the breech be the presenting part, the 
 sphincter ani is found relaxed, it does not contract on the finger 
 passed within it, and sometimes there is an escape of meconium. 
 With an arm presentation, the limb is perhaps discovered quite 
 flabby and moist, instead of swollen and livid as when the child 
 is alive ; while the cuticle may be abraded or even extensively 
 separated. And lastly, in prolapse of the funis there is a com- 
 plete absence of all pulsation in the umbilical vessels, if the in- 
 fant be dead ; this fact being ascertained not by a momentary
 
 248 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 examination, but by a careful exploration, so as to be sure tbat 
 the pulsations are not merely suspended, but that they have ab- 
 solutely and entirely ceased. 
 
 3. The Symptoms of Abortion. — The symptoms vary some- 
 what according to the cause of the miscarriage, and the period 
 of pregnancy at which it occurs. During the early days of ges- 
 tation the phenomena are scarcely more noticeable than those 
 which happen in many cases of d3-smenorrhoea. A few bearing- 
 down pains are experienced, there is some amount of physical 
 and mental depression, the patient makes complaint of more or 
 less aching in the loins and about the sacrum, and sooner or 
 later the ovum is expelled whole or in shreds. Not uufrequently 
 the mass is mistaken for a clot of blood, and is at once thrown 
 away ; the woman mere!}' imagining that her monthly flow has 
 been more abundant, and attended with greater pain, than usual. 
 
 The case is different at a somewhat more advanced stage of 
 gestation, when the pregnancy is interrupted by some element 
 operating slowly — such as chronic foetal or maternal disease. 
 The mother first suffers from lassitude and depression of spirits, 
 loss of appetite, thirst, nausea, palpitations, cold extremities, with 
 perhaps attacks of faintness. She experiences a sense of weight 
 and chilliness in the lower part of the abdomen, with irritability 
 of the bladder. The breasts become weak and flaccid ; and there 
 is a constant heavy aching sensation in the back and loins. Two 
 prominent symptoms may then be noticed — viz., hemorrhage 
 and uterine pain ; either of which will now and then exist alone 
 without disturbing the process of gestation, though when both 
 occur together the ovum is almost sure to be expelled. If a 
 vaginal examination be instituted while a pain is on, in a case 
 where pregnancy has advanced up to or beyond the fourth mouth, 
 the uterus can be felt to contract or harden sensibly ; the rigidity 
 diminishing as the pain ceases. Perhaps, too, the os will be 
 found open, and the membranes beginning to protrude; and 
 then the practitioner may be certain that only a short time will 
 elapse before the escape of the waters and the expulsion of the 
 foetus with its placenta. In some cases the hemorrhage proceeds 
 to a serious extent for two or three days before the ovum comes 
 away ; or if the embryo should pass and the placenta be retained, 
 a constant and exhausting bleeding will be kept up until the
 
 SYMPTOMS OF ABORTION. 249 
 
 latter is discharged spontaneously or removed by art. It cannot 
 be too strongly impressed upon the practitioner that in most in- 
 stances of threatened abortion a vaginal examination should be 
 gently made, with the finger well lubricated, in order to form a 
 positive diagnosis. Such an examination, properly conducted, 
 cannot — as some have said — produce that expulsion which it is 
 the object of our art to prevent. Supposing the os and cervix 
 uteri be detected sufficiently patulous to admit two fingers easily; 
 or provided the cervix be found so obliterated that on passing 
 the finger over the lower segment of the uterus no neck can be 
 distinguished; or should the ovum be felt projecting down the 
 cervix or partly protruding through the os, — in either case it will 
 be worse than useless attempting to stop the expulsive process. 
 For in instances of this kind it is evident, that the ovum is at 
 least partially detached from its connection with the uterus ; and 
 assuredly the patient will not be safe until the whole product of 
 conception has come away. 
 
 When the abortion is the result of some accident — e. g., a fall, 
 blow, or sudden fright — the violence is generally at once fol- 
 lowed by a sharp pain in the abdomen and by liemorrhage ; while 
 in some cases the ovum comes away almost with the first gush 
 of blood. Of course the earlier the pregnancy, the more likely 
 is the last-mentioned result to happen ; for it may be again stated, 
 that at an advanced period of gestation a certain interval almost 
 always elapses between the accident and the abortion, during 
 which the patient — having recovered from the immediate shock — 
 is often apparently nearly well. 
 
 In cases of premature labor, the process of parturition is sel- 
 dom as regular and rapid as in labor at the full term. This cir- 
 cumstance will be easily understood by remembering the length 
 and hardness of the cervix during the seventh and eighth months, 
 the slowness with which the os then dilates, and the compara- 
 tively feeble contractile powers of the uterus. On the other 
 hand, the effect of these conditions is somewhat diminished by 
 the smaller size of the ofifspring, and the greater ease with which 
 its tissues may be compressed. The longer the interval which 
 elapses between the death of the child and the labor, the less 
 also will be the risk of serious flooding; for since the child's 
 death lessens the activity of the uterine circulation, and perhaps 
 partially obliterates a greater or lesser number of the utero-pla-
 
 250 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 cental vessels, so the latter bleed but little on the separation of 
 the afterbirth. When the membranes get ruptured at about the 
 same time that the child dies, and labor does not supervene for 
 many days, then the action of the external air on the child's 
 body produces rapid putrefaction. The maternal system in con- 
 sequence is very apt to become much deranged ; high fever prob- 
 ably sets in ; and unless the delivery be hastened by art, purulent 
 absorption may take place and prove fatal. 
 
 The fact has been already noticed that the death of one embryo 
 in a multiple pregnancy by no means'usually leads to its imme- 
 diate expulsion. But the contrary sometimes, though rarely 
 happens ; and abortion of one foetus takes place, whilst the other 
 continues to grow in the uterus. Dr. Whitehead relates the fol- 
 lowing interesting example of this occurrence: 
 
 A woman of strong mind, thirty-two years of age, and in the seventh month 
 of her sixth pregnancy, was in a grocer's shop ordering some goods, when a 
 heavy weight fell upon the instep of her left foot. She was removed home, 
 in great pain; and whilst sittinij; with the injured limb in a foot-bath, she 
 felt a sudden and violent struggle within her, followed immediately by a 
 plentiful escape of the liquor amnii. The medical man who was sent for, 
 finding the pains of labor strong and frequent, and a foot already low down 
 in the vagina, proceeded to deliver; and a puny female child was burn, alive 
 and apparently healthy. Its left foot, which had been the first to present, 
 was found to be firmly contracted towards the inner aspect of the limb, the 
 heel being raised, and the solei muscles rigid and unyielding; but by the 
 proper employment of extension with bandaging, the use and symmetry of 
 the foot were eventually restored. After some ineffectual efforts to bring 
 away the placenta, the abdomen was examined, when it was found that there 
 was another child, the birth of which was hourly expected. In the course 
 of ten days — no indications of labor coming on — the patient was sufficiently 
 recovered to attend to her household duties, which she continued to do until 
 the completion of the natural term of pregnancy, when she was safely de- 
 livered of a full-grown male child, in vigorous health. This event happened 
 precisely sixty-five days after the first birth ; and then only did milk appear 
 in the mother's breasts, so that she was enabled to nurse both the children.' 
 
 M. Desormeaux has also given an account of a very remark- 
 able case in which there must have been a triple pregnancy: 
 
 "line dame enciente pour la premii^re fois a I'age de quarante ans, fit une 
 faussecouche a deux mois et demi; bientot apres, les symptoraes de la gros- 
 sesse reparurent ; des mouvemens d'enfant se firent sentir a I'epoque ordi- 
 
 1 On the Transmission from Parent to Offspring of some forms of Disease, &c. Second 
 Edition, p. 21. London, 1857.
 
 SYMPTOMS OF ABORTION. 251 
 
 naire ; a sept, mois, elle eprouva une frayeur vive, suivie de phenomenes 
 qui annongaient la niort de I'enfant; cependant il existait toujours mouve- 
 niens dsins I'uterus. Enfin, apr^s deux mois, cette dame accoucha d'un en- 
 fant mort, et d'un autre qui etait vivant et bien portant. Rousset, dans sou 
 Traite de V Hyaterotomotokie, a rapporte un esemple analogue."^ 
 
 After a miscarriage or premature labor has taken place, the 
 physician must satisfy himself that the whole product of concep- 
 tion has come away. This, it need scarcely be said, he does by 
 making a vaginal examination, and by carefully scrutinizing the 
 aborted mass. So long as any part of the foetus or its membranes 
 remains in the uterus, the mother is exposed to two great sources 
 of danger. The first and most pressing is the risk to life from 
 flooding, which nothing will check eflectively and permanently 
 but the ejection of the retained foreign body; the second source 
 of mischief is the putrefaction of the portion left behind, and in 
 consequence purulent absorption, uterine phlebitis, &c. 
 
 The fact must not be forgotten that inversion of the uterus may 
 happen after abortion. The occurrence of this accident has 
 generally been considered only possible after parturition at an 
 advanced period of gestation ; and in most instances it has been 
 thought to be due to the employment of injudicious force in re- 
 moving the placenta. These views are, however, somewhat in- 
 correct; for it has happened after miscarriage at the third and 
 fourth month, and in other cases after natural labors where there 
 has been no manual interference of any kind. Three cases — 
 there are probably others with which I am unacquainted — have 
 been published in which inversion of the uterus occurred after 
 abortion at an early period of pregnancy — viz., one by Lisfranc,^ 
 one by Dr. Skae,^ and one by Dr. Sidey.* In the first, the ac- 
 cident happened at about the third month of pregnancy ; and 
 thouo'h the woman suffered afterwards from an abundant leucor- 
 rhoeal discharge, pains in the pelvis and loins, and sympathetic 
 disturbance of the stomach, yet five years elapsed before the cause 
 of her bad health was discovered. The chief points in the second 
 instance are as follows : 
 
 1 Dictionnaire de Medecine. Article, Avortement. "Deuxieme Edition. Tome iv, p. 
 466. Paris, 1833. 
 
 2 Clinique Cliiriiraieale de I'Hopital de la Piti(?, tome iii, p. 380. Paris, 1843. 
 
 3 The Northern Journal of Medicine, vol iii, p. 66. Edinburgh, 1845. 
 * Edinburgh Medical Journal, p. 271. September, 1866.
 
 252 THE PREMATURE EXPULSION OF THE FGETUS. 
 
 » 
 On the evening of Saturday, 25th January, 1845, Dr. Skae was requested 
 to visit a poor woman, who was said to be very ill in consequence of having 
 had a miscarriage. The patient was thirty-six years of age : had been mar- 
 ried sixteen years : had been pregnant eioht times, and gone the full period 
 in six : and her labors had never been unduly severe. She was found in a 
 state of great distress and exhaustion; and complaining of severe headache, 
 with intense pain in the back and both iliac regions. She also stated that 
 she experienced constant bearing-down pain attended with flooding, and a 
 sensation of something having fallen down within her. The history was that 
 ten days before, she had been seized with flooding: that on the following day 
 abortion took place, she being four months pregnant : and that two days af- 
 terwards she got up to attend to some household matters, but the flooding 
 increased to such an extent as to necessitate "her return to bed. She had 
 kept her bed until the 25th January, when at 10 o'clock in the morning she 
 was seized with sickness : while engaged in the act of vomiting, which was 
 severe and continued, she was sensible of something falling down within her; 
 and until Dr. Skae's visit, that sensation continued, along with bearing-down 
 pam, flooding, n)uch general uneasiness, and extreme prostration. On in- 
 troducing the fingers into the vagina, the passage was found nearly filled with 
 an elongated irregular spherical tumor, of firm consistence, and having shreds 
 of membrane attached to it; while on passing a finger up to the os uteri, the ' 
 neck of the tumor could be traced entering within it, and having an equally 
 firm attachment, as it were, around the whole circumference of its inner 
 margin. Feeling certain that the mass consisted of the uterus in a state of 
 almost complete inversion. Dr. Skae grasped the organ, and by moderate but 
 steady and continued compression, in the direction of the os uteri, succeeded 
 in about twenty minutes in returning the whole mass. The following day 
 there was a slight projection of the fundus at the os uteri, but it was easily 
 pushed upwards into its proper position. She then gradually recovered, be- 
 ing ultimately restored to perfect health. 
 
 The third example was reported to the Obstetrical Society of 
 Edinbnrgli, on 11th July, 18GG. The principal features in tlie 
 case, as described by Dr. Sidey, are these. This gentleman 
 said: 
 
 On the 20th May, I was sent for to see Mrs. G., who was five months ad- 
 vanced in pregnancy, and found her complaining of pelvic pain. On exam- 
 ination, the parts were all very tender, and the os uteri could scarcely be 
 reached on account of extreme tightness. The pain continued till the 24th, 
 when suddenly, without any faintness, there was a feeling of extreme disten- 
 sion and fulness, the abdominal tumor reaching above the umbilicus in the 
 evening. Uterine pains came on, when a large clot was expelled, and within 
 the neck the placenta was i'elt firmly adhering; no mure henidrrhage how- 
 ever occurred. On the 2<)th, the uterine pains again recurred, and the foetus 
 and placenta were expelled very much blanched, except the portion which 
 had evidently adhered to the neck and lower part of the uterus. On exami- 
 nation, a large tumor was felt, which proved to be an inverted uterus caused 
 by a fibrous tumor forcing its way through the os. Two fingers of the right 
 hand were passed upwards on the rough surface of what appeared to be the 
 fundus, at the same time pulling the tumor up with the other hand until an
 
 DIAGNOSIS OF ABORTION. 253 
 
 OS appeared to have been formed, and the uterus assumed a natural state. 
 Since then she has done well. 
 
 4. Thr Diagnosis of Abortion. — Tt is often very important 
 that the hemorrhage of an early abortion should not be mistaken 
 for the menstrual flow. One way in which any error may be 
 avoided is by remembering that the catamenial discharge, unless 
 very abundant, does not coagulate, owing to the admixture of 
 tlie blood with the acid vaginal secretions; and even in severe 
 examples of menorrhagia the clots are seldom very large or firm. 
 In cases of abortion, however, the blood rapidly coagulates, and 
 large solid masses of it may come away. The same thing, it is 
 true, happens in the hemorrhage arising from cancer of the uteras, 
 as well as in that due to the presence of a polypus; but then both 
 these diseases give other indications of their nature which can 
 hardly be overlooked. The eftusion of the liquor amnii is also 
 a valuable sign; though it must be remembered that a copious 
 discharge of watery fluid may take place in hydrometra and in 
 hydrorrhoea. Cases have been recorded where pregnancy has 
 proceeded naturally and uninterruptedly forweeks after the com- 
 plete escape of the amniotic fluid. I cannot, however, help 
 doubting the correctness of some of these histories. Occasionally, 
 no doubt, a portion of the liquor amnii comes away in conse- 
 quence of a rent or tear in the upper part of the membranes. 
 Moreover, it is possible that the flow in other instances has been 
 due to the discharge of a sort of false amniotic fluid, — a fluid 
 which has accumulated in that space sometimes found existing 
 between the amnion and chorion even to the end of gestation. 
 
 Patients not unfrequently imagine that they have aborted and 
 that the ovum has come away, wdien nothing of the kind has 
 happened. The following case afibrds a good example of this 
 error ; and as the patient's history is instructive in other ways, 
 its full relation may be allowable: 
 
 On the 17th November, 1858, I went to Maidenhead to see a lady, in 
 consultation with Mr. Frank Goolden. The patient was twenty-eiirht years 
 of age. had been married six years, and was the mother of five children. 
 The cataraenia first appeared when she was twelve years old : they are usu- 
 ally natural in quantity, appear regularly when not pregnant, and are o:ener- 
 ally followed by leucorrhoea. She suffers much from hemorrhoids at the 
 monthly periods. She does not seem at any time to have enjoyed very ro- 
 bust health ; having especially been subject to relaxation of the bowels, as 
 well as to fits of hysteria and fainting. She is very susceptible to the infiu-
 
 254 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 enee of mesmerism, and ten years ago was mesmerized every night for three 
 months, to relieve general restlessness and toothache; but being- seized at 
 the end of this time with a violent attack of hysteria, this course of treatment 
 was discontinued. All her labors — except the fourth — have been remarkably 
 rapid, and usually attended with but little suffering. She has never been 
 able to suckle any of the children. With her first child she went seven 
 months; she was delivered on the 12th Marcli, 1853, soon made a good re- 
 covery, and by care reared the infant. At the end of a few months she again 
 became pregnant; about the sixth week of gestation and again at the twelfth 
 there was a severe attack of uterine hemorrhage, with all the symptoms of 
 abortion, so that she imagined her pregnancy at an end; an opinion, how- 
 ever, which proved to be erroneous, for at the eighth month — on 2Sth July, 
 1854 — she was delivered of a living child. Sevei-al months now elapsed 
 before conception took place for the thiid time : then at the seventh month 
 symptoms as of approaching labor set in, and continued for two days, but the 
 gestation was not interrupted, and she was delivered at the full period, on 
 25th January, 185G. For some weeks after getting about she suffered from 
 procidentia uteri, in consequence of over-exertion ; but this did not prevent 
 her becoming pregnant about the commencement of May, 1856. At the end 
 of three months from the date of conception she had an attack of flooding, 
 which lasted many days, so that she felt almost certain that she had aborted ; 
 and every month until the time of delivery the hemorrhage returned, though 
 it was less abundant. At the full period, on 7th February, 1857, she gave 
 birth to a dead child ; but though her labor was attended with considerable 
 flooding, she made a good recovery. Nine months now passed away before 
 she conceived for the fifth time; again experiencing symptoms of abortion 
 about the third month, but nevertheless going her full Uiue. Up to the day 
 of her labor — 29th August, 1858 — she had no difficulty in getting about, 
 and her health was good. The labor was very rapid, so much so that the 
 child was born before she could be placed upon the bed: the after-pains were 
 also very severe, and she passed many large clots of blood. Ten days after 
 delivery she discovered that she had lost all power in the left leg ; and at 
 the same time found, that any attempt to put it to the ground was attended 
 with great pain in the pubic region, which pain also extended down the left 
 thigh. It was owing to the persistence of this loss of power that my opinion 
 was sought. 
 
 I found her weak and pale; with a quick and feeble pulse; pretty good 
 appetite; able to sleep well; and free from pain except when the limb was 
 moved. She was unable to lift the left leg at all, but sensation was not im- 
 paired ; no reflex actions could be excited by tickling the sole of the foot. 
 There was neither swelling nor tenderness about the hip or any part of the 
 limb; the uterus was healthy, and of normal size; the left ovary appeared 
 to me to be slightly enlarged, but only slightly ; the bowels were regular, and 
 the evacuations healthy; while the urine was normal in quantit}', and free 
 from albumen or any morbid excess of phosphates or lithates. Upon attempt- 
 ing to stand she complained of "'a dragging pain in the lower part of the body, 
 as though everything were coming away from her;" and there was then also 
 much pain in the back. In talking these facts over witii Mr. Goolden, it 
 was agreed that the paralysis was probably the result of the pressure of the 
 child's head upon the nerves and muscles during its passage through the 
 pelvis; and that in all likelihood the loss of power was kept up by the 
 anaemic condition of the patient. She was ordered small doses of steel ;
 
 PROGNOSIS IN ABORTION. 255 
 
 good nourishing food ; to take pepsine if her digestive powers seemed to re- 
 quire it; and to have a gentle galvanic current passed daily through the 
 limb. She was also to avoid becoming pregnant for some months. In spite 
 of the latter precept being unattended to, this lady gradually recovered ; and 
 I have since heard that although she experienced her usual symptoms of 
 impending abortion at about tlie fourth month, yet she went her full time, 
 had an easy labor, and afterwards did well. 
 
 From one motive or another abortion may be feigned ; or a 
 woman may falsely charge another person with having at- 
 tempted to commit this crime. Dr. Taylor mentions that a 
 young female was admitted into Guy's Hospital, in April, 1846, 
 who charged a policeman with having given her some substance 
 to produce abortion, and with subsequently having effected this 
 mechanically. According to her statement also, the man had 
 previously had forcible intercourse wnth her. She was not ex- 
 amined until nearly two months after the alleged perpetration 
 of the crime, when Dr. Lever found that there were no grounds 
 for believing that she had ever been pregnant.^ The length of 
 time which was allowed to elapse between making the charge 
 and the alleged commission of the offence, afforded presumptive 
 evidence that the crime had not been committed. 
 
 I was consulted in 1858 by a woman who seemed desirous to 
 press a similar charge against her husband, with wdiom she lived 
 very unhappil3\ Her statement was that the catamenia had been 
 absent for rather more than five months, and that she deemed 
 herself pregnant. Five days before consulting me, she said that 
 her husband compelled her to submit to his passing an iron 
 skewer into the vagina; she experienced great pain, and soon 
 afterwards had a discharge of blood with several "lumps like 
 flesh." On examination, all the organs of generation were found 
 to be healthy : there was no lochial discharge, the mucous mem- 
 brane of the, vagina was of a pale pink color, the uterus did not 
 seem to be enlarged, and it was proved that the cavity was of the 
 natural size by the uterine sound only passing for two and a half 
 inches. Moreover, the breasts were not full, nor were the nipples 
 turgid. The investigation proved to me conclusively that the 
 woman's statement as to her pregnancy was absolutely untrue. 
 
 5. The Prognosis in Abortion. — Since the days of Hippoc- 
 
 1 Medical Jurisprudence. Fourth edition, p. 489. London, 1852.
 
 256 THE PREMATURE EXPULSION OF THE F(ETUS. 
 
 rates the statement has been repeatedly made and credited, that 
 the danger of an abortion is greater than that of a natural labor 
 at the full term. This observation requires some modification, 
 for, as a general proposition, it is not correct. In the first or 
 second month the ovum with its appendages generally escapes 
 without producing any noticeable illness. In the third and fourth 
 months, however, there is often considerable danger from hemor- 
 rhage, owing to the rigidity of the os and cervix uteri, and the 
 slowness with which their tissues dilate. The danger again be- 
 comes lessened after the fifth montlr. At all periods the risk 
 will be diminished in proportion to the completeness with which 
 the uterus throws ofl:" its contents, and the firmness with which 
 this organ subsequently contracts. 
 
 Again, the acute diseases to which lying-in women are liable, 
 are much more severe than any of those disorders which may 
 follow an abortion. It is true that in the latter case some chronic 
 afifection of the organs of generation is often left behind which 
 may be troublesome for weeks or even months after the accident ; 
 but then there is little or no danger to life to be apprehended 
 from such a disease. 
 
 The cause of the abortion must also influence the prognosis. 
 A miscarriage originating through the influence of some slowly 
 operating maternal or foetal disease is attended with much less 
 serious consequences than one produced suddenly by an accident, 
 or by the exhibition of irritating medicines, or by puncturing the 
 membranes. Tardieu reports thirty- four cases of criminal abor- 
 tion, the death of the mother resulting in consequence in no less 
 than twenty-two.^ So, too, an abortion occurring during the pro- 
 gress of an acute inflammation of the brain, lungs, heart, liver, 
 or peritoneum, forms a highly dangerous complication. 
 
 The great source of danger in most abortions is the hemorrhage. 
 Although a woman may lose a very large quantity of blood, and 
 yet as a general rule recover, still every now and then fatal cases 
 occur. I have more than once remarked that when a portion, 
 but not the whole, of the ovum and its membranes has been ex- 
 pelled, the patient is very liable to re[)eated attacks of hemor- 
 rhage, from which she may ultimately sink. Mr. Humphreys, 
 
 1 Annales d'Hyfjifeiie Piibliqiie et cle Medecine L6gale. Deiixieme S^rie. Tome v, 
 p. 145. Paris, ISOG.
 
 PROGNOSIS IN ABORTION. 257 
 
 of Shrewsbury, has related a case which is instructive, and proves 
 how even a very small piece of placenta may cause fatal flooding.- 
 The chief facts are these : 
 
 A healthy woman, aged thirty-seven, the mother of five children, aborted 
 at the third month, on 28th August, 1858. The loss of blood was not great 
 at the time, and she did not keep her bed. At the end of ten days Mr. 
 Humphreys was hastily summoned to her, and found her blanched and almost 
 pulseless ; while the bed was saturated with blood, which was " then pour- 
 ing out of the vagina in a hissing stream." The vagina was plugged with a 
 silk handkerchief. This was removed at the end of six days, when the canal 
 was washed out with cold water; but an hour afterwards the bleeding re- 
 turned. The vagina was replugged, and the plug allowed to remain three 
 days. There was no bleeding when it was removed, nor until three days 
 afterwards, when the hemorrhage suddenly recurred. Pressure was made 
 over the pubes by pads and a towel ; and she was ordered successively com- 
 pound infusion of roses with an excess of acid, ergot, acetate of lead and 
 opium, gallic acid, muriated tincture of iron, and turpentine. The uterus 
 was examined and found to be flabby; the end of the forefinger only could 
 be passed into the os. Galvanism was applied directly to the uterus on three 
 occasions ; vaginal injections of cold water were freely used ; enemata of cold 
 water were frequently administered; and subsequently the uterus was in- 
 jected with a strong infusion of matico, and then with gallic acid. The 
 bleeding, however, though checked for a time, invariably returned ; and at 
 length the patient died, two months after the miscarriage. On examining 
 the uterus after death there was found at the upper part a rugged patch of 
 adventitious membrane the size of a shilling. This membrane was of a very 
 dark color; while on examining it closely, it was found to be made up in 
 great part of vessels with open mouths and sinuses. P]vidently, it was a por- 
 tion of the placenta ; which being more than usually adherent at that part, 
 had not been detached from the uterus at the time of the miscarriage. A 
 probe passed readily down the open mouths of the vessels deep into the struc- 
 ture of the uterus. It was with some difficulty peeled off the lining mem- 
 brane of the uterus, with which it appeared to be perfectly organized.^ 
 
 Sometimes a portion of the placenta remains in the uterus, 
 partly or wholly separated, without producing flooding. It may 
 then undergo decomposition ; while if any of the products of 
 putrefiiction become absorbed, very severe constitutional irrita- 
 tion will be developed, with all the symptoms of putrid infection. 
 The earliest indication of this condition is a very fetid state of 
 the lochia, and an abundant flow ; followed in a day or so by a 
 violent attack of shivering. The rigor is succeeded by high fever, 
 a temperature gradually rising above 100° F., and a pulse beat- 
 ing about 120. There is thirst and nausea ; the skin looks sallow ; 
 
 1 British Medical Journal, New Series, No. ci, p. 1006. London, 4tli December, 1858. 
 
 17
 
 258 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 the tongue becomes drj, and thickly coated ; the countenance 
 assumes an anxious expression ; and there is a throbbing head- 
 ache, with intermitting attacks of delirium. At the end of from 
 forty-eight to seventy-two hours peritonitis results ; and then the 
 abdomen gets greatly distended as well as exquisitely tender, 
 there is constant nausea and vomiting, and often diarrhoea with 
 dark colored unhealthy stools. The delirium becomes of a low 
 muttering kind, and does not pass off; the debility and restless- 
 ness get extreme ; the countenance assumes a pinched and hag- 
 gard expression ; and death usually closes the scene at some time 
 between the fifth and fifteenth days from the first invasion of the 
 symptoms. This description, like that of most diseases indeed, 
 applies only to a tj'pical case. Fortunately the sketch can some- 
 times be drawn in rather brighter colors. The blood-poisoning 
 may be less intense. The peritoneum is not always involved. 
 When the putrid mass gets wholly detached and comes away 
 early, the chances of recovery are greater than where it is ex- 
 pelled only in shreds ; but even in cases complicated with peri- 
 tonitis the result is not necessarily fatal. Yet the patient may 
 succumb although we succeed in early clearing out the cavity of 
 the uterus ; or she may recover only after the formation of secon- 
 dary abscesses, and after going through a period of protracted 
 suffering. 
 
 In connection with this subject it is important to remember, 
 that there is sometimes a supplemental placenta — placenta spuria 
 or place7ita succenturiata ; — that is to say, a portion of the pla- 
 centa, of variable size, is so far separated from the main part of 
 the organ as only to be connected by a thin membrane. Should 
 this connection become torn after labor, the placenta might easily 
 come away while the supplemental portion remained attached to 
 the uterus. Hence, without the practitioner being in the least 
 degree to blame, secondary hemorrhage or other untoward symp- 
 toms would probably set in, and give rise to considerable trouble. 
 
 It occasionally happens that the vascular connection of the 
 placenta with the uterus remains intact after the expulsion of the 
 embryo; or after the death and atrophy of the latter, the after- 
 birth may continue to be developed. In this way hydatidiform 
 masses and other morbid products called moles are formed; the 
 nature of which will be treated of in the succeeding chapter. 
 Moreover, after the expulsion of the foetus, complete absorption
 
 PROPHYLACTIC TREATMENT. 259 
 
 of the placenta is said sometimes to have taken place ; and cases 
 are related by trustworthy authors where this extraordinary 
 phenomenon has been thought to have occurred. Skeptical as I 
 am about such an event, and believing rather that the organ has 
 really come away in the form of debris, still it cannot be affirmed 
 that absorption is absolutely impossible. But it is certain that 
 even if the possibility of this contingency be granted, neverthe- 
 less its occurrence must be so rare that it ought not to be allowed 
 to bias our practice in the slightest degree. Indeed no one will 
 deny, that the chances are innumerably greater in favor of the 
 supervention of flooding or putrid infection from retention of 
 the placenta, rather than of simple absorption. 
 
 6. The Treatment of Abortion. — This portion of our sub- 
 ject has to be considered under two heads : (1) The treatment 
 necessary to prevent abortion. And (2) that which is to be 
 adopted when this accident seems unavoidable. 
 
 (1) The prophi/lactic or preventive measures. — These consist 
 cbiefly in the removal of all causes likely to induce irritation of 
 any portion of the sexual system, and in the adoption of such 
 measures as are calculated to keep the maternal system in a state 
 of good health. "When the female is of a plethoric and excitable 
 temperament, everything should be done to insure tranquillity 
 of mind and body. Thus, the diet ought to be light and free 
 from stimulants ; and diluents, such as lemonade and soda-water, 
 are to be freely allowed. The bowels must be kept regular — if 
 necessary by mild laxatives. Small doses of digitalis with the 
 solution of citrate of ammonia, or a tincture of the American 
 wild cherry,! may often be given with advantage. Regular but 
 gentle exercise in the open air ought to be permitted. Not more 
 than eight hours should be passed in bed; and the patient had 
 better sleep in a well-ventilated apartment, on a mattress rather 
 than on a feather bed, and with light bed-clothes. 
 
 For women of feeble constitutional powers, a nourishing diet, 
 the moderate use of wine or beer, warm clothing, daily exercise, 
 agreeable mental occupation, early liours, and tonic medicines, 
 will prove highly beneficial. Aperients are to be avoided. "With 
 
 ' Take of, — Tincture of American Wild Cherry, 3 fluid drachms; Sohnion of Citrate 
 of Ammonia, 12 fluid drachms; Camphor Water, to 8 fluid ounces. Mix and label, — 
 " One-sixth part three times a day."
 
 260 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 regard to the class of tonics, I have seen the greatest good from 
 the various preparations of cinchona, either with or without the 
 mineral acids ; these being preferable, as a rule, to the ferrugin- 
 ous drugs. 
 
 In all cases, unyielding stays and tight-lacing are to be for- 
 bidden. If the abdominal walls be relaxed, or if they are pendu- 
 lous from an undue accumulation of fat, or if there be too much 
 space between the recti muscles, great comfort will ensue from 
 wearing a properly-adjusted belt. In aggravated forms, a belt 
 of elastic material is not capable of aflbrding sufficient support; 
 and then a large oval metal plate, either with curved springs such 
 as are used for keeping trusses in position, or preferably with 
 firm bands, will be invaluable. Mr. Heather Bigg has frequently 
 made such instruments for patients under my care; these appli- 
 ances having proved remarkably effective and singularly com- 
 fortable, because so constructed that the w^earer is always able to 
 increase or diminish the pressure according to her requirements. 
 Then again, either sponging the lower part of the trunk and the 
 hips with cold water will be useful, or the tepid hip-bath can be 
 employed, especially, where the patient has been in the habit of 
 using it. So also, it will always be as well to advise great mod- 
 eration with regard to sexual intercourse ; while in some in- 
 stances it may even have to be forbidden altogether. In the 
 latter case, it is generally better to urge the patient to sleep in a 
 bed separate from her husband. These rules are to be more 
 strictly attended to at all those periods when the catamenial flow 
 would be on, were the woman not pregnant ; and it is advisable 
 for the practitioner to calculate these dates for the patient, and 
 to tabulate them, so that no mistake may be made. There can 
 be no doubt that the influence of the ovarian or menstrual moli- 
 men is felt to a considerable extent by some women during preg- 
 nancy, especially in the earlier months. Consequently, every 
 precaution ought to be taken at the times when this influence is 
 in action, to prevent that congestion occurring which is the fore- 
 runner of hemorrhage and abortion. 
 
 When the disposition to miscarriage is dependent upon a di- 
 minished vitality of the uterine system or functional weakness 
 of its nutritive vessels, Dr, Metsch says that tonic and stimu- 
 lant medicines acting powerfully on the circulation of the uterus 
 are required ; and of all such substances savine is the most to be
 
 PROPHYLACTIC TREATMENT. 261 
 
 relied on.^ The very careful selection of appropriate cases for 
 the use of this powerful drug is necessary ; local or general ple- 
 thora, or serious disease of any internal organ contraindicating 
 its use. If the proneness to abortion depends upon augmented 
 irritability and contractility — a condition not always opposed to 
 the first named — the savine alone does not suffice ; and then Dr. 
 Metsch administers the ergot of rye with an infusion of savine. 
 Moreover, if former abortions hav5 been attended with great 
 urinary irritation, this physician recommends the addition of a 
 few drops of tincture of cantharides to each dose of the medicine. 
 For either class, regulation of the diet, abstinence from sexual 
 excitement, and rest in the horizontal position as long as pain is 
 present, are indicated. Although Dr. Metsch relates several 
 cases, in proof of his confidence in the utility of savine and ergot 
 being well-founded, yet I am strongly disposed to advise my 
 readers not to follow the plan of treatment he recommends with- 
 out some special reason, I have never yet seen a case where I 
 could adopt it with the prospect of its being beneficial ; and the 
 remedies seem to me so calculated in the majority of instances to 
 do harm, that I am afraid of them. This opinion is given with 
 the greater confidence because it is believed that from simpler 
 remedies we may obtain all that can be desired. 
 
 One of the best agents with which I am acquainted for those 
 troublesome cases of repeated miscarriage, occurring in weak and 
 irritable women in whom there is an absence of vascular conges- 
 tion and any specific disease, is assafoetida. This agent was first 
 recommended by Dr. Laferla, of Malta ;^ who says that he tliought 
 of it while reflecting upon those instances where the foetus having 
 reached a certain period of development dies prior to birth, the 
 mother in this way sometimes bringing forth a succession of dead 
 infants. He was disposed to attribute the occurrence to debility 
 or inertia of the uterus; and in searching for means to invigorate 
 the condition of this organ without inducing its contractions he 
 remembered Sydenham's commendations upon assafoetida in 
 hysteria and especially in cases of debility of the womb. Whether 
 these views are correct or not it is certain the medicine does great 
 good, especially in nervous susceptible women who are so prone 
 to abort. The dose whicli I usually administer is about five 
 
 ' Zeitschrift fiir Geburtsljiinde, Band xxvi, pp. 339, 355. Berlin, 1849. 
 ^ Medico-Cliiiiirgical Review. New Series, vol. vi, p. 266. London, 1S47.
 
 262 THE PREMATURE EXPULSION OF THE FCETUS, 
 
 grains of the extract every night at bedtime, or each night and 
 morning; and I generally take care that the patient shall have 
 had from half an ounce to one ounce before arriving at that 
 period of her pregnancy at which she has formerly aborted. 
 Wlien the drug gives rise to dyspepsia vrith cardialgia, as it some- 
 times will, its use should be completely suspended for a few days, 
 unless a few doses of bismuth cures these symptoms. Beyond 
 causing a little indigestion, however, I have never seen any in- 
 jurious consequences from the prolonged use of assafoetida. On 
 the contrary, my estimation of its value has much increased since 
 first recommending it. 
 
 Where the previous interruptions to the pregnant condition 
 have been due to the efiect of the syphilitic poison, there is no 
 remedy for stopping the further ravages of this disease to be 
 compared with mercury. Iodide of potassium, chlorate of pot- 
 ash, nitric acid, assafoetida, &c., are in such instances worse than 
 useless. Mr. Langston Parker believes that when a woman has 
 been diseased previous to pregnancy, and at the time of concep- 
 tion has a well-marked constitutional syphilitic taint; or, if 
 healthy at the time of conceiving, she contract a primary sore, 
 and become constitutionally diseased early in her pregnancy ; 
 then, in either case, there may be a hope of cure, during gesta- 
 tion, with a prospect of preserving the child, if an appropriate 
 treatment be adopted. But, if the woman have been perfectly 
 healthy, previous to her conceiving, and the ovum be diseased 
 by the semen of a tainted father, and the mother become subse- 
 quently aft'ected through the medium of the foetus in utero, there 
 is little hope of cure till after delivery. 
 
 In administering mercury to pregnant women any one of the 
 usual preparations may be had recourse to ; but for many con- 
 siderations I frequently give the preference to the perchloride. 
 The chief reasons for this selection are the ease with which it can 
 be taken, the almost certainty that it will not produce salivation, 
 and the length of time for which it can be persevered with. 
 When required by the system, none of the functions of the body 
 are disturbed in any way by this preparation. Under its influence 
 the patients regain a state of sound health to which they may 
 have long been strangers ; they increase considerably in weight; 
 their secretions become perfectly natural ; and they eat and digest 
 and sleep well. Moreover, they lose that fearful mental depres-
 
 PROPHYLACTIC TREATMENT. 263 
 
 sion wliicli is sucli a frequent reeult of tlie contaminated state of 
 the blood. A dose of the perchloride, varying from the sixteenth 
 to the eighth of a grain, may be given twice or thrice daily, for / 
 two or three months; while it should be administered either in/ 
 solution or in a pill, and with a small quantity of henbane orl 
 conium to prevent any irritation of the intestinal mucous mem- \ 
 brane. Moreover, although the clieinist may regard a mixture 
 of the perchloride of mercury and bark as an unscientific com- 
 pound, yet experience has taught me that it is very valuable in 
 many cases where the influence of this metal is needed in an 
 enfeebled or strumous subject. A favorite formula, is one fluid 
 drachm (= gr. Jg) of the pharmacopoeial solution of the per- 
 chloride, the same quantity of the compound tincture of bark, 
 ten minims of the compound tincture of chloroform, and an 
 ounce of peppermint water. — In cases where it is necessary to 
 get the system quickly under the influence of mercury, the com- 
 bination of inunction with the mercurial vapor bath, will more 
 safely and easily eftect this than any other proceeding. "When a 
 patient comes under treatment soon after a miscarriage and before 
 again becoming pregnant, it is of course necessary that her hus- 
 band should undergo a mercurial course as well as herself. — 
 "With regard to the use of iodide of potassium in these cases I 
 can add but little to what has been already said. I have no faith 
 in its doing any permanent good ; and knowing its value in caus- 
 ing the menstrual flow in certain forms of simple amenorrhoea, I 
 should be afraid of its directly producing abortion. 
 
 When the history or symptoms in any particular case seem to 
 indicate that the previous foetal deaths have been due to disease 
 of the placenta, the treatment must — in the present state of our 
 knowledge — partake somewhat of an experimental character. 
 The foetal type of respiration resembles that of fishes; for just 
 as the blood of the fish is sent into the vessels of the gills to be 
 purified by the oxygen in tlie surrounding water, so the blood of 
 the foetus is sent into the tufts or terminal branches of the foetal 
 portion of the placenta to be exposed to the oxygen contained in 
 the maternal blood, JSTow Sir James Simpson has very inge- 
 niously suggested that by the administration of certain agents 
 we may render the maternal blood a more highly oxygenating 
 medium than it is ordinarily ; so that, when applied to the foetal 
 placental tufts, it may make up, by the quality or intensity of the
 
 •264 THE PKEMATURE EXPULSION OF THE FCETUS. 
 
 respiratory change which it there produces, for that loss of quan- 
 tity which is a necessary consequence of a portion of these pla- 
 cental tufts being already destroyed by disease.^ With this view 
 the patients have been kept constantly on small doses of alkaline 
 salts, such as chlorate of potash, nitrate of potash, bicarbonate 
 of soda, &c., given several times a day on an empty stomach ; just 
 as Dr. Stevens proposed to accomplish the purification of the 
 uon arterialized blood of fever and cholera patients. Sir James 
 Simpson generally gives from ten to thirty grains of the chlorate 
 of potash several times a day ; but whether this preparation really 
 does afford oxygen to the system or not may be considered a de- 
 batable question. It seems, however, certain that patients have 
 frequently spoken of a perceptible influence on the strength of 
 the movements of the foetus being exercised by these salts. And 
 clearly, if they act in the manner supposed on the maternal blood, 
 the foetus must, under their use, be placed in a better and purer 
 atmosphere; while in this purer atmosphere — so to speak — it 
 will be capable of living for a few weeks longer than it would 
 otherwise. Acting on the same principle I have prescribed the 
 peroxide of hydrogen, which has seemed to have had a favorable 
 action, more especially when given simultaneously with mild 
 chalybeates. Very possibly also, the latter may invigorate the 
 child, and prevent those placental diseases — such as fatty degen- 
 eration — which are perhaps connected with want of power in the 
 foetal economy or circulation. 
 
 There is another plan of treatment which is applicable to these 
 cases, as well as to those where foetal life has been extinguished 
 in successive pregnancies at about the same time from any cause. 
 This is, the induction of premature labor at about the seventh 
 or eighth calendar month. Probably every obstetric physician 
 has met with instances in which this practice has been success- 
 fully adopted. The following case is a good example of its 
 value : 
 
 III July, 1858, I delivered a lady of a .stillborn female child at the full 
 term of gestation. The placenta was affected extensively witii fatty degenera- 
 tion. 1'he result of the labor caused great mental distress to the parents, as 
 it was the third pregnancy which had ended in the same unfortunate manner ; 
 but it was not altogether unexpected by the mother, as no foetal movements 
 
 ' The Obstetric Memoirs ami CoMtribiitions of James Y. Simpson, M. D, &c. Edited 
 by Drs. Priestley and Storer. Vol. ii, p. 4.'J9. Edinburgh, 1S5(J.
 
 CURATIVE TREATMENT. 265 
 
 had been perceived for the fourteen previous days, and the lady had suffered 
 from weakness and great depression of spirits. A careful investigation of 
 the medical history of both the parents threw but little light on the case ; for 
 it could only be learnt that the mother had a hereditary tendency to phthisis. 
 On the 24th December, the catanienia ceased, after having been on for five 
 days ; ana a few weeks subsequently I was informed that my patient was 
 pregnant. When it was found at a later period, that this statement was correct, 
 permission was readily obtained to bring on premature labor when the eighth 
 month was reached. Accordingly on the 1st September, 1859, I introduced 
 a small sponge tent into the os uteri, and left it there. At the same time a 
 common exhausting glass was iVequently applied to each nipple. Uterine 
 contractions supervened on the following d;iy, which were kept up by the ad- 
 ministration of full doses of ergot ; until, after an easy labor, delivery of a deli- 
 cate female infant was safely accomplished. The mother made a speedy re- 
 covery; and in January, 1860, the child was strong and healthy. 
 
 Great stress has been laid by most writers on tlie necessity for 
 abstaining from the performance of surgical operations upon 
 pregnatit women. It has often been said that even the extraction 
 of a tooth has caused abortion. Without denying that it is as 
 well to be cautious under these circumstances, still I am sure that 
 mischief may arise from an excess of care. The evils which re- 
 sult from constant pain and sleepless nights, or which arise from 
 the employment of opiates to give temporary relief to suffering, 
 can scarcely be exaggerated. The shock of an operation, more- 
 over, is so greatly diminished by the use of chloroform, while 
 both the preparatory and subsequent treatment of patients are so 
 different to what they were a few years ago, that I am certain 
 surgical proceedings may now be safely resorted to which could 
 not formerly have been employed. 
 
 (2) Tlie treatment of Abortion ivhen expulsion appears unavoid- 
 able. — The measures to be adopted under these circumstances 
 require to be selected with g»eat caution; because unless the ex- 
 pulsion of the contents of the uterus seems to be quite inevitable, 
 attempts should be made to prevent it. On the other hand, care 
 must be taken to guard the patient from the dangerous conse- 
 quences of retaining the ovum when it is blighted or detached 
 from the uterus ; for under such circumstances it can only be re- 
 garded as an irritating foreign body. 
 
 Let us suppose that the practitioner is called upon to treat a 
 case of threatened abortion at the third or fourth month. Allow 
 that there is hemorrhage, slight rigors, pains in the back and 
 gioins, and general depression ; but that no complaint is made
 
 / 
 
 266 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 of frequently-recurring, betiring-clown, expulsive pains, like those 
 of labor. His first duty will be to make a careful vaginal exami- 
 nation. Then if the os uteri be found firm and unyielding, or 
 only slightly open, his efforts are to be directed towards control- 
 ling the hemorrhage and quieting the uterus. To accomplish 
 this, the strictest tranquillity is to be enjoined. All cold applica- 
 tions to the hypogastri uiu — so often resorted to — are to be avoided ; C 
 since they can only serve to drive the blood from the surface, and 
 probably to induce uterine contractions. Acid drinks, lemon- 
 ade, &c., may be freely given ; while ice to suck, or common 
 fruit water ices, will prove very grateful. With regard to drugs 
 much care is necessary. If the uterine fibres appear irritable, 
 t and we therefore wish to prevent contraction, then a full dose of 
 )*belladonna should be administered, giving it either by the mouth 
 or, often preferably, by the rectum. The beneficial effects of this 
 drug are usually very striking; and I have known it act effi- 
 ciently even when the os uteri has become somewhat dilated by 
 the action of moderate pains. Sometimes astringents do great 
 good ; no remedy of this class being more efficient than gallic/ 
 acid in frequently-repeated doses of ten grains. In my hands, 
 no drug has proved more useless than the often-vaunted acetate 
 of lead, unless given in very much larger quantities than are 
 usually prescribed. Supposing the os uteri, instead of being 
 firm, is found soft and relaxed, belladonna will do harm. I 
 have then found the compound tincture of cinnamon a valuable 
 medicine. Two drachms should be given every two or three 
 hours, until the bleeding ceases, or until a sense of nausea is 
 experienced. Where the hemorrhage is rather abundant, the 
 gallic acid may be advantageously prescribed in combination 
 with the cinnamon; or the officinal glycerine and gallic acid 
 will be found an elegant, preparation. When the patient is 
 weak and ansemic, the tissues soft, and the circulation languid, 
 the ammonia iron-alum 'is preferable to the cinnamon and gallic 
 acid ; ten grains being administered in distilled water every four 
 or six hours.' 
 
 1 Dr. Burns speaks very hijjlily of the effects of arsenic in the hemorrhage of threat- 
 ened ciljortioii, but US I have had no experience of tlie utiitity of this metal in such cases, 
 it is not mentioned in the text. This gentleman says that he knows of no remedy so 
 prompt in arresting not only the hemorrhage but the uterine contractions. He gives 
 twenty (lro|)s of Fowler"s solution at once, and then ten (irops every ten minutes. This 
 agent is stated to be equally vaUiable in menorrljagia, and in cases of prolonged or ex- 
 cessive lochial discharge. — American Journal of Medical Sciences. New Series, vol. 
 xxxviii, p. 393. Philadelphia, 1859.
 
 CURATIVE TREATMENT, 267 
 
 In cases where the hemorrhage is very profuse we may he \ 
 sure that there is a consiclerahle separation of tlie ovum from 
 the uterus ; while the chances of preserving the foetus will be I 
 small. ISTevertheless, we may try to j)revent, ,exp,ulsionj, and in i 
 such cases iio^ingle remedv is so valuable as opium. The diffi.- \ 
 culty with this drug is to give such a dose as will induce enough 
 uterine cont raction to close the orifices of the bleeding vessels, 
 I and uoniiJXe. \If the contractions go on beyond this point, the 
 expulsion of the fcetus will occurs As a general rule it will be 
 better not to commence with a larger dose than one grain. 
 
 When an abortion seems to be impending it sometimes hap- 
 pens, on making a small vaginal examination, that a mass can 
 be felt protruding through the os uteri. Now it is not always a 
 very easy matter to decide whether this is an ovum, or merely a 
 coagulum of blood. Perhaps, the patient is not even pregnant; 
 there being merely a clot of blood at the mouth of the womb, 
 the consequence either of hemorrhage from a tumor or of a re- 
 tention of the menses. The distinction between a clot and an 
 ovum is on all grounds very important therefore. If in preg- ^ 
 nancy we attempt to remove a clot when the ruptured vessels ' 
 are plugged with it, we shall be directly doing that which it 
 ought to be our object to prevent. Hence, to decide this point, 
 the practitioner must keep his finger in contact with the sub- 
 stance lying in the os uteri, and wait for the accession of a pain; 
 * and then ascertain whether the presenting mass becomes tense, 
 advances lower, and increases somewhat in size, as will happen 
 when it is the ovum. " On the other hand, if it be a coagulum, 
 which it is weir""EiTbwn assumes a fibrous structure, it will nei- 
 ther become tense nor descend lower, but be rather compressed.— 
 Generally speaking, the ovum feels like a soft bladder, and at 
 its lower end is rather round than pointed; whereas a plug of 
 coagulum feels harder, more solid, and less compressible, and is 
 more or less pointed at its lower end, becoming broader higher 
 up, so that we generally find that the coagulum has taken a com- 
 plete cast of the uterine cavity. If we try to move the uterus by 
 pressing against this part, it will instantly yield to the pressure 
 of the finger, if it be the ovum ; whereas the extremity of a co-C 
 agulum under these circumstances is so firmly fixed, that when |^ 
 pressed against by the finger the uterus will move also. When 
 abortion happens at a later period of pregnancy, 'we shall be able
 
 268 THE PREMATURE EXPULSION OF THE F(ETUS. 
 
 to feel the different parts of the child as the os uteri gradually 
 dilates; viz., the feet, or perhaps the sharp edges of hones, 
 although we cannot distinguish the form of the head, from the 
 cranial hones being so compressed and strongly overlapping 
 each other. "^ 
 
 Where the bleeding is so continuous as to endanger life, or 
 when it occurs in combination with uterine contractions, and 
 particularly with rupture of the membranes, then the expulsion 
 of the product of conception is to be hastened With this object 
 the OS uteri may be irritated and dilated by the introduction of 
 the finger, while the ergot of rye should be given in sixty-grain 
 doses every half hour. Where the symptoms are not urgent, it 
 will often be advisable to trust at first to the natural efforts alone; 
 the practitioner contenting himself with watching that no unto- 
 ward circumstances arise. If the uterine contractions, however, 
 are slight, a dose of ergot — with or without fifteen or twenty 
 grains of borax — can do no harm ; while by making the pains 
 stronger, it may help to cause the detrusion of the ovum entire, 
 a circumstance which is much to be desired. Not unfrequently 
 the OS uteri dilates so very slowly, that the expulsion is consider- 
 ably delayed. Under such circumstances, if serious flooding be 
 present, small pieces of ice should be passed into the vagina, or 
 enemata of cold w^ater can be repeatedly used ; but these failing, 
 the tampon or plug is the only resource. The best material with 
 which I am acquainted for plugging the vagina is cotton-wool ; 
 small pellets of this substance being introduced one after the 
 other, and pushed right up, and even into the os uteri, until the 
 vagina is quite full. Dewees recommends the use of a sponge 
 large enough to fill this canal, soaked in vinegar. The blood 
 gets infiltrated into the pores of the sponge, and coagulating, 
 forms a large clot; which not only seals up the vagina hermet- 
 ically, but is borne without inconvenience for many hours. 
 Whatever material be used, care must be taken to ascertain that 
 the body oF the uterus is not afterwards enlarging under the in- 
 fluence of internal hemorrhage; an occurrence which is not 
 likely to take place, however, unless the pregnancy has advanced 
 to the fifth month. Wlien the plug is withdrawn at the end of 
 twelve hours or so, the mouth of the w^onib is generally found 
 
 ' llolil On 01)stetric Exploration. Quoted from Dr. Rigby's System of Midwifery, 
 p. 93. Loinlon, 1844.
 
 CURATIVE TREATMENT. 269 
 
 fully dilated, and the foetus and membranes projecting through 
 it ; so that these structures can be readily removed by hooking 
 the finger into them, or by seizing them with a pair of properly- 
 made forceps. 
 
 In cases where the foetus is expelled alone, and the placenta 
 and membranes do not at once follow, it may be advisable to 
 wait about an hour — provided there is no bleeding — to allow the 
 uterus to throw them off" spontaneously. If this practice fails, 
 attempts must be made to remove the structures. The ergot of 
 rye wnll often excite contractions, and cause the uterus to empty 
 itself Or two of the fingers may be introduced into the uterine 
 cavity, and the mass taken hold of; or a pair of slender forceps, 
 deeply grooved at the extremity, can be gently passed, and the 
 substance seized and withdrawn. Galvanism may also occasion- 
 ally be resorted to, in the place of these measures ; the positive 
 pole of the battery being applied to the upper part of the spine, 
 and the negative to the cervix uteri through a glass tube. In 
 every instance, stimulants should be freely administered if the 
 w^oman be much exhausted; while she should not be left until 
 the hemorrhage has been controlled, nor until the system has 
 rallied. 
 
 Before concluding this chapter it ought to be noticed that the 
 following train of symptoms sometimes occurs, and places the 
 patient's life in great danger : 
 
 A woman aborts at about the third or fourth month, and the substance 
 expelled is thrown away instead of being examined by the medical man. 
 For the succeeding twelve or twenty days everything has progressed most 
 satifsfactorily, so that the usual habits of life have been resumed. But sud- 
 denly, possibly after a little more exertion than ordinary, a violent attack of 
 flooding sets in, giving rise to great depression and alarm ; and the prac- 
 titioner is hastily summoned. He, finding no general symptoms to account 
 for the hemorrhage, very properly makes a vaginal examination ;• but merely 
 discovers that the os is small and contracted, the cervix only slightly or not 
 at all developed, and the body of the uterus perhaps rather larger than com- 
 mon. Under the influence of rest, astringents, ergot, galvanism, the plug, 
 or the unassisted efi'orts of nature, all bleeding ceases in the course of a day 
 or two; but the cessation is of short duration, for the same symptoms return, 
 and the patient becomes greatly prostrated. Again, and perhaps again this 
 happens, unless a correct diagnosis be formed, and proper treatment adopted. 
 The cause of the mischief in all probability is the retention of a small por- 
 tion of the ovum, perhaps — as in the case of Mr. Humphreys already quo- 
 ted — of a piece not larger than a shilling; and unless this is got away, the 
 hemorrhage is very likely to return, and in the end to prove fatal.
 
 270 THE PREMATURE EXPULSION OF THE FCETUS. 
 
 The treatment I have successfully practised under such cir- 
 cumstances as those just described, and which I would therefore 
 strongly recommend, is this : The mouth of the womb is to be 
 dilated by the introduction of sea-tangle or sponge tents ; a small 
 one being first employed, which at the end of twenty-four hours 
 is to be replaced by a larger one, and this by another, until the 
 requisite amount of dilatation be obtained. By means of the 
 finger passed into the uterine cavity, or by the aid of a pair of 
 forceps, the piece of ovum is to be drawn away ; a proceeding 
 which can generally be accomplished provided the substance is 
 not very rotten, or is not firmly adherent to the walls of the 
 uterus. In the event of the latter being the case, the cavity must 
 be explored by the finger to discover the seat of attachment ; and 
 then the substance is to be scraped away either by liecamier's 
 curette or by Simpson's uterine gouge. In careful hands the 
 adoption of this mode of treatment will be followed only by the 
 best results. The bleeding will permanently cease; while ferru- 
 ginous tonics, with a free animal diet, will ultimately restore the 
 patient to perfect health. After an abortion of even a favorable 
 character, as much caution and care will generally be required 
 as after a labor at the full term. Strict rest in bed should be 
 enjoined for a few days ; a nourishing diet, with or without stimu- 
 lants, is to be allowed ; and opiates, cooling aperients, or astrin- 
 gent tonics are to be given, according to the indications present. 
 Only a gradual return to the usual occupations is to be per- 
 mitted ; and it will be advisable to forbid sexual intercourse 
 until a week or two after the general health has been completely 
 re-established.
 
 AN EARLY OVUM. 271 
 
 CHAPTER VI. 
 
 THE EXAMINATION OF SUBSTANCES EXPELLED FROM THE UTERUS, Etc. 
 
 1. An early ovum — Mode op examining it — The appearances of the decidual cov- 
 erings — Decidual cotyledons, and their office. — 2. Moles — The nature of 
 these substances. — 3. The vesicular mole — Its origin in cystic disease of the 
 chorion — General characters op the disease. — May true hydatid cysts be 
 formed in utero? — 4. The menstrual decidua — Its identity with the true 
 decidual covering op the ovum. — 5. MembrAnous formations from the vagina 
 — Exfoliation op the vaginal epithelium. 
 
 The practitioner of obstetric medicine is not imfrequently 
 called upon to give an opinion as to the nature of some sub- 
 stance wbicli lias been expelled from tbe uterus or vagina ; and 
 especially perhaps may he be required to say whether such sub- 
 stance is the result or not of conception. The fair fame of more 
 than one chaste woman has been blotted by the ignorance or 
 carelessness of the examiner, under these circumstances ; but it 
 is to be hoped that the days when such errors were made have 
 permanently passed away. 
 
 The substances which maybe expelled from the female organs 
 of generation, and the structure of which may be disputed, are 
 these: (1) An early ovum ; (2) A mole; (3) A vesicular mole : 
 (4) The menstrual decidua ; and (5) Membranous formations 
 from the vagina. These will now be considered seriatim. 
 
 1. An Early Ovum. — Within the first month, the ovum, is 
 generally so broken up during its expulsion, that its texture can 
 hardly be recognized. This is not the case after the fourth or 
 fifth week, when the structure usually remains sufiiciently dis- 
 tinct to allow of its nature being niade out by a careful scrutiny. 
 To examine the mass properly, it shoukl be soaked in water for 
 a day or two, so as to remove the coagulated blood with which 
 it is infiltrated. The component parts are then to be cautiously 
 and slowly separated under water. It frequently happens, that 
 although we fail to find the embryo, yet we may be able to
 
 272 
 
 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 recognize the ovum sufficiently to assert that it is the product of 
 conception. Should an embryo or a portion of one be discovered, 
 however, the nature of the substance is of course decided. 
 
 Fig. 10. 
 
 AN ABORTED OVUM IN THE SECOND MONTH. (After Wagner.) 
 
 A fragment nf the dccidiia vera, o ,■ deridua rcflexa, h; albmnen, c, lying between the chorion, c. and 
 the amnioi, d ; tliH crabryo, //. floiitin^ in liinior amnii; unihiliciil vesicle./, connected with the intes- 
 tine of the embryo by a slender prolongation — the vitelline or umbilical duct. 
 
 In an early abortion, the whole lining of the uterus, together 
 with the decidua reflexa or ovuli, is frequently thrown off entire; 
 constituting a somewhat triangular-shaped cast of the uterine 
 cavity. The outer surface of tlie mass consists of a soft and red 
 and uneven or shaggy pulpy membrane — the uterine decidua; 
 the internal surface of which is smooth, generally thrown into 
 slight folds, and studded with very minute depressions, which are 
 scarcely perceptible to the naked eye. These characters are 
 perhaps scarcely sufficiently distinctive to enable us to speak 
 positively as to the nature of the substance. But there is another 
 remarkable feature in the organization of this pe.culiar product, 
 which was first pointed out by Dr. Montgomery, and which he 
 thus describes : " licpeated examinations have shown me that 
 there are, on the external surface of the decidua vera, a great
 
 I 
 
 AN EARLY OVUM. 273 
 
 number of small cup-like elevations, having tlie appearance of 
 little bags, the bottoms of which are attached to, or embedded in 
 its substance ; they then expand, or belly out a little, and again 
 grow smaller towards their outer or uterine end, which, in by far 
 the greater number of them, is an open mouth when separated 
 from the uterus ; how it may be while they are adherent I can- 
 not say. Some of them, which I have found more deeply em- 
 bedded in the decidua, were completely closed sacs. Their form 
 is circular, or very nearly so ; they vary in diameter from a twelfth 
 to a sixth of an inch, and project, about the twelfth of an inch, 
 from the surface of the decidua. Altogether, they give one the 
 idea of miniature representations of the suckers of the cuttle- 
 fish\"^ This author regards these "decidual cotyledons" — or 
 " Montgomery's Cups," as they are now often termed — as reser- 
 voirs for nutrient fluids separated from the maternal blood, to be 
 thence absorbed for the support and development of the ovum. 
 The fact, that during the early periods of gestation the ovum 
 derives its nourishment by imbibition through the connection 
 existing between the decidua and the villi on the outer surface 
 of the chorion, renders the correctness of this opinion highly 
 probable. Moreover, as the decidua is now known to consist of 
 the hypertrophied mucous membrane of the uterus, so it is almost 
 certain that these cups are identical w^ith those utricular glands 
 or follicles which are found as a system of tortuous canals rami- 
 fying through this membrane in the unimpregnated state. 
 
 Internal to the uterine decidua is the ovular or chorial decidua, 
 the outer surface of which is nearly smooth, while the inner is 
 marked by irregular depressions or shallow pits leading to tortu- 
 ous canals. These lacunae have been occupied by the arborescent 
 villi which shoot from the surface of the chorion, and which thus 
 form the bond of union between the foetal and the maternal 
 membranes. These villi are never found but on the chorion or 
 uterine surface of the placenta ; and hence their discovery is a 
 sufficient proof of the nature of the substance under examination. 
 
 In abortions occurring during the first six or seven weeks, it 
 not unfrequently happens that the ovular decidua with the em- 
 bryo and remainder of the secundines is thrown oft" separately 
 from the uterine decidua, this membrane becoming detached 
 
 1 The Signs and Symptoms of Pregnancy. Second edition, p. 253. London, 1856. 
 
 18
 
 274 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 subsequently. Sometimes, also, the embryo comes away alone 
 at first, and is followed by the secundines; although this rarely 
 happens until the formation of the placenta is further advanced 
 tlian it is by the end of the second month. 
 
 It is important to remember that an embryo may die, and either 
 remain as a little lifeless mass, or become broken up and lost, and 
 yet that its membranes may not be expelled for weeks or months 
 afterwards. Thus, a woman becomes pregnant just before her 
 husband leaves for a voyage of eight or nine months' duration. 
 On his return, an ovum of the second or third month happens to 
 be expelled. Kow unless we can explain this circumstance, the 
 woman may have the most unjust suspicions cast upon her repu- 
 tation. At one of the meetings of the Pathological Society, Mr. 
 Thomas Ballard exhibited a specimen for the purpose of proving 
 the truth of this observation.^ The preparation consisted of a 
 portion of ovum, resembling a small placenta, from which the 
 cord and thinner portions of membrane had disappeared ; and it 
 was expelled on the 4th March, 1857, after a modified labor of 
 six hours' duration, attended with a good deal of hemorrhage. 
 The evidence adduced of its having been retained until the full 
 period of gestation was as follows: In October, 1856, the patient 
 engaged Mr. Ballard to attend her in her expected confinement 
 in the following March ; she being then four months advanced 
 in pregnancy. The catamenia had not appeared since the middle 
 of June. The usual signs of pregnancy existed until the 18th 
 October. Then she had a discharge of blood, which continued 
 until Christmas, though only very slightly after the first two 
 days. She had also during this time constant pain in the back, 
 while she no longer increased in size; but she was not conscious 
 of a solid substance having passed from her at any time. The 
 pain and slight hemorrhage entirely ceased at Christmas. After 
 this date she had a continued discharge of watery fluid and 
 whites, but no return of pain until the specimen exhibited was 
 expelled at the beginning of March. 
 
 A separated ovum presenting at the partially-dilated os uteri 
 has been mistaken for a polypus ; or, conversely, a polypus may 
 be regarded as a dead ovum. In either case, the mistake is 
 generally due to the abundant hemorrhage which the foreign 
 
 ^ Transactions of the Pathological Society of London, vol. viii, p. 2S1. London, 
 1857.
 
 MOLES. 275 
 
 body gives rise to. But if any doubt be felt by tbe practitioner, 
 an examination with the speculum will remove the uncertainty. 
 For as regards a polypus, the projecting part is seen to be of a 
 bright red color, with blood exuding from it. This is a condition 
 never witnessed with an ovum. To the touch also, there is a 
 feeling of greater firmness communicated by a polypoid tumor 
 than by the membranes of the embryo, even though the latter 
 are infiltrated with coagulated blood. In either case, an erroneous 
 diagnosis is not of much consequence. For whatever the nature 
 of the body ma}' be, it must be removed ; the risk of flooding 
 being considerable until extraction is accomplished. On draw- 
 ing down the polypus, of course the pedicle will be seen or felt, 
 and this will have to be divided. In taking away the ovum, the 
 chief point requiring attention is to bring away the whole of the 
 mass. 
 
 2. Moles. — Much difference of opinion has existed among au- 
 thors as to the nature of those substances which are commonly 
 described under the term of moles. This confusion has chiefly 
 arisen from very various substances having been indiscriminately 
 classed together under this epithet ; such as polypi, dysmenor- 
 rhceal membranes, condensed coagula of blood, decayed ova, &c. 
 
 My own opinion is that there are but four kinds of moles, 
 properly so called; and that they are all the result of conception. 
 Thus, we may have presented to us the deciduae with both its 
 layers and cavity infiltrated Vv^ith blood ; or, a placenta which has 
 continued its growth after the death of the foetus; or, the degener- 
 ated remains of the placenta; or, the hydatidiform or vesicular 
 mole. 
 
 The _^rs^ substance may have its origin in thiswise: During 
 the earliest weeks of pregnancy, from a sudden shock or other 
 cause, blood is effused into the decidual cavity, filling it with a 
 clot, and generally obliterating all trace of the embryo. If the 
 substance be quickly expelled, it will exhibit the triangular shape 
 presented by the uterus at the commencement of gestation; but 
 if retained, firm layers of fibrine often become formed upon its 
 external surface, and it will perhaps increase to the size of an 
 orange or even get larger. Supposing no blood is poured into 
 the decidual cavity, either the entire embryo may be found, or 
 only a portion of it ; while the cleciduse with the coagulated fibrine
 
 276 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 form a pale yellowish and fleshy envelope, varying from the 
 eiffhth of an inch to one inch in thickness. 
 
 The second species of mole arises, when the foetal germ, dying 
 soon after conception, becomes atrophied or absorbed ; although 
 the placenta and membranes continue to grow. These tissues 
 derive their nourishment from the inner surface of the uterus; 
 and they become transformed by progressive development into 
 an indistinctly fleshy and vascular mass. This may be retained 
 in the uterus for several months ; giving rise during the whole 
 time to many of the symptoms of normal pregnancy, together 
 generally with repeated attacks of flooding. Sometimes the hem- 
 orrhage is almost constant; in many cases it comes on irregularly 
 after undue excitement; while in others it is periodical, and sim- 
 ulates an attack of ordinary monorrhagia. 
 
 The third and most uncommon form of mole consists merely 
 of the placenta or a portion of it ; which, having been imper- 
 fectly nourished on the uterine surface, has become almost an 
 amorphous mass. Usually, entire groups of the villi are found, 
 on a microscopic examination, to have been altered; the most 
 frequent metamorphosis consisting of an infiltration of a grayish- 
 brown molecular substance, which destroys their transparency 
 and renders them more or less opaque. In the early stages of 
 this disease, the opacity is confined to the clavate extremities of 
 the villi ; but as the accumulation increases, the whole of each 
 villus gets infiltrated. As the villi furtlier degenerate, their diam- 
 eter becomes lessened; and groups of them collapse. The tissues 
 of tlie stems of the villi are also frequently seen to be in a state 
 of fatty degeneration ; and this change may sometimes be found 
 afiecting the arteries of the umbilical cord at their insertion into 
 the placenta. The aft'ected portions of the placenta are generally 
 observed to be quite bloodless. If this degeneration of the villi 
 occur at an early period, the embryo will not be found; as it has 
 probabl}' been partly or completely dissolved. The remains of 
 the umbilical cord, enlarged and pulpy, may sometimes be made 
 out; the free extremity being ragged or shreddy. 
 
 Organized bodies, somewliat resembling to the naked eye these 
 masses of degenerated placenta, are now and then discharged 
 from the uterus. They are usually pale-colored and soft and 
 oval-shaped substances of variable size; they are frequently mixed 
 with coagula ; no chorion villus can be discovered in any portion
 
 THE VESICULAR MOLE, 277 
 
 of their structure, but merely connective tissue with cells of va- 
 rious kinds ; and there is no vestige of a cavity for the reception 
 of the embryo. It is probable that these substances merely con- 
 sist of a new formation of connective tissue ; this having been 
 produced on the uterine wall quite independently of impregna- 
 tion. As a rule, such structures are thrown ofi' and expelled by 
 the hemorrhage to which they give rise. After they have come 
 away, the os uteri may remain open and patulous and perhaps 
 slightly torn for some days ; there may be a thin colored discharge, 
 from a slight oozing of blood resembling tlie lochia; and the 
 breasts will possibly be found enlarged and tender. The areola 
 round the nipples, however, is seldom as dark as it is in preg- 
 nancy ; while the breasts do not contain milk. Nevertheless, 
 under these circumstances, an erroneous opinion might be formed 
 that the patient had been pregnant and aborted. To prevent 
 any mistake, the substance which has been expelled should be 
 carefully examined. 
 
 T\\Q fourth species of mole is of more importance than the other 
 varieties ; and hence may advantageously be treated of in a sec- 
 tion by itself: 
 
 3. The Vesicular Mole.^— The chorion is subject to certain 
 morbid alterations which are deserving of attention. The most 
 remarkable of these is the transformation of its villi into vesicles 
 or cysts, which are intimately united together by little pedicles. 
 The product thus arising from this cystic disease of the chorion 
 is known as the vesicular or hydatidiform mole ; the cysts being 
 likewise spoken of by some authors as "uterine hydatids." It 
 seems to me, however, very desirable to abolish altogether this 
 latter designation ; inasmuch as it conveys and perpetuates an 
 erroneous impression as to the^nature of these bodies. Cruveil- 
 hier first demonstrated their non-hydatid nature ; and all suc- 
 ceeding observers who have carefully examined their structure 
 have confirmed the statements of this distinguished author. 
 
 The general characters of this disease can be studied in any 
 pathological museum, and hence they are generally well known. 
 A portion, or perhaps the whole, of the chorion is found covered 
 with pellucid vesicles containing a limpid serous fluid ; each ves- 
 icle having long and slender and often branching pedicles. The 
 sacs are oval or pyriform-shaped ; their walls are clear, or marked
 
 278 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 with opaque clots; and they may be simple, or may present other 
 cj'sts projecting from their tissues. Two questions will arise in 
 the mind of the physician who examines a vesicular mole. First, — 
 What is the nature of the change in the chorion villi which re- 
 sults in the production of these vesicles ? And second, — What 
 causes the change? — With regard to the first question, Metten- 
 heimer insists that these bodies are cysts ; and Paget adopts the 
 same view. The mode in which their formation probably takes 
 place is thus described by these pathologists : Certain of the 
 cells in the proper villi of the chorion, deviating from their cell- 
 form, and increasing disproportionally in size, form cysts, which 
 remain connected by the gradually elojigated and hypertrophied 
 tissue of the villi. On the outer surface of the new- formed cysts, 
 each of which would, as it were, repeat the chorion, and surpass 
 its powers, a new vegetation of villi sprouts out, of the same 
 structure as the proper villi of the chorion. In these begins 
 again a similar development of cysts; and so on ad infinitum.' 
 Each cyst, as it enlarges, seems to lead to the wasting of the cells 
 around it; and then, moving away from the villus in which it 
 was formed, it draws out the base of the villus, which strengthens 
 itself, and forms the pedicle on which the cyst remains suspend- 
 ed.^ — Now Gierse, and subsequently Dr. Graily Hewitt, have dis- 
 sented from these opinions. In a specimen which the latter 
 gentleman had the opportunity of submitting to microscopic ex- 
 amination, he found the vesicular bodies to possess the same 
 structure as that of normal chorion villi ; but the cells on the 
 surface were wider apart, and the villi were distended by a serous 
 fluid, giving rise to the enlargements. From this it would ap- 
 pear that in the healthy villi and in the altered ones we have 
 precisely the same structures ; and hence it cannot be necessary 
 to have recourse to a cyst theory to account for the appearances. 
 If these observations be correct it necessarily follows that in the 
 vesicular mole we have not a new formation, but simply an alter- 
 ation and degeneration of existing structures.^ 
 
 The second question to be considered is, — What are the cir- 
 cumstances which induce this pathological change ? On this 
 
 1 Lectures on Surgical Patlioloiry, delivered at the Royal College of Surgeons of Eng- 
 land. By James Paget, F R.S. Revised and edited by William Turner, MB., &e. p. 
 421. London, 1863. 
 
 2 Transactions of the Obstetrical Society of London. Vol. i, p. 249. London, 1860.
 
 THE VESICULAR MOLE. 279 
 
 point Dr. G rally Hewitt differs materially from other observers. 
 It has been universally supposed that tlie transformation in the 
 ; villi of the chorion was the starting-point of the aifection: in 
 '■^ other words, that the disease of the chorion was the cause, the 
 death of the embryo the eifect. On the contrary, this gentleman 
 contends that the death of the embryo occurs first, and the chor- 
 ionic transformation subsequently. Reargues, as just noticed, that 
 the hydatidiform mole results from a degeneration of structures 
 arrested in their development. Death of the embryo involves 
 arrest of chorionic development, but not necessarily cessation of 
 vitality in the chorion villi ; for these may continue to grow pro- 
 vided the decidua be not separated from the uterus, and this 
 peculiar growth will then result in the formation of the vesicular 
 mole. — After attaining a certain degree of development, the cho- 
 rion villi do not appear to be capable of undergoing the change 
 in question. The conditions necessary for that change are not 
 present; and if the foetus dies, no hydatidiform mole can be pro- 
 duced. The middle or end of the third month is probably the 
 limit within which the alteration can originate. In most of these 
 cases no trace of the embryo is to be found ; or if found, it is very 
 small, and very strikingly disproportionate to the bulk of the 
 mole. The evidence on this point shows, then, that the embryo 
 perishes at so early a period as often to leave no traces behind 
 it; or, in other words, that it does not survive a period, which 
 may be roughly fixed as the end of the second month. 
 
 The question has sometimes been raised as to whether a portion 
 of the fully developed placenta left in the uterus — that portion 
 extracted at the time of labor being free from cystic degeneration 
 — can subsequently become the seat of hydatidiform disease ? 
 Thus, a pregnant ^voman loses her husband : at the time of labor 
 part of the placenta is retained : this portion may undergo — let 
 us for a moment suppose — cystic degeneration and become en- 
 larged, so that when expelled some weeks or months afterwards 
 it will give rise to most injurious suspicions against the widow's 
 virtue. Now, can this really happen ? In the present state ot 
 our knowledge it must only be replied that such an occurrence 
 is in the highest degree improbable ; but there are two conditions 
 which forbid my saying that it is impossible. One possible oc- 
 currence is, that a small portion of the chorion villi may have 
 become accidentally separated from the embryo at an early period,
 
 280 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 and have been then altered ; while the remainder has grown 
 normally. The other condition which should be admitted arises 
 in cases of twin gestation, when one ovum perishes at an early 
 date and the chorion villi degenerate. The diseased mass may 
 then be retained after the expulsion of the healthy foetus at the 
 normal termination of gestation ; or it may be expelled some 
 weeks previously without interfering with the other embryo and 
 placenta. This latter occurrence seems to have taken place in 
 the case of the celebrated anatomist Bdclard ; whose mother when 
 she was about four months advanced in pregnancy with him, 
 expelled a large vesicular mole. 
 
 The vesicles when expelled vary in sjze from a pin's head to 
 a large grape, being connected with each other in bunches by 
 very fine pedicles. They generally also exist in great numbers, 
 so as to form large flocculent vesicular masses the size of the 
 adult head ; while when expelled they are tinged with blood, sa 
 that if placed in water they will often be found to resemble — to 
 use the grapliic words of Dr. Gooch — " myriads of little white 
 currants floating in red currant juice." The symptoms which 
 indicate their presence in the uterus are not sufliciently distinct 
 or constant to be entitled to much confidence ; for they merely 
 consist of some of the early signs of pregnancy, — such as sup- 
 pression of the catamenia, a mammary areola of about the second 
 or third month, perhaps morning sickness, with enlargement of 
 the abdomen and uterus. The most characteristic symptom, 
 however, is the frequent occurrence of irregular uterine dis- 
 charges — sometimes of blood, oftentimes of water. In many 
 cases it has been also noticed that the uterus is disproportion- 
 ately large for the supposed period of pregnancy ; while it gives 
 the impression of being less firm than in healthy gestation. 
 Sometimes, a loud uterine souffle may be heard. It need 
 scarcely be said that there is an absence of fcetal movements, 
 and that "no foetal heart-beat can be detected ; although it is not 
 uncommon for the patient to assert that she can distinctly feel a 
 child. Occasionall}^ the pregnancy goes on to the time when it 
 should naturally end, — that is to say for nine months from the 
 day of fecundation; at which period labor pains set in, accom- 
 panied with hemorrhage. Unless the practitioner recognizes 
 the nature of the case in good time, and empties the uterus by 
 the introduction of his hand, the flooding may prove fatal before
 
 THE VESICULAR MOLE. 281 
 
 tlie womb throws off its morbid contents spontaneously. When 
 the mass has been entirely removed or expelled, the uterus con- 
 tracts as after a natural labor. Milk will even be abundantly 
 secreted by the breasts for a few days ; and there may follow a 
 kind of locbial discharge. A practitioner, called in for the first 
 time two or three days after such a delivery, miglit imagine that 
 an infant had been born and made away with; while the patient, 
 if she had received no medical attendance, and had thrown away 
 the vesicular mole, would be placed in an awkward predicament. 
 Her description of the mass would have to be trusted to, more 
 conclusive evidence being unobtainable. And the phj'sician, 
 remembering the foregoing facts, would at least be wise to give 
 her the benefit of any doubt he might feel.^ 
 
 In conclusion a few words may be said upon the question as 
 to whether true hydatids can be discharged from the uterus. It 
 seems to me that the bare possibility of this occurrence is not 
 to be denied. Just as hydatid tumors may form in the liver, 
 spleen, omentum, muscular structure of the heart, and bones, 
 &c. ; so there is no reason why they should not arise in the 
 walls of the uterus, and acephalocysts be discharged by the 
 vagina owing to the rupture of the tumor into the uterine 
 cavity. So rare, however, is this occurrence, that I only know 
 of one recorded instance of it. Rokitansky, speaking of this 
 disease, states — "Cysts are very rarely formed in the uterus ; we 
 have not met with a single example in Vienna, and I mj'self 
 have only inspected one case of uterine acephalocysts,"^ Should 
 another such instance occur in the practice of any one of my 
 readers, he will find no difficulty in deciding upon the true 
 nature of these parasitic bodies.-'' 
 
 ^ TVie remarks in the text of course show that I believe tliese vesicular moles to be 
 undoubtedly due to a prior act of fecundation. The only recent author of any note who 
 decidedly maintains the oppot^ite opinion is Dr. Bedford. This iientleman, aiguing 
 from the often fallacious guide of analogy, says: "There is innch discrepaiipy of opinion 
 as to the cause of these hydatid growths. The weiglit of testimony appears to refer 
 their origin to conception, n)any authors of high name contending that the presence of 
 these growths is undoubted evidence of previous pregnancy. That a diseased ovum 
 may form the nucleus of hydatid development in uiero. cannot be denied. But, on the 
 other hand, we believe that they may exist independently of conception, in the same 
 way that polypi, fibrous tumors, and various other substances, sarcomatous and osseous, 
 are occasionally found in the virgin womb." Clinical Lectures on the Diseases of 
 Women and Children. By G S. Bedford, M.D. Fourth edition, p. 43. New York, 1856. 
 
 2 A Manual of Pathological Anatomy. By Carl Rokitansky, M.D., &c. Sydenham 
 Society's Edition. Vol. ii, p 291. London, 1849. 
 
 ^ See the author's Practice of Medicine, Fifili Edition, p. 547, for an account of the 
 hydatid tumor and its structure, &c.
 
 282 SUBSTANCES EXPELLED FROM THE UTERUS. 
 
 4. The Menstrual Decidua. — When we examine, with a 
 quarter-inch object-glass, the normal catamenial fluid, it will 
 generally be seen to contain a considerable quantity of epithe- 
 lial debris; showing thereby tliat the healthy mucous membrane 
 lining the uterus has a periodical tendency to shed its superficial 
 cells. The uterine mucous membrane becomes congested and 
 swollen, I believe, in most women at each monthly period. But 
 in some forms of dysmenorrhcea it gets more hypertrophied ; and 
 then being exfoliated, is expelled with distressing bearing-down 
 pains in the menstrual discharge. This dysmenorrhoeal mem- 
 brane is generally passed in fragments; but ever}' now and then 
 it comes away whole, forming a complete triangular-shaped cast 
 of the entire uterine cavity. It is rough exterjially, having a 
 cribriform appearance, produced by the pores of the utricular 
 follicles or glands ; whilst internally it is smooth and moist. 
 The menstrual decidua is in structure identical with the true 
 decidual covering of the ovum; but it may generally be distin- 
 guished from it by the circumstance that it is more flimsy and 
 unsubstantial in character, that it is chiefly made up of layers 
 of flattened or cylindrical epithelium, and that its gland ducts 
 are very much smaller. 
 
 Occasionally small fibrinous substances, somewhat resembling 
 almonds in shape and size, are expelled from the cavity of the 
 uterus. These consist either of condensed coagula of blood, or 
 of a layer of coagulable lymph partially organized, or of dysme- 
 norrhoeal membranes around which blood has been eft'used. On 
 making a section of one of these latter masses, it will be found 
 to consist of an external coat of coagulated blood lined by the 
 membrane, the smooth surface of which is laid open by the in- 
 cision. Mad. Boivin has related a case where a tumor of this 
 kind was expelled, and where it was turned inside out; so that 
 the smooth surface of the membrane formed its external cover- 
 ing. She supposes this happened by the upper portion of the 
 membrane having been first detached from the uterus by blood 
 insinuating itself between the two surfaces, and forcing the ad- 
 ventitious sac inwards and downwards, until at length it was 
 completely inverted, and of course its surfaces reversed.^ These 
 substances are doubtless often due to some peculiar inflammatory 
 
 ' Traite Pratique des Maladies de lUterns, et de ses annexes. Par Mad. Boivin et 
 A. Dugfes. Tome ii, p. 419. Paris, 1833.
 
 MEMBRANOUS FORMATIONS FROM THE VAGINA. 283 
 
 action in tlie uterus producing false membranes, similar to those 
 morbid products occasionally found on hollow viscera lined with 
 mucous membrane. They are all formed quite independently of 
 sexual intercourse. 
 
 5. Membranous Formations from the Vagina. — Exfoliation 
 of the vaginal epithelium occurs in certain abnormal states of the 
 system, especially when astringent injections are being used ; the 
 epithelium mixed with mucus coming away in flakes, or being 
 passed in masses which form more or less perfect casts of the 
 flattened vaginal canal. These pseudo-membranous and parch- 
 ment-like patches are seen by the microscope to be composed of 
 squamous ef)ithelium ; they are generally found to be suificiently 
 strong and firm to bear free handling. Many museum prepara- 
 tions labelled " False Membranes from the Uterus," very possibly 
 consist in reality of these vaginal substances. 
 
 A very remarkable feature in the case of an unmarried lady 
 suffering from hysterical neuralgia, which simulated all sorts of 
 diseases, was the almost daily formation and expulsion, with con- 
 siderable pain, of these membranous casts of the vagina. Dr. 
 Montgomery, under whose care the lady was placed, says that 
 they were quite transparent, of a light straw color like gold- 
 beater's leaf, about two and a half inches long, hollow, the cavity 
 about an inch in diameter, and closed at one end but open at the 
 other. The patient had preserved three dozen bottles full. It 
 is remarked that they might easily have been mistaken for a por- 
 tion of the transparent membranes of the ovum. 
 
 The amount of suffering induced by the temporary loss of the 
 vaginal epithelium varies very much in different cases. Some- 
 times the smarting is acute, so that a tactile examination cannot 
 be borne ; but generally the epithelial coat is reproduced very 
 quickly, and then there is merely some slight itching and irrita- 
 tion. One patient complained of great uneasiness in sitting 
 down, and of a peculiar crawling sensation in the vagina ; while 
 another, under my own care, compared her pains to those felt 
 from a slight burn. Occasionallj', there is evidence of the exist- 
 ence of chronic inflammation — subacute vaginitis. Very often, 
 however, the local symptoms are inconsiderable; the practi- 
 tioner's attention being only directed to them when the patient 
 presents one of the membranous formations for examination.
 
 284 EXTRA-UTEKINE GESTATION. 
 
 CHAPTER VII. 
 
 EXTRA-UTERINE GESTATION. 
 1. Introduction : Changes which occur in the uterus in misplaced gestation — A 
 
 DECIDUA formed — The OVUM HAS ITS PROPER MEMBRANES, THE CHORION AND AMNION 
 — The GROWTH and death of THE FCETUS. — 2. VARIETIES — ThE TUBO-OVARIAN, 
 TUBAL, AND INTERSTITIAL ORTUBO-UTERINE. — 3. SYMPTOMS — THE CATAMENIA USUALLY 
 
 SUSPENDED — Mammary changes and morning sickness — Enlargement of abdomen 
 
 NOT symmetrical — SEVERE PAINS IN PELVIS — A CHARACTERISTIC CRY — SiGNS DE- 
 TECTED BY A VAGINAL EXAMINATION — The PHENOMENA WHICH FOLLOW RUPTURE OP 
 
 THE CYST. — 4. Treatment — The precautions needed to prevent or retard rup- 
 ture OP the cyst — The measures which offer a chance of moderating the 
 hemorrhage after laceration — The steps to be pursued after the extinction 
 of fcetal life. 
 
 1. Introduction. — The normal place of abode for the embrj'o 
 during gestation, it need scarcely be said, is the cavity of the 
 uterus. From some cause or other, however, it occasionally 
 happens that the impregnated ovum does not reach this part ; 
 and we then have, as a consequence, a form of extra-uterine 
 pregnancy. 
 
 Various kinds of misplaced gestation undoubtedly occur among 
 the lower animals, though it has been asserted by at least one 
 physiologist, that this accident is peculiar to woman. Probably 
 the earliest recorded instance is that by Felix Platerus ; who de- 
 scribes the case of a cow, which, in 1597, conceived again during 
 the retention of an extra-uterine calf ^ So, also, it has long since 
 been show^n that this abnormal from of pregnancy may occur in 
 the bitch and in the sheep ;^ while Haller describes a pregnancy 
 of this kind in the hare.^ In the bird it not unfrequently hap- 
 pens that the yolk or ovulum after escaping from its ruptured 
 capsule in the ovarj^, instead of passing down the oviduct escapes 
 into the peritoneal cavity ; where it either becomes absorbed, or 
 it will be retained without foetal development taking place, or it 
 
 1 Observationum in Hominis Affectibns pleri<qne, Corpori et Anirao Fiinctionutn 
 LtKsioue, Dolore, &o., p. "230. Basilete, 1641. 
 
 2 The Philosophical Transactions AbriHged, &c. Vol. v, p. 531. London, 1709. 
 
 ^ Dis()ut.ationes ad Morborum Histoiiam et Curationein Facientes. Tomus iv, p. 795. 
 Lausaiinte, 1758.
 
 INTRODUCTION. 285 
 
 may almost immediately cause the death of the hen. In these 
 cases the oviduct still secretes the albumen and membrane and 
 shell ; which are expelled without having any yolk in their in- 
 terior. 
 
 Doubtful examples of misplaced pregnancy in the human 
 female have been put on record, though not minutely described, 
 manj' centuries since ; but probably the first unmistakable case 
 of the kind is that related by Felix Platerus. This author — in 
 the volume already quoted from — reports that a concubine at the 
 end of her third pregnancy, in the year 1583, had labor pains for 
 eight days. These then subsided, without delivery taking place; 
 but some time afterwards a small tumor formed just above the 
 umbilicus, from which — on an incision being macle — a semi-putrid 
 foetus was extracted. The patient recovered, and survived the 
 operation one year. M. Cordj^eus, who was a contemporary of 
 Platerus, Gregory Horstius of the seventeenth century, James 
 Primerose, who practised at Hull, and whose remarkable work, 
 De MuUerum morbis et nymptomatis, was published in 1655, G. F. 
 Hildanus at the commencement of the seventeenth century, the 
 younger Piolanus about 1649, the Abbe de la Roque about 1682, 
 J. D. Santorinus in the eighteenth century, William Smellie, and 
 a host of writers since this time, have all reported instructive and 
 well-authenticated cases. 
 
 When this irregular form of gestation occurs, the same changes 
 take place in the uterus as happen in the early stages of healthy 
 pregnancy. The entire organ becomes enlarged and congested, 
 its texture is rendered soft and spongy, the arteries and veins 
 increase in size, and the mucous membrane gets hypertrophied 
 so as to form a true decidua. This decidua after a time loses its 
 vascularity and gradually degenerates and breaks up ; for having 
 no office to perform, it follows the law which regulates the decay 
 of all functionless organs. Dr. Robert Lee considers that the 
 deciduous membrane is not always, if ever, formed in the uterus 
 in extra-uterine conception ; but that it sometimes surrounds the 
 chorion. Almost all observers agree, however, that Dr. Lee is 
 in error ; it being the general opinion, that if in any particular 
 instance the decidua be not found, it is only because it has been 
 expelled by uterine contractions with the coagula and hemor- 
 rhagic discharges, either soon after, or just prior to, the death 
 of the foetus. Whether a decidua is also formed around the ovum
 
 286 EXTRA- UTERINE GESTATION. 
 
 in its abnormal position is uncertain ; Schroeder van der Kolk 
 asserting that such is the case, while Virchow denies it. A re- 
 view of the few trustworthy facts bearing on this point, which 
 have been recorded, leads me to believe that the sac containing 
 the ovum is not lined by a decidua. A delicate tissue, it is true, 
 can sometimes be found ; but this has only the structure of plas- 
 tic lymph or fibrine, all the elements of a decidual membrane 
 being absent. It is, however, certain, that in these foetations the 
 ovum has its own proper membranes — the outer chorion and the 
 inner amnion ; wliile most frequently an adventitious cyst is 
 developed around the whole substance, the growth and expan- 
 sion of which cyst only ceases with the termination of the foetal 
 life. 
 
 The walls of the cyst ma}^ vixvy in thickness from one to several 
 lines ; and usually they contract adhesions with all the surround- 
 ing viscera. The bloodvessels of the sac are often large, especi- 
 ally at that part to Avhich the generally thin but expanded [)lacenta 
 is attached. Although it would at first sight seem impossible 
 for the foetus to live and grow in these misplaced gestations, yet 
 the development of its organs appears to progress at the ordinary 
 ratio, and to be subject to the same general laws as in normal 
 pregnancy. " In ninety-eight cases," says Dr. Campbell, speaking 
 of the tubo-ovarian variety, " in which we can decide, or nearly 
 so, on the stage of pregnancy, the foetus in seventy-nine patients 
 died at the close of nine months, or soon thereafter; one^ in the 
 eighth; seven, about the seventh; one, in the sixth; two, in the 
 fifth; two, m the fourth; five, in the third; and one, at the end 
 of the first month. "^ When the misplaced foetus dies, it gener- 
 ally undergoes decomposition. This change may either happen 
 soon after its death, or, on the other hand, not for some years ; 
 during which time, surrounded by the cyst, it may be the cause 
 of so little inconvenience, that the parent will perhaps again be- 
 come pregnant, and bear a live child. "Where putrefaction occurs, 
 the decomposed structures give rise to infiammation in the sur- 
 rounding tissues; suppuration takes place; and the foetal bones 
 and tissues often become removed througli artificial openings in 
 the abdominal walls, rectum, vagina, or urinary bladder. Besides 
 this mode of termination, which greatly endangers the mother's 
 
 ' A Memoir on Extra-Uterine Gestation, p. 110. Edinburgh, 1840.
 
 INTKODUCTION. 287 
 
 life, there is another that is much more favorable. The soft 
 parts of the foetus and its involucra become in part absorbed, and 
 in part changed into a fatty substance (lipopsedion); or the entire 
 foetal body becomes converted into a calcareous mass (lithop?e- 
 dion) ; or it is largely altered into cartilage or bone (osteo[i?edion). 
 In either case, the mass will frequently be retained for many 
 years without the w'oman's health being apparently injured. A 
 third termination to an extra-uterine conception is the sponta- 
 ncQiis rupture of the foetal cyst, or of the dilated utero-ovarian 
 veins, or of the Fallopian tube, or of the vessels in the walls of 
 the cyst, at a somewhat early period of pregnancy ; and the rapid 
 death of the mother from the large quantity of blood which is in 
 consequence eilused into the peritoneal cavity. 
 
 If we inquire into the causes of these singular fcetations, our 
 information appears sadly at fault. The most frequently admitted 
 explanation is said to be found in the existence of a morbid con- 
 dition of theFallopian tube; such as undue narrowness, spasmodic 
 contraction, excess or defect of length, paralysis, inflammation 
 and engorgement, or induration of the fimbriated extremity. 
 Possibly, also, the existence of any disproportion between the 
 ovule and the area of the tube will serve to prevent the passage 
 of the former into the uterus. Some writers have imagined that 
 mental agitation from fright during coition might exert an influ- 
 ence in producing extra-uterine gestation ; and three or four 
 striking instances are recorded in favor of the correctness of this — 
 at first sight — highly improbable view. 
 
 A remarkable circumstance connected w^ith this subject has 
 been especially noticed by Dr. Oldham and Dr. Arthur Farre ; 
 viz., that in a large number of cases of tubal gestation the corpus 
 lutenm corresponding with the ovum impregnated has been found 
 in the ovary of the opposite side to that of the tube in which the 
 ovum is developed. Thus, suppose the left Fallopian tube to 
 contain the ovum, the right ovary may show the corpus luteum 
 of a corresponding date ; or vice verm. The probable explana- 
 tion of this curious phenomenon seems to be, — that at the time of 
 the ovule quitting the ovary, the gland is embraced by the fim- 
 briated extremity of the tube of the opposite side. This tube 
 conveys away the ovule, and the latter then becomes fecundated 
 in its cavity ; but being delayed by the angle formed by the bend- 
 ing of the oviduct, the progress of the ovum is obstructed until
 
 288 EXTRA -UTERINE GESTATION. 
 
 it has attained too great a size to permit of its entering the uterine 
 cavity. In contirmation of this view, Dr. Farre mentions that 
 there is a preparation in the Anatomical Museum of the Uni- 
 versity of Cambridge, in which both the Fallopian tubes are seen 
 to be grasping the same ovary; their extremities being fixed to 
 this gland by morbid adhesions. Dr. Tyler Smith gives a ditier- 
 ent explanation of the matter; for he supposes that the ovum 
 after descending one Fallopian tube traverses the upper part of 
 the uterine cavity, and then ascends the opposite oviduct by an 
 antiperistaltic action, or by the ciliary currents which move from 
 below upwards. In thinking over these cases it seems to me 
 probable, that the hypotheses of both these gentlemen are correct: 
 that is to say, that sometimes the opposite tube conveys away the 
 ovum, and sometimes the latter performs a long journey from 
 the ovary of one side, across the uterus, into the passages be- 
 longing to the other side. jSIy reasons are these : The prepara- 
 tion in the Cambridge Museum seems undoubtedly to prove the 
 possibility of Dr. Farre's explanation. An example of pregnancy 
 in a rudimentary horn of the uterus recorded by Professor Scan- 
 zoni,' equally satisfies me as to the justness of Dr. Tyler Smith's 
 opinion. In this case a foetus was partly develojjed in a rudi- 
 mentary horn seated on the left side of the uterus. The horn 
 ruptured, and the woman quickly sank from the resulting hem- 
 orrhage : at the necropsy the corpus luteum was found in the 
 right ovary. IsTow it is clear that if the left Fallopian tube had 
 stretched over to the right side to grasp the ovary, its bend must 
 have formed such an ano-le that the ovum would have been ob- 
 structed in the tube itself, and could not have reached the uterus. 
 Hence it can only be allowed that in all probability the ovum 
 passed through this latter organ. Bischofl' also notices that he 
 examined the body of a bitch, whose right ovary had one while 
 the left had five corpora lutea; yet there were three ova in each 
 half of the uterus, so that two must have crossed from the left 
 to the right side. 
 
 But in the year 1863, Professor Luschka met with a case which 
 seems to set all speculation at defiance. A woman died in the 
 third month of gestation. From the right and rudimentary horn 
 
 ' Verliandhingen der Physioalisch-Meilicinischen Gesellscbaft in Wurzburg. Band 
 iv, p, ]. Wurzburg, 1854.
 
 INTRODUCTION. 
 
 289 
 
 of tlie uterus it was found that a foetus of ten weeks had escaped 
 with its placenta through a laceration. The left horn of the 
 womb was normally developed : its mucous membrane was not 
 only swollen but detached, so as almost to form a loose bag, 
 having the texture of the decidua, in the uterine cavity. There 
 was no foetus in this horn. The left ovary contained a corpus 
 luteum in appearance corresponding with the period of preg- 
 nancy. There could not be seen any vestige of a corpus luteum 
 in the right ovary : hence it was evident that the foetus had pro- 
 ceeded from the left ovary. But the most careful examination 
 failed to trace any communication between the developed and 
 the rudimentary horns. The right horn was rudimentary, and 
 was connected with the developed horn or uterus proper, by a 
 solid largish cord which had a blind termination.^ These con- 
 ditions are well shown in the following drawing : 
 
 Fig. 11. 
 
 THE ANTERIOR VIEW OF THE MALFORMED UTERINE ORGANS OP A 'WOMAN WHO 
 DIED AT THE AGE OF THIRTY-TWO. ONE-THIRD OF THE 
 
 NATURAL SIZE. (After Luschka.) 
 
 The drawing shows thp developed and rudimentary horns of the uterus. In the latter, there has 
 been a lateral fi'^siire ; through which the foetus has escaped with its placenta. Connecting the rudi- 
 mentary with the developed horn, there is only a solid ligamentous cord. 
 
 Professor Luschka suggests, that as the transit of the ovum 
 must have been extra-uterine, it may have been accomplished 
 by the right Fallopian tube crossing over to the left side and 
 
 1 Monatschrifc fiir Geburtskunde uiid Franenkrankheiten. Band xxii, p. 3L. Ber- 
 lin, 1863. 
 
 19
 
 290 EXTRA-UTERINE GESTATION. 
 
 grasping the left ovary. Granting the probability of this being 
 the case, however, the difficult question remains, — How did the 
 ovule become fecundated? Did the oviduct of the developed 
 horn first grasp its proper ovary, and then, when impregnation 
 had occurred, loosen its hold so as to allow the right tube to take 
 up the fecundated ovum ? Improbable as this explanation seems, 
 yet I confess my inability to solve the problem in any other way. 
 
 2. Varieties of Extra-Uterine Gestation. — Three orders of 
 extra-uterine gestation were formerlj^ described by authors; viz., 
 ventral, tubal, and ovarian. In 1824, Dr. Breschet gave an ac- 
 count of a fourth form under the name of Graviditas in Uteri 
 substantia.^ Since this observer's day, the zeal of obstetric 
 writers has led some of them to make as many classes of this 
 abnormality as possible; and hence we find them detailing eight 
 and even ten varieties. Such a minute subdivision, however, is 
 perplexing and quite unnecessary; and partly therefore for these 
 reasons, and partly on account of circumstances which will pres- 
 ently be evident, I shall onl}^ speak positively of three forms. 
 These are — the tubo-ovarian, the tubal, and the interstitial or 
 tubo-uterine varieties. At the same time it is allowed, that the 
 possibility of ovarian foetation can hardly be denied; although, 
 while granting this, it may be asserted that such an occurrence 
 is of extreme rarity. The fact must be remembered, that in the 
 dissection of cases of extra-uterine pregnancy it is by no means 
 constantly that the exact original seat of the ovum can be made 
 out; for the inflammatory adhesions which the cyst-walls have 
 contracted with all the surrounding tissues and organs, no less 
 than the pressure which the foetus has exerted upon these parts, 
 give rise to a confused mass of disease which it is often impossi- 
 ble to unravel. Hence may be explained much of the discrep- 
 ancy of opinion which has existed as to the possible seats of an 
 extra-uterine gestation. 
 
 The tuho-ovariayi pregnancy is that variety in which the cyst- 
 walls are at first formed by the pretcrnaturally firm union of the 
 fimbriated termination of the Fallopian tube with a part of the 
 ovarian parietes. As the ovum and its cyst progressively enlarge, 
 the infundibular end of the oviduct gets greatly hypertrophied ; 
 
 ^ Medico-Cliiriirgical Transactions, vol. xiii, p. 33>. London, 1S27.
 
 VARIETIES. 291 
 
 wliile the cj^st walls become united to the surrounding abdomi- 
 nal viscera and tissues. By this means the sac is not only 
 strengthened, but — as it were — is partly formed by the adjacent 
 intestine, omentum, mesenter}', &c. Thus it has doubtless hap- 
 pened, that many of these cases have been described as examples 
 of ventral foetation, having their origin in the precipitation of the 
 fecundated ovum into the cavity of the abdomen. Some years 
 ago, the possibility of abdominal gestation was disputed ; and 
 the progress of physiological and pathological science since those 
 days has nuiterially served to strengthen, if not entirely to con- 
 firm, the correctness of these doubts. The fact has now been 
 established by ample testimonj^ as I have already remarked, that 
 the unimpregnatcd ovule quits the Graafian follicle at certain 
 definite periods, and passes into the Fallopian tube and uterus. 
 In one or other of these parts it either perishes, or becomes fecun- 
 dated if a fruitful intercourse occur. Whether this law admit of 
 any exceptions is uncertain. Yet it is an important question, 
 whether the ovule may be impregnated before leaving the Graa- 
 fian follicle, and consequently while it is still in the ovary ? 
 Were this point decided in the aflirmative — as I believe it Avill be 
 by-and-by — not only would one obv^taele to the belief in ventral 
 pregnancy be removed, but there could no longer be any diffi- 
 culty in determiniiig that cases of ovarian gestation miglit also 
 occur. This would naturally follow from its being granted that 
 the ovary was the seat of fecundation, and the successful coitus 
 the cause of the escape of the ovum from the follicle ; for of 
 course it is easy to see, that under these circumstances and by 
 some acciilent the ovum might be retained in the gland and there 
 developed. And until the year 1825 it was generally allowed that 
 this might happen, — that the foetus might really be developed 
 within the proper structure of the ovary, although the occurrence 
 was thought to be by no means common. M. Velpeau, however, 
 then began to doubt the truth of the alleged tact ; and he brought 
 forward four examples of supposed ovarian gestation, in all of 
 which the tumor was found on careful dissection to be external 
 to the }H'oper coat of the ovar^'. Subsequent investigations have 
 led many authors to indorse M. Velpeau's opinions ; and GeofiVoy 
 St. Ililaire, Pouchet, Dr. Allen Thomson, Dr. Arthur Farre, and 
 others, have expressed their strong doubts as to the possibility of 
 the occurrence of ovarian gestation. One thing seems certain,
 
 292 EXTRA-UTERINE GESTATION. 
 
 that not only have cases of tubo-ovarian pregnancy been mis- 
 taken for, and described as, true ovarian gestations ; but that 
 ovarian cysts containing hair, teeth, &c., which arise quite inde- 
 pendently of pregnancy, have also been erroneously regarded in 
 the same way. 
 
 Allowing the truth of all this, however, it appears exceedingly 
 difficult to deny the possibility of ovarian pregnancy. Dr. Ma- 
 rinus, in his " Memoire snr la Grossesse Extra-Ut(^rine," after 
 reviewing many of the opinions now held on this subject, says, — 
 "Do these facts prove tbat conception cannot take place in the 
 interior of the ovary ? By no means, for to these facts we can 
 oppose others quite as conclusive in favor of internal ovarian 
 pregnancy. In the presence of observation, in questions of this 
 nature, reason is silent. We have seen and examined in the ana- 
 tomical and pathological museum at Wurzburg three anatomi- 
 cal preparations, wdiich Plesselbach has described, consisting of 
 ovaries, each containing in its interior a foetus, of which the largest 
 appears to be two and a half months old. The parietes of the 
 germiferous gland are thickened and vascular internally, especi- 
 ally at the part where the placenta is adherent."^ And again, 
 at the N'ew York Obstetrical Society, on the 21st February, 1865, 
 Dr. Kammerer presented a specimen of extra-uterine gravidity, 
 from a woman thirty years of age, who died in 1864. The case 
 as related is brief, but it is explicit : 
 
 The patient had been under Dr. Kannnerer's treatment for chronic me- 
 tritis ; but all remedies had been discontinued, with the exception of the in- 
 troduction of a lar^re sound once a month, to keep the cervix open. Seven 
 or eight years previously she had borne a child. She became again preg- 
 nant; and a little time subsequently was taken suddenly ill, with symptoms 
 of internal hemorrhage and peritonitis. Death occurred in a few hours. At 
 the autopsy, several quarts of blood were found within the peritoneal cavity; 
 while on the left ovary, a rent revealing the source of the blood was seen. 
 Opening the ovary, an embryo was discovered about four weeks old. No 
 decidua was seen within the uterine cavity.^ 
 
 ISTow as the preparation was shown to the members of the So- 
 ciety, and as no gentleman is said to have questioned the cor- 
 rectness of Dr. Kammerer's views, the conclusion that the case 
 was really one of ovarian gestation can scarcely be shirked. And 
 
 ' Joiirnsil de Medecine de Briixelles. Vol. xlii, )) 400. Bruxelles, 1806. 
 2 The New York Medical Joiinml. Vol. i, p. 141. New York, 1865.
 
 VARIETIES. 293 
 
 indeed, in one respect it is more satisfactory than the three 
 preparations seen by Dr. Marinus. For whereas Dr. Ivammerer 
 exhibited the ovary soon after removal from the body, the prep- 
 arations examined by Dr. Marhius liad been put up in spirit 
 more than forty years previously. Finally, in the work of Ber- 
 nutz and Goupil two examples of ovarian pregnancy are quoted, 
 in both of which death occurred about the third month of ges- 
 tation, from rupture of the ovary. ^ 
 
 The tubal variety is much the most common of all the forms 
 of extra-uterine pregnancy. This is just what might be expected 
 when it is remembered that the Fallopian tube may so easily be- 
 come the seat of fecundation, — the part where the essential male 
 and female elements come into contact. "When the ovum gets 
 arrested and developed at some point of the oviduct between its 
 expanded termination and the spot where it enters the uterine 
 parietes, the walls of the tube get enormously dilated, and grad- 
 ually become developed into an oval sac. As, however, these 
 walls can only become expanded to a somewhat limited degree 
 in most women, it usually happens that between the second and 
 fourth month the tissues rupture ; and the patient very quickly 
 dies from the copious hemorrhage which takes place. The quan- 
 tity of blood which may be poured into the cavity of the perito- 
 neum, under these circumstances, is really immense ; many cases 
 'being recorded where it is said to have amounted to eight and 
 ten pints. Sometimes, rupture of the tubal wall takes place at 
 an earlier period than the second month ; and Rokitansky states 
 that he has known it do so a fortnight after conception. When 
 the rupture occurs within the first few weeks of pregnancy, the 
 exact situation of the ovum can readily be made out ; since the 
 walls of the oviduct alone form the cyst containing the embryo, 
 and they are generally found free from any adhesions to the 
 neighboring viscera. 
 
 It has been suggested by Dr. Kussmaul, of Heidelberg, that 
 many of the recorded examples of tubal pregnancy have been so 
 designated erroneously; they having, in truth, been instances 
 of gestation occurring in the stunted rudimentary horn of the 
 so-called uterus unicornis. The uterus unicornis with the rudi- 
 mentarj^ horn, is equally adapted for pregnancy, as the same va- 
 
 1 Clinical Memoirs on the Diseases of Women. Vol. i, p. 249, and note. Translated 
 for the New Sydenham Society, by Alfred Meadows, M.D. London, IbGG.
 
 294 
 
 EXTRA-UTERINE GESTATION. 
 
 rietj without the horn. But when the rudimentary horn con- 
 tains the foetus, we then unfortunately have — what does not 
 otherwise occur — rupture of this part, expulsion of the embryo 
 into the abdominal cavity, and fatal hemorrhage or peritonitis. 
 The fissure of the rudimentary horn is always discovered near 
 the origin of the Fallopian tube ; while in these cases the de- 
 veloped horn is found thickened, and having a deciduous lining. 
 When gestation occurs in the simple unicorn uterus, there ap- 
 pears to be neither difficulty nor danger ; for many women with 
 this malformation have borne several children. Pregnancy has 
 also been known to exist in the rudimentary horn, when there 
 could not be distinguished any previous channel of communica- 
 tion with the well-developed horn ; but in these cases it has 
 usually been said, that the seminal fluid has passed from the 
 developed horn to the ovule discharged from the ovary in con- 
 nection with the rudimentary horn, and that then the canal has 
 become obliterated from changes occurring in the decidua. 
 
 Fig. 12. 
 
 TUBAL PREGNANCY. 
 
 The right Fallopian tube has been laid open to show the foetus, which has arrived 
 at about the third month of gestation. 
 
 The interstitial or tubo-uterine pregnancy is a rare variety of 
 misplaced gestation. In it the ovum becomes developed at that 
 particular portion of the canal of the tube which traverses the 
 uterine parietes. Hence, the cavity containing the embryo ap- 
 pears as if constructed within the proper tissues of the uterus; 
 and its parietes are indeed chiefly formed of the smooth muscular 
 fibre, as in the ordinary gravid organ. As the walls of the sac
 
 VARIETIES. 295 
 
 undergo development, they acquire considerable thickness ; and 
 consequently are often able to bear such excessive distension, 
 that the pregnancy may go on until the full period, or even con- 
 siderably beyond it. In some of these cases of graviditas inter- 
 stitialis it happens very remarkably that the placenta is found in 
 the proper cavity of the uterus, although of course the foetus is 
 wholly out of it. One of the most interesting examples of this, 
 out of the four or five which are recorded by Patuna, Iloffmeis- 
 ter, Dezeimeris, &c., occurred in the practice of a Mr. Hay, of 
 Leeds ; who considered the case to be unique, and communicated 
 the particulars to Dr. William Hunter. The chief points worthy 
 of note are these : ^ 
 
 The wife of A. B., aged thirty-five, of a good habit of body, was seized, 
 when two months advanced in her second gestation, with pains resembling 
 colic; but at the end of two or three days they were subdued by simple 
 remedies. The pains did not return until four months afterwards, when they 
 became much more severe and diffused than before. The acuteness of the 
 attack was alleviated, but the intense suffering was always reproduced by the 
 foetal movements. At the close of the eighth, and again in the middle of 
 the ninth months, there were false labor pains; and an examination per 
 vaginam showed that the cervix uteri was harder and longer than Mr. Hay 
 expected to find it at the stage of pregnancy to which the patient had attained. 
 Near the end of the ninth month, a violent attack of vomiting set in, which 
 lasted two days; and soon afterwards, the term of gestation being concluded, 
 the movements of the child ceased, and the violent pain which had existed 
 for nearly four months subsided. The breasts began to swell, and milk soon 
 flowed from the nipples; complaint was made of an uncommon coldness in 
 the abdomen; there were frequent attacks of spurious labor pains; there was 
 a trifling sero-sanguineous discharge from the vagina ; and the patient suffered 
 much from violent sickness. In three months from the time that labor ought 
 to have come on, death put an end to the misery. The post-mortem exami- 
 nation revealed the existence of old adhesions between the omentum, intes- 
 tines, peritoneum, and a large peculiar sac, which occupied nearly the whole 
 abdominal cavity. Besides a well-formed foetus, free from every mark of de- 
 composition, the cyst — the walls of which were about one-eighth of an inch 
 thick — contained some chocolate-colored fluid and a little pus. The umbili- 
 cal cord passed from the abdomen of the foetus through a narrow aperture, 
 into a cavity whose walls were from one-half to seven-eighths of an inch in 
 thickness ; which cavity was found to be that of the uterus, and to be of much 
 smaller dimensions than the sac which contained the foetus. The placenta 
 was very large, and with the uterus weighed two and a half pounds avoirdu- 
 pois. The Fallopian tube on the left side was very small; the place of that 
 on the right was occupied by the beginning or orifice of the sac.^ 
 
 The foregoing history seems to be highly instructive in several 
 
 1 Medical Observations and Inquiries. By a Society of Physicians in London. Second 
 edition, vol. iii, p. 341. London, 1769.
 
 296 EXTRA-UTERINE GESTATION. 
 
 points of view: First, from the foetus having been just as well 
 developed in its abnormal position as it would have been in a 
 norn)al pregnancy; secondly, from the efforts which were spon- 
 taneously made to expel the child at the termination of the 
 natural period of pregnancy; and thirdly, from the placenta 
 having been attached to the internal surface of the proper uterine 
 cavity, instead of to the walls of the artificial sac. The foetus 
 seems certainly to have perished as soon as it had completed the 
 ordinary nine months of intra uterine life. This has not always 
 happened, however; inasmuch as some cases have been noticed 
 where the child would appear to have continued to live and grow 
 for a few weeks beyond the average term of gestation. 
 
 3. Symptoms of Extka-Uterine Pregnancy. — ^These are very 
 much the same in all the varieties. Speaking generally, the 
 patient usually believes herself to be pregnant in a normal man- 
 ner. There is at first but little constitutional disturbance, or not 
 more than is common in natural gestations ; nor is any marked 
 local uneasiness experienced so long as the part containing the 
 embryo can accommodate itself to the foreign body. Indeed, in 
 many recorded cases it is remarked that the women have enjoyed 
 excellent health, or that they have been free from any unusual 
 symptoms until the close of the seventh or eighth month ; though 
 certainly in others the most severe suflering has been complained 
 of after the first few weeks. 
 
 In most instances, the catamenia are suspended ; though in 
 many the flow appears regularly, and in some is then profuse. 
 When there are indications of much uterine excitement, it is not 
 uncommon for the patient to have attacks of flooding; on which 
 occasions, as coagula and masses of flbrine are passed, erroneous 
 suspicions may be entertained that abortion has taken place. 
 The breasts enlarge and the areolae darken, as in ordinary cases. 
 Sometimes there is morning sickness, but this is often absent, and 
 is seldom very severe ; the patient being more frequently annoyed 
 with diarrhoea and troublesome tenesmus, as well as with irrita- 
 bility of the bladder. Where the gestation continues, the foetal 
 movements are felt at the usual period of quickening. The ab- 
 domen also becomes enlarged and tender to the touch, the in- 
 crease in size being evidently one-sided ; though in rare examples 
 the enlargement is regular and symmetrical, and merely has a
 
 SYMPTOMS. 297 
 
 form diftering from that of natural pregnancy. The fitful but 
 severe attacks of pain which are experienced in the pelvis, as well 
 as in the hypogastric and inguinal regions, are particularly char- 
 acteristic of this condition. Sometimes these attacks pass off in 
 a few minutes; on other occasions they continue for hours, and 
 induce great depression of both mind and body. The late Dr. 
 Ileim, of Berlin, was in the habit of teaching, that during these 
 paroxysms of pain the patient speaks in a so-called " character- 
 istic" whining tone of voice; which, it was said, could not be 
 mistaken when once it had been heard. Most observers, how- 
 ever, now regard this opinion in the light of a fallacy. On in- 
 stituting a vaginal examination when the gestation has so far 
 advanced that there is palpable abdominal enlargement, a pelvic 
 tumor may perhaps be detected, in addition to the uterus ; or an 
 irregular portion of the foetus will sometimes be felt occupying 
 the recto-vaginal pouch, and pusliing the uterus close to the pubes. 
 More commonly, however, the foetal tumor is out of the cavity 
 of the pelvis; the os uteri being likewise reached with some diffi- 
 culty, owing to the uterus being drawn above the pelvic brim. 
 The cervix, if felt, may be found congested ; while the uterine 
 cavity though somewhat enlarged is empty, as the use of the 
 uterine sound will prove. It need scarcely be said, however, 
 that this instrument must be employed with very great caution ; 
 and only when the diagnosis is otherwise tolerably clear, or at all 
 events when there are distinct indications that there is no.normal 
 pregnancy. The evidence derived from practising auscultation 
 over the tumor is often unsatisfactory. If there be much pressure 
 upon the aorta or iliac arteries, a loud and diffused blowing sound 
 will be perceptible. The fcetal heart is not always to be detected, 
 even when the child is alive; but if heard, it is usually only 
 audible over a limited space, at a much higher point in the ab- 
 domen than in healthy pregnancy advanced to the same period, 
 and at uncertain times. 
 
 When an extra-uterine pregnancy terminates in rupture of the 
 cyst, exceedingly grave phenomena ensue. The time at which 
 the walls give way is liable to some variation ; but in tubal ges- 
 tation — the form with which we are best acquainted — it undoubt- 
 edly very generally happens between the commencement of the 
 second and the end of the fourth month. The premonitory 
 symptoms may be so slight as to pass unnoticed, or they nuiy be
 
 298 EXTRA-UTERINE GESTATION. 
 
 well-marked. In the latter case, the most cliaracteristie are, — 
 impairment of the health, languor and mental depression, pros- 
 tration, nausea and vomiting, irritability of the bladder and rec- 
 tum, abdominal pains, and sanguineous discharges from the 
 uterus. With the tubal form also, laceration perhaps generally 
 occurs suddenly without any warning, and while the patient is 
 in the enjoyment of good health. But in any case, immediately 
 after the rupture, the most excruciating and sickening abdominal 
 pains set in; which gradually increase in severity up to a certain 
 point, and then suddenly and completely subside. The abdomen 
 sinks, the tumor disappears and a feeling is experienced as of 
 something having given away. The surface of the body quickly 
 becomes cold and pale; the countenance gets anxious; the sick- 
 ness is most distressing; and the pulse is found to be very quick 
 and contracted or feeble. In a ver^^ short time, cold clammy 
 sweats break out ; and while the poor victim is expressing her- 
 self as feeling comfortable and free from pain, perhaps a few 
 convulsive rigors occur, and death takes place from the internal 
 hemorrhage. Should the bleeding be less copious the patient 
 often rallies after a time from the first shock, and for some hours 
 hopes of recovery are entertained. But these happy dreams are 
 soon dispelled, acute peritonitis sets in, and a fatal termination 
 commonly occurs before the close of the third day. If, under 
 the judicious use of opium and other remedies, the patient be 
 enabled to resist the violence of the inflammatory symptoms, she 
 may still perish at a rather later period from exhaustion ; yet this 
 danger being likewise avoided, there is a chance that the prod- 
 uct of gestation will become inclosed in a new cyst, and that the 
 woman may be restored to a certain degree of health. 
 
 Supposing the foetal cyst to remain uninjured, there is still a 
 fear of hemorrhage occurring within the sac ; in which case 
 death can happen without a drop of blood being poured into 
 the peritoneal cavity. Or, the cyst continuing entire, there is 
 the risk of the dilated utero-ovarian veins getting ruptured: 
 while in tubal pregnancy, the walls of the canal may alone be 
 broken, and fatal hemorrhage result. These perils surmounted, 
 however, the gestation may advance more or less nearly to the 
 close of the natural term. Then labor pains will come on ; 
 which efforts at parturition usually continue for three or four 
 days and then subside, perhaps to return at uncertain intervals
 
 SYMPTOMS. 299 
 
 during the few succeeding weeks or months. Indeed, cases have 
 been reported where the pains of childbirth have recurred at 
 intervals for more than three years; while in an instance pub- 
 lished by Lospicliler, the attempt at labor returned every nine 
 months for a period of six years. Generally, the foetus dies 
 either before or just after the completion of the ninth month; 
 but instances are recorded where vitality seems to have been re- 
 tained for as long a time as four, or even five months, beyond 
 this period. 
 
 With the cessation of the foetal life, the walls of the cyst would 
 appear slowly to undergo a process of degeneration ; so that in 
 a space of time varying from a few weeks to some years sup- 
 puration occurs, followed by ulceration and perforation into 
 the neighboring viscera. Thus, the foetal debris ultimately gets 
 discharged by openings forming through the walls of the vagina, 
 rectum, bladder, stomach, or abdomen. Although the process 
 of expulsion, in this way, is very tedious and greatly endangers 
 the mother's life, yet many women recover from it. Indeed, 
 Dr. Campbell mentions two cases where the patients each had 
 the products of three extra-uterine gestations in their abdomens 
 at the same time ; while in both individuals all the decomposed 
 structures were evacuated through the abdominal parietes, and 
 each recovered. The following interesting case has been re- 
 corded by Dr. Galiay, in which extra-uterine pregnancy oc- 
 curred twice in succession in the same patient, and terminated 
 favorably on both occasions. The history, abbreviated from the 
 report, is as follows : 
 
 A young woman shortly after marriage, was laid up for several days in 
 consequence of injuries which she received during a quarrel, Slie recovered 
 iwithout much inconvenience, and soon afterwards found that she was preg- 
 nant. The pregnancy seemed to follow the usual course, until — at the 
 proper time — symptoms of labor set in ; but the pains went off without 
 being followed by any result. Months passed away, during which she re- 
 mained of great size; until, after a long interval, she was seized with acute 
 but intermitting pains in the abdomen and groins and anus. After a con- 
 siderable period — in 1829 — a violent attack of pain came on, accompanied 
 by a desire to evacuate the bowels; but she was unable to relieve herself. 
 On examination, the bone of a foetus was found firmly impacted within the 
 sphincter ani ; which being removed, she passed a number of other bones, 
 and then got well. Until 1884 she enjoyed good health, when she again 
 became pregnant. After some interval as before, the fragments of another 
 foetus were expelled per anum, without pain or constitutional disturbance.
 
 300 EXTRA-UTERINE GESTATION. 
 
 It is noted that she soon regained her health, and was well when the case 
 was reported.' 
 
 The length of time that a foetus and its envelopes may some- 
 times be retained as a foreign body within the organism of 
 the mother, witliout producing serious miscliief, is very remark- 
 able. The following case is perhaps one of the most curious on 
 record : 
 
 Anna Mullern, of the village of Leinzell, near Gemund.in Suabia, died at 
 the age of ninety-four, after she had lived a widow forty years. Six-and- 
 forty years before her death she declared herself to be with child, and had 
 all the usual tokens of pregnancy. At the end of her reckoning the waters 
 came away, and she was taken with the paifls of labor. These continued 
 upon her seven weeks, and then subsided under the use of medicine. Some 
 time after this she recovered perfect health ; except only that her belly con- 
 tinued swelled, and that now and then, upon any exercise, she felt a little 
 pain in the lower part of it. Subsequently, she had two healthy children; 
 but remained firmly persuaded that she was not delivered of what she first 
 went with. On the 11th March, 1720, she died; and a large hard mass 
 was then found in the abdomen inclosing a foetus.^ 
 
 A remarkable case, somewhat analogous to the foregoing, oc- 
 curred in the practice of Dr. Montgomery: 
 
 In the year 1828, a woman was admitted into the Cork Street Fever Hos- 
 pital, with considerable enlargement of the abdomen. Her history was, that 
 eight years previously she had been in labor two days, when the pains sud- 
 denly ceased ; and the child instead of being born, rose up — as she expressed 
 herself — into her stomach. After remaining in bad health for about two 
 years, she again experienced the symptoms of pregnancy; and this time gave 
 birth to a child which did not survive. The former child still reniained in 
 the cavity of the belly ; and during its continuance there, she bore three 
 children, the last of whom lived. Ultimately a fistulous opening formed 
 near the umbilicus. This opening was enlarged, and the original child 
 removed. It was in a state of wonderful preservation, measured twenty- 
 two inches in length, and had attached to it about two feet of the umbilical 
 cord.^ 
 
 The particulars of a tliird noteworthy instance may be also 
 mentioned : 
 
 A wonian, forty years of age, was suddenly seized with symptoms of in- » 
 ternal strangulation, from which she sank. Dr. Christian, under whose care 
 she was, discovered in the abdomen a large tumor, situated in the right iliac 
 fos^sa and lumbar region. This tumor had first appeared some months after 
 her marriage, twenty years before, at which time labor had come on at the 
 
 1 Gazette M6dicale tie Paris. 20tli July, 18.17. 
 
 ^ The Philosophical Transactions Abiidgetl, vol. vi, part iii, p. 212. London, 1733. 
 
 ^ The Signs and Symptoms of Pregnancy. Second edition, p. 350. London. Ib56.
 
 SYMPTOMS. 301 
 
 sixtli or seventh month, without any result : the movements of the foetus 
 having suddenly ceased, and th'e labor itself having been arrested. After 
 this period she had borne eight children. The autopsy showed a tumor of 
 the size of a large ostrich's egg, enveloped in a cyst with ossified walls, ex- 
 cept at its superior part, and inclosing a foetus of six or seven months This 
 was as well preserved as if it had been artificially inclosed after the labor, — 
 still having its umbilical cord fixed to the interior wall of the envelope which 
 represented the placenta, and which was completely ossified.^ 
 
 Dr. R. Wagner has described the dissection of a remarkable 
 case of lithopffidion : 
 
 A woman, aged sixty-eight, died suddenly. She had borne five children 
 at twenty-four years of age. Subsequently she believed herself again preg- 
 nant, when she fell sick with typhus. During this illness the movements of 
 the child ceased. Notwithstanding that the infant had been retained twenty- 
 nine years in the abdomen it was entire, although much contracted. It 
 weighed 3 J lbs., and was of the size of a child's head. 'J'he soft parts were 
 much dried ; some bones showed strong calcification ; the scalp and one ear 
 had grown to the membranes. Whether the extra-uterine gestation was 
 primary or secondary Dr. Wagner does not decide. The woman had rejected 
 an offer of Caesarean section twenty-nine years before.^ 
 
 In a case of tubular gestation, with probable rupture, related 
 by Mr. R. W. Watkins, the foetus had been retained in the cav- 
 ity of the peritoneum for more than forty-three years. During 
 this time, the foreign body had given rise to no local or consti- 
 tutional effects of any importance. The woman's death, at the 
 age of seventy-four, was due to chronic renal disease. The au- 
 topsy reveale.d a mummified lithopsedion, connected by its um- 
 bilical cord to the placenta; this organ having its attachment to 
 the peritoneal covering of the broad ligament near the left ovary. 
 The uterus was healthy.^ 
 
 Another history that may here be quoted, is one which shows 
 that it is possible in instances of twin conception for one embryo 
 to be properly developed in the uterus, while the other is lodged 
 in one of the oviducts : 
 
 On the 9th April, 1849, Dr. Craghead, of Danville, Virginia, was called 
 to a negro woman belonging to a Mr. Conway. She was thirty-five years 
 
 ^ Quoted by L'Unioii Medicale, tome v, p. 3-34, Paris, 1S51, — from The Philadelphia 
 Medical Examiner. 
 
 2 Archiv filr Heillcunde, 1SG5. Quoted from The British and Foreign Medico-Chi- 
 rurgical Review. Vol xxxvii, p. 537. London, ] b66. 
 
 ^ Transactions of the Obstetrical Society of London. Vol. viii, p. 106. London, 
 1867.
 
 302 EXTRA-UTERINE GESTATION. 
 
 old, of stronsr constitution, and had previously enjoyed excellent health. She 
 had one child at an early age; lived without a husband till she was nearly 
 thirty, when she married ; and shortly afterwards gave birth to her second 
 child. Again she lived "sine niarito," in which state she remained until 
 the Christmas of 1848. Having menstruated early in January, 1849, and 
 not since, she supposed herself pregnant. About the 1st of April, she com- 
 plained of pains resembling those of colic; in consequence of which her master 
 bled her, and gave her an aperient with occasionally a dose of laudanum. Dr. 
 Craghead found the poor woman feverish, and complaining of considerable 
 abdominal pjiin and soreness ; while upon examination a tumor was discovered 
 in the left iliac region, which was excessively tender. Bleeding was again 
 resorted to, and calomel and opium administered ; and on the 17th April she 
 was so much better that she spoke of walking out. She took some cathartic 
 pills at bedtime. In the night she awoke in pain and made several ineffec- 
 tual efforts to evacuate the bowels, remarking that she felt "as if there was 
 something in her which ought to come away." A few hours afterwards she 
 was found in a state of collapse; with a cold skin, scarcely perceptible pulse, 
 a swollen abdomen, tenesmus, &c. About the evening she rallied ; and con- 
 tinued to improve slightly until towards the close of the day of the 19th 
 April, when labor pains set in, and in a short time she aborted. The foetus 
 was well-formed, five inches in length, and evidently of rather more than 
 three months' development. The mother lived until the evening of the '21st, 
 when she died rather suddenly. On making a post-mortem examination, 
 the whole abdominal cavity was found filled with coagulated blood and serum, 
 which had proceeded from the rupture of some of the vessels of the left Fal- 
 lopian tube. This tube was greatly enlarged and converted into a membranous 
 sac ; which sac contained a foetus of the same size as the one delivered per 
 vias naturales. In other words, it was well-formed, five and a half inches 
 long, with a cord and placenta.^ 
 
 But one of the most extraordinary instances with which I am 
 acquainted, of uterine and extra-uterine pregnancy, progressing 
 simultaneously to the full period of gestation, has been reported 
 by Mr. Louis R. Cooke. The principal features in the patient's 
 history, as related to the Fellows of the Obstetrical Society of 
 London, on the 3d June, 1863, are these : 
 
 E. E. — , aged thirty-nine years, who had previously had three natural de- 
 liveries, was taken in labor on the 8th December, 1862. During the pregnancy 
 there had been no great inconvenience, beyond dragging pains and an un- 
 usual sense of weight in the abdomen. On an external examination, the 
 abdominal swelling was found to have its greatest prominence considerably 
 to the left side, and about on a level with the umbilicus ; the whole tumor 
 also being more circumscribed, better defined, and more spherical in form 
 than usual. The limbs of a foetus were distinctly traced through the ab- 
 dominal walls; while a placental souffle was audible over a large portion of 
 the tumor. A vaginal examination showed the canal much elongated, its 
 
 1 Tlie American Journal of the Medical Sciences. New Series. Vol. xix, p. 114. 
 Phiiadelpliia, J8L0.
 
 SYMPTOMS. 303 
 
 rugae obliterated, and the os uteri drawn up out of reach. Suspecting an 
 abnormal gestation, Mr. Cooke requested Mr. Spencer Wells to see the patient 
 with him, and he attended with Dr. Kuman, of Vienna. It was thought 
 there were two sets of foetal heart-sounds; while the extensive surface over 
 which the placental bruit was heard gave rise to a suspicion of two placentfe. 
 The opinion given, therefore, was that a double uterine foet;ition existed. As 
 the pains were slight, and occurred only at long intervals, the bladder was 
 emptied and a grain of opium administered. 
 
 On the 9th December, it was found that Mrs. R. had passed a good night. 
 At six o'clock in the afternoon strong labor pains set in, and Mr. Cooke was 
 sent for. On making an examination, he discovered that the sacral concavity 
 was now occupied by a firm and resisting and rounded tumor, which was im- 
 movable. Its presence reduced the antero-posterior diameter of the inlet to 
 less than two fingers' breadth. The os uteri was completely dilated ; and a 
 small portion of the convex cranial surfiiee of a foetus could be reached. In 
 consultation with Dr. Greenhalgh and Mr. Meates, it was decided to put the 
 patient under the influence of chloroform, so as to suspend the action of the 
 abdominal muscles; in order that an attempt might be made to displace the 
 tumor, and turn the child. Failing in this, the Cfesarean section was to be 
 performed. However, after the employment of some force, the tumor was 
 pushed out of the vagina, and delivery completed by version. The child 
 was dead. The placenta was removed without diflBculty. The woman becau)e 
 very much exhausted, and gradually sank ; death occurring within forty-eight 
 hours of the operation. 
 
 At the autopsy, twenty-one hours after death, the abdomen was carefully 
 opened; when the first thing revealed was the body of a full grown female 
 foetus contained in its n)en)branes, which were unruptured and full of fluid. 
 The anterior or external surface of the chorion was perfectly smooth, and in 
 immediate relation with the abdominal peritoneum. Beneath the tumor the 
 uterus was seen, partially contracted and unruptured. On opening the foetal 
 membranes and removing the foetus, it was found that the placenta was 
 firmly attached to a shallow capsule formed of the expanded and enlarged 
 fimbriae of the right Fallopian tube, which was much elongated. A stylet 
 could be passed along the tube from its uterine extremity to the expanded 
 portion, when it became arrested by the placenta.^ 
 
 Two other cases, somewhat resembling* the foregoing, have 
 been reported. In one, by Pellischek, it seems certain that 
 extra-uterine gestation was complicated with uterine pregnancy ; 
 for this physician having delivered the uterine foetus, felt another 
 living child in the left hypochondrium while he was extracting 
 the placenta. It was determined not to interfere. At the end 
 of a year the tumor had much diminished, and the mother was 
 enjoying good health.^ The second instance has been related by 
 Dr. Pennefather. The points of interest are as follows : 
 
 1 Transactions of the Obstetrical Society of London. Vol. v, p. 14-3. London, 1864. 
 
 2 A Biennial Retrospect of .Medicine, Surgery, and their Allied S(!ienoes, for 1865-66, 
 p. 396. Published by the New Sydenham Society, 1867.
 
 304 EXTRA- UTERINE GESTATION. 
 
 A lady, aged tliirty-eiaht, the mother of five children, miscarried in August, 
 
 1861. She again became pregnant in the following October. In April, 
 
 1862, she was seized with violent pain in the abdomen, which was relieved 
 on passing- a large quantity of scybala. Tenderness and vomiting and flatu- 
 lence remained. The abdomen attained an enormous size subsequently, and 
 there was almost constant sickness. On the 4th September, a full grown 
 female infant was born. As the abdomen remained large, it was examined : 
 the foetal tick and movements were distinguished Ergot was given : it 
 acted powerfully on the uterus, but no second child was born. It was then 
 believed that this foetus was extra-uterine. The patient subsequently got 
 about, but suffered much both locally and constitutionally. In March, 1868, 
 an opening formed in the vagina, through which a portion of foetal skull pro- 
 truded. By dilating the opening, a full grown male child was gradually 
 brought forth. For some days all the faeces pa.ssed by the vagina. But the 
 wound ultimately closed, and the patient made a complete recovery.^ 
 
 From the symptom-s and histories of the typical cases which 
 have now been detailed it seems evident, that the dingnosis of 
 extra-uterine gestation is very often surrounded by great diffi- 
 culties. It is therefore incumbent upon the practitioner not to 
 form an opinion from the existence of any single feature in the 
 history or examination of a given case ; but rather to draw his 
 conclusions from a careful analysis of all the symptoms presented. 
 It has been from a neglect of this precaution, that medical men 
 have laid open the abdominal cavity to extract imaginary infants. 
 A fertile and lively fancy has been allowed to paralj'ze the judg- 
 ment. Even Dr. Ernest Ludwig Ileim, who — during a practice 
 extending over sixty years — had under his observation thirty- 
 three cases of misplaced gestation, permitted and indeed per- 
 suaded a woman to submit to gastrotomy, where there was found 
 neither a foetus nor a tumor of any kind. This instance has been 
 already quoted (Chap. Ill, div. 1) ; but it may be mentioned that 
 the mistake seems to have been caused by Heim's attaching 
 undue importance to the occurrence of severe intermitting pains, 
 the cessation of the catamenia, the existence of a peculiar moan- 
 ing cry, and the patient's assertions that she daily felt the move- 
 ments of the child. 
 
 The importance of making a correct diagnosis need not be 
 further enforced by examples of the sad results which have fol- 
 lowed from careless or inexact observation. It is obvious, that 
 the position of a woman suffering from such a gestation as we are 
 now considering is a most critical one ; and if our treatment is to 
 
 1 Tlie Lancet, p. OSS. London, 20th June, 1SG3.
 
 TREATMENT.^ 305 
 
 liave any effect in retarding or preventing the rupture of the cyst, 
 it will only be through its being practised at an early date. 
 
 4. Treatment of Extra-uterine Pregnancy. — This part of 
 our sul)ject may be advantageously considered under three heads : 
 viz., first, the precautions whicli are needed to prevent or retard 
 rupture of the cyst; secondly, the measures which offer a chance 
 of moderating the hemorrhage that always follows laceration ; 
 and thirdly, the steps to be pursued after the extinction of foetal 
 life. 
 
 (1) The importance of preventing or even retarding laceration 
 of the cyst cannot be over-estimated. "When the cyst ruptures 
 within the first few weeks of gestation, this accident is invariably 
 fatal to the mother. Where, this occurrence is delayed until a 
 more advanced period, the event — though generally most disas- 
 trous — does not inevitably cause death. Supposing, therefore, 
 we find a patient presenting, in addition to the ordinary signs of 
 pregnancy, such symptoms as have been already detailed, every 
 precaution must be taken to prevent bodily fatigue, mental agita- 
 tion, or the least extraneous irritation of the uterine organs. In 
 other words, a pregnant woman who has occasional sharp attacks 
 of abdominal pain, a frequent sanguineous discharge from the 
 vagina, a tumor in either iliac region, and a womb so drawn up 
 into the vagina that its mouth and cervix can only be reached 
 with diificulty, ought to be kept free from excitement of every 
 kind. The most rigid quiet and rest in the recumbent posture 
 should be enjoined; sexual intercourse is to be strictly forbidden ; 
 all stimulants must, as a general rule, be disallowed; the diet had 
 better be light, and perhaps meagre; and the patient's apartment 
 should be well ventilated and not overheated. Moreover, undue 
 action of the abdominal muscles by vomiting, straining at stool, 
 lifting heavy weights, &c., is to be restrained ; and immediately 
 any pain is experienced, or there are any symptoms of the com- 
 mencement of uterine contractions, opium — either by itself, or 
 especially in conjunction with belladonna — must be freely ad- 
 ministered. These drugs will prove invaluable if judiciously used ; 
 and perhaps, speaking generally, it will be found much more ad- 
 vantageous to give them by the rectum than by the mouth. 
 
 An interesting question here presents itself — viz., Can we in 
 any way destroy the embryo at an early period, so that by pre- 
 
 20
 
 306 EXTRA-UTERINE GESTATION. 
 
 venting its further growth the integrity of the cyst may be main- 
 tained ? 
 
 There are, I believe, at least three ways in which this may 
 probably be effected. In the first place, tlie injection of half a 
 grain of morphia, in solution, through the vaginal wall into the 
 cj'St, will probably prove fatal to the embrj-o. Remembering 
 the susceptibility of the new-born infant to opium, it can readiiy 
 be imagined that a young foetuB must succumb when the fluid 
 around it is impregnated with this drug. In having recourse to 
 this proceeding it will be found that the syringe usually emi^loyed 
 for hypodermic injections answers very well. 
 
 Secondly^ by withdrawing the fluid contents of the foetal cyst 
 through a fine and long trocar and canula the same object may 
 be gained. The puncture can either be made through the ab- 
 dominal parietes, or preferably through the vagina. The same 
 amount of care is necessary as would be employed in evacuating 
 the fluid contents of a hepatic hydatid tumor. A case which I 
 believe to be unique, and which happily illustrates the value of 
 this plan of treatment, has occurred in my own practice : 
 
 On the 4th July. 1867, I was requested by Mr. Marsh, of St. John Street, 
 Clerkenwell, to see Mrs. W. in consultation with him. The fear was that 
 preg:nancy existed, and that the uterus hud become retroverted. 
 
 From the patient I learnt that her age is thirty. She has been married 
 seven years. Has had one abortion, and three living children : the last child 
 ■was born in April, 1865. Has not been pregnant since until the present 
 occasion ; is convinced she is now in the family way. The catamenia, which 
 are always regular, were due on the 20th March, but they did not come on. 
 During April and May she had frequent attacks of " spasms and sickness." 
 On the 25th May, the courses came on rather profusely and lasted for one 
 week : they have not been on since. Now suffers from sickness, great pain 
 in the pelvis, difficult micturition, and .severe attacks of spasm. On making 
 a vaginal examination, I found the whole recto-vaginal fossa occupied by a 
 tumor, which gave me the impression of beino; cystic, though no fluctuation 
 could be detected. The cervix uteri was pushed towards the pubic arch. 
 The tenderness of the parts was, however, so excessive that only an imper- 
 fect examination could be made. It was therefore determined to administer 
 a full dose of opium, and wait for twenty-four hours. 
 
 On the following day she was placed under the influence of an anaesthetic 
 (a mixture of equal parts of chloroform and ether). On then examining, I 
 felt convinced that the tumor was not formed by the uterus, but that in all 
 probability it was a case of pelvic haematoceie caused by an extra-uterine 
 foetation. To make sure that there was no natural pregnancy I allowed the 
 sound to glide into the uterine cavity : without employing the least force it 
 entered for five inches. As the syniptoms were urgent, Mr. Marsh agreed 
 in the propriety of puncturing the swelling behind the uterus. I therefore
 
 TREATMENT. 307 
 
 passed a very fine trocar and canula into it, and allowed a tumblerful of almost 
 pure blood to flow away. By this operation cons^iderable relief was given 
 for a time. Especially was the sickness checked, so as to allow of the free 
 administration of nourishment. Still her condition was a perilous one ; at 
 one time being much better, and at another making both Mr. Marsh and 
 myself anxious for the result. 
 
 On the morning of the 8th August she had an action of the bowels, with 
 si^cient difficulty to attract attention. On examining the bed-pan, there 
 was found in the motion a flattened and decomposed, but quite perfect foetus. 
 This had arrived at about the third month of development. Immediately 
 afterwards, improvement set in. By the end of the month she was free from 
 every unfavorable symptom, and was able to sit up. 
 
 Thirdly, in place of either of the foregoing plans, recourse 
 may be had to electro-puncture. The following case shows that 
 this operation has been attended with success ; while it serves to 
 illustrate the method to be pursued : 
 
 Madame Marie-Anne Ceccherini, of Pisa, twenty-nine years of age, and 
 the mother of four children, presented in the third month of her fifth preg- 
 nancy, at the commencement of 1^^53, a tumor in the left iliac fossa. This 
 was looked upon by Dr. Bachetti and Drs. Burci, Torri, and Bartolini, who 
 were called in consultation, as the result of a tubal extra-uterine foetation. 
 It was first attempted to arrest the development of the foetus, and conse- 
 quently to prevent the fatal hemorrhage, by friciions of belladonna, and after- 
 wards of the iodide of mercury ; but recourse was finally had to electro-puncture, 
 with the view of destroying the foetus, this being accomplished by the 
 implantation of two needles into the tumor, and then by directing into the 
 latter an electro-magnetic current. Some pain was experienced by the pa- 
 tient, but it was surmised that the development of the foetus was arrested. 
 Nor were the physicians disappointed in this respect. The tumor rapidly 
 diminished, and was reduced to the size of a pigeon's egg, after having been 
 as large as a man's fist. Moreover, the catamenia, which had not appeared 
 for three months, returned ; and the patient was ultimately dismissed as cured. ^ 
 
 It may of course be asked whether the diagtiosis in this in- 
 stance was quite correct, and whether the tumor might not have 
 been simply an ovarian one. But taking all the circumstances 
 of the case into consideration, I think it may justly be said that 
 most probably the opinion of Dr. Bachetti was quite right, and 
 that the electro-puncture destroyed the foetal life. 
 
 (2) Unhappily it very often happens that the patient is seen by 
 the physician for the first time when rupture of the cyst has taken 
 place. She is found, under these circumstances, in a state of 
 collapse ; with an anxious exsanguined countenance, a hardly 
 
 1 L'Union Medicale. Tome xi, p. 168. Paris, 1857.
 
 308 EXTRA- UTERINE GESTATION. 
 
 perceptible pulse, and rapidly sinking vital powers. Endeavors 
 must then be immediately made to obviate the alarming ten- 
 dency to death by syncope. Brandy, or any stimulant which may 
 be at hand, ought to be freely given. The patient's head should 
 be laid rather lower than the trunk. A full dose of solid opium — 
 such as two or even three grains of the extract — had better be 
 exhibited. Although I have no faith in such applications, yet it 
 is only orthodox to recommend that pounded ice, or ice and salt, 
 or cloths dipped in cold vinegar and water, be placed over the 
 abdomen, in order to moderate the bleeding if possible. Should 
 tliese means fail, but little more can be done. Yet there are pos- 
 sibly to be found practitioners of sufficient boldness, who would 
 give the patient such a desperate chance as might be afforded by 
 opening the abdomen, and attempting to stop the bleeding by 
 placing a ligature round the uterine end of the oviduct. 
 
 (3) As regards that more fortunate class of cases where no lacer- 
 ation takes place and the pregnancy goes on to the full term, the 
 foetal life generally becomes extinct soon after the cessation of the 
 ineffectual labor pains. In these instances, the foetus can either 
 remain as a foreign body in the maternal abdomen and give rise 
 to little or no inconvenience ; or suppuration will take place 
 within the cyst, its walls may become adherent to the surrounding 
 viscera or parietes, and subsequently an opening may form through 
 the latter, or ulceration may take place into the rectum or vagina, 
 or bladder. "When an opening is thus spontaneously made through 
 the abdominal parietes, the aperture can often be most advan- 
 tageously enlarged to permit the removal of the putrelied foetus. 
 This proceeding was first successfully performed in the year 1550, 
 again in 1590, and in many instances subsequently. Dr. Campbell 
 well remarks in his Memoir on Extra- Uterine. Cfestation, p. 150, 
 that "when the suppurative process is established, or a breach 
 is actually formed in the parietes of the abdomen, experience 
 proves that the integuments may, with safety, be largely incised, 
 or the pre-existing aperture freely dilated with success. Of 
 thirty cases in which gastrotomy was performed, or the breach 
 dilated, twenty-eight patients recovered. In twelve cases of 
 gastrotomy performed after the suppurative process was well 
 advanced, ten of the operations were successful. Of nine women 
 operated on, however, during the existence of foetal life, or soon 
 after its extinction, the wliole died. By these fifty-one operations,
 
 TREATMENT. 309 
 
 only two children were preserved ; and in one of tliese even, the 
 details are too marvellous for belief." The important fact here 
 mentioned, that all the women operated upon during the exist- 
 ence of foetal life, or soon after its extinction, died, must not be 
 forgotten ; for it proves to my mind conclusively, that gastrotomy 
 should never be performed with the object of preserving the 
 foetus. Indeed, if adopted at all, it ought not to be resorted to 
 until some time after the child's death ; when the system of the 
 parent — though affected by the irritation set up by the foetus — 
 has been restored as nearly as possible to the condition of the 
 non- pregnant state. 
 
 Whether the employment of a powerful caustic is likely to be 
 more successful than the use of the knife, or whether the abdo- 
 men may be safely opened at an earlier period by the former than 
 by the latter, cannot now be decided. Perhaps, however, the fol- 
 lowing instructive case may serve to throw some light on this 
 question. The report by Dr. Martin runs thus : 
 
 The patient was the wife of a projirietaire, in one of the country districts of 
 France. She was thirty-six years of age, of sound constitution, and had mar- 
 ried when nineteen years old. One year afterwards she gave birth to a child : 
 but she did not again become pregnant until after an interval of fifteen years, 
 at the end of October, 1855. Towards the close of the December of the same 
 year she was seized with violent pains, resembling those of labor ; which were 
 followed by true peritonitis, with intense fever. When this had been sub- 
 dued, the abdomen, which before presented nothing remarkable, had so 
 changed in form as to give rise to the supposition of extra-uterine gestation. 
 Difference of opinion upon this head prevailed among those consulted ; and 
 there is no account of the progress of the case until the beginning of August, 
 1856, i. e., the termination of the normal period of pregnancy. Then pains, 
 as if announcing approaching delivery, set in ; but these were at first irregu- 
 lar, vague, and purposeless. On the 8th August, however, they had become 
 severe; and now on examining the uterus, no doubt could be entertained of 
 the existence of extrauterine pregnancy, and the urgency for interference 
 became obvious. It was determined by the practitioners consulted in the 
 case, in order to prevent effusion into the peritoneal cavity to secure the for- 
 mation of adhesions between the cyst and the walls of the abdomen by the 
 employment of caustics for effecting the opening. The first application was 
 made on the 11th August (the mother had felt the child move the evening 
 before, although no sounds were audible to the ear), the caustic paste being 
 so directed as to produce an eschar about eighteen inches in length, running 
 parallel to the linea alba, and being about three fingers' breadth to the left 
 of the umbilicus, which was situated opposite to the middle of the eschar. 
 The application of the paste — the composition of which is not stated — was 
 repeated twice, and Canciuoin's paste was also applied three times ; the mor- 
 tified parts being carefully removed by the bistoury after each cauterization, 
 and the caustic again applied at the bottom of the wound. After the fifth
 
 310 EXTRA-UTERINE GESTATION. 
 
 application the cyst and the membranes were opened, not a drop of blood 
 havino; been lost. On the 2Qth August, i. e., fifteen days after the first ap- 
 plication h;id been made, extraction was performed. Much liquor aninii, 
 discolored by meconium, had already flown away ; and on pushing back the 
 bead, which projected through the artificial opening, the foetus was found 
 to be free and floating as in its natural cavity. The cyst, which was a line 
 and a half in thickness, was intimately united by solid adhesions to the in- 
 ternal wall of the abdomen, so that no fear existed of eff'usion into the peri- 
 toneum. The edges of the aperture were enlarged as much as possible by 
 the removal of the debris of the eschar, without going beyond the limits of 
 the cauterization, or giving rise to bleeding. As the child was dead and the 
 head very large, an incision was made into the scalp, so that the frontal and 
 parietal bones might be extracted Pelvic version was then performed with 
 great facility, and a well-developed child removed. About half an hour 
 after severe hemorrhage came on ; and the placenta was found to be so ad- 
 herent to the cyst as to require to be detached piecemeal. The bleeding 
 then ceased, but the patient sufl"ered from prolonged syncope, requiring the 
 use of restoratives. Compresses soaked in vinegar and water were applied 
 to the wound, and kept on by means of a towel, which exerted moderate com- 
 pression on the abdomen. These were left on for three days, when the 
 coagula of blood which had formed in the cyst were removed. During the 
 first four days the patient felt very enfeebled, but no inflammation super- 
 vened ; and at the end of a week she was comparatively well and comforta- 
 ble. Every day injections were thrown into the wound, at first of an emol- 
 lient, and afterwards of an astringent nature. Gentle laxatives were given 
 from time to time, and the strength was kept up by good diet. At the end 
 of the third week she was able to walk in her garden. The last report comes 
 down to the 25th September, when she appeared to be going on quite well, 
 getting up every day. The wound was still an inch in length and six in 
 depth, but in a very healthy state. ^ 
 
 Two instances were recorded in 1860, in which the operation 
 of abdominal section was successfully resorted to by Dr. Stutter 
 of Sydenham, and Mr. Adams of the London Hospital, for the 
 removal of dead extra-uterine infants retained several weeks be- 
 yond the full period of pregnancy." In both of these cases, the 
 risk of using the knife appeared to be much less than the danger 
 arising from the constitutional irritation which was set up by the 
 foetus. But out of fourteen other recorded cases, in which abdom- 
 inal section was performed without the previous formation of 
 any fistula, recovery only followed in five. It is also deserving 
 of notice, that in the two successful instances above referred to 
 the afterbirth was found firmly adherent. Consequently no at- 
 tempts were made to extract this organ ; although in Dr. Stutter's 
 
 ^ Revue M^dicale. Tome ii, p. G?."?. Paris, 18.56. 
 
 2 Medical Times and Gazette, pp. 55 and 57. 21st July, 1S60.
 
 TREATMENT. 311 
 
 case the placenta loosened and was removed en masse on the fifth 
 day after the operation, while in Mr. Adams's patient the cord 
 was expelled on the fourth day with portions of disintegrated 
 placenta. The fact can be statistically proved, that the forcible 
 removal of the placenta, unless this structure be found quite loose, 
 adds very much to the danger of the operation. 
 
 Attempts have occasionally been made to extract the foetus 
 en masse by an incision through the walls of the vagina ; and in 
 a few apparently well-selected cases, success has been the result. 
 Thus, of ten examples, the mother recovered in six; while in 
 three the infant's life was also saved. Unless, however, some 
 prominent part of the child's body can be distinctly traced 
 through the wall of the vagina, or unless there are peculiar and 
 very urgent reasons for interfering, it will be better to trust to 
 an expectant line of treatment, which if less brilliant is more 
 secure. Cazeaux relates, that in a case where the head of the 
 foetus, from being wedged at the superior strait, could readily be 
 felt through the posterior and upper part of the vaginal parietes, 
 Professor P. Dubois — notwithstanding sharp opposition from 
 several of his colleagues — resolved upon freely incising the 
 vaginal wall and cyst, so that he might apply the forceps and 
 remove the child bodily. After the incisions had been made, 
 however, an intimate adhesion was discovered between the cyst 
 walls and the foetal head, which prevented further proceedings. 
 ^Nevertheless, the operation was not without benefit; for in the 
 course of a few days it was followed by the discharge of a putrid 
 mass comprising all the soft parts of the foetus. Subsequently, 
 the detached bones of the skeleton were gradually extracted, the 
 cystic walls slowly contracted, the opening healed by degrees, 
 and at the end of two months the woman was completely cured. 
 At the time of operating the patient had been pregnant twenty- 
 two months.
 
 312 SUPERFffiTATION. — MISSED LABOR. 
 
 CHAPTER yill. 
 
 SUPERF(ETATION.— MISSED LABOR. 
 
 1. SUPERFCETATION — ThE POSSIBILITY OF ITS OCCURRENCE OFTEN DENIED — ManY OF THE 
 CASES BROUGHT FORWARD TO SUPPORT IT, TO BE EXPLAINED ON OTHER GROUNDS — 
 The CHIEF VARIETIES OF DOUBLE UTERI — SuPERFCETATION MAY OCCDR WHERE 
 THE UTERUS IS NOT BILOBED — ThE UTERINE CAVITY IS NOT CLOSED UNTIL THE 
 OVUM ATTAINS SUCH A SIZE AS TO FORCE THE DECIDUA REFLEXA INTO CLOSE AP- 
 POSITION WITH THE DECIltCTA VERA. — 2. MiSSED LABOR — DEFINITION — ItS OCCUR- 
 RENCE IN DOMESTIC ANIMALS — EXAMPLES IN THE HUMAN SUBJECT. 
 
 1. Superfcetation. — The best definition of the term superfoe- 
 tation which can be given is this, that it is the occurrence of a 
 new conception, tvhile the cavity of the uterus is already occupied by 
 an embryo. For example, — a woman one or two months ad- 
 vanced in pregfiancy, again becomes impregnated : she gives 
 birth to the first child mature when it has reached the ninth 
 month of intra-uterine growth, and the second also mature one 
 or two months later. This is a case of superfcetation, or super- 
 impregnation. The belief in the possibility of this occurrence 
 is by no means universally entertained at the present day; 
 although by many of the old w^riters little hesitation is felt on 
 the subject. Thus Aristotle refers to the matter, remarking 
 that " it happens sometimes that an abortion takes place, and 
 ten or twelve products of superfcetation come away." Harvey 
 cites an instance of it. In 1738, J. P. Gravel wrote a learned 
 treatise De Superfoetatione. Haller in his writings gives an 
 account of all the cases, the histories of which he has been able 
 to collect.^ And Brassavolus — some two centuries earlier — 
 asserted that he had seen superfcetation epidemic! 
 
 Without assenting to the views of the last-named author — who 
 possibly was the Joe Miller of his day — it seems undeniable that 
 a few curious and well-authenticated cases have happened, 
 which can only be explained by allowing the truth of the oc- 
 
 ■ Elementa PliysioIogiEe Corporis Humani. Toinus viii. Lausannte, 1757.
 
 SUPERFCETATION. 313 
 
 casional occurrence of superfoetation. At the same time it must 
 be remembered, that many of the examples brought forward in 
 support of this doctrine may be explained without having re- 
 course to it. The instances usually adduced are such as these : 
 A woman has been delivered, at the natural termination of ges- 
 tation, of a full-grown foetus and a shrivelled ovum. Or, there 
 has been a delivery at the same time of two children, one being 
 more developed than the other. Or, a negress has given birth to 
 twins of different colors, as in a case mentioned by Dr. Mosely.^ 
 Or, lastly, a woman has borne a mature child, and three or four 
 months afterwards a second fully developed and healthy child. 
 ISTow, with regard to the first and second class of cases, it seems 
 certain -that they may have been, and indeed usually were merely 
 ordinary twin pregnancies; in the first instance one ovum having 
 been blighted but retained, in the second case one foetus having 
 been better nourished than the other. Still this view fails to 
 explain all the instances of the second class, as the following 
 history — related by Dr. T. B. Taylor— seems to prove: 
 
 A nejiress about thirty-five years old, was delivered of twins in May, 1848 ; 
 one a mulatto, the other a negro child. She had been u)arried many years 
 to a negro — a slave on the same plantation as herself — and had had several 
 children by him. Her menstrual discharge had occurred for several months 
 previous to her pregnancy at the full of the moon. She felt herself pregnant 
 by her customary signs, about the middle of the month ; and to confirm her 
 suspicions, at the next period the menses did not appear. About three 
 weeks from the time she first felt that she had conceived, and one week after 
 her menses had failed to appear at the proper period, she had sexual inter- 
 course once with a white man. At birth, the mulatto child bore marks of 
 
 ^ A negro vi'Oinan brought fortli two children at a birth, botli of a size, one of which 
 was a negro, the other a mulatto. On being interrogated as to the cause of their dis- 
 similitude, she said she perfectly well knew the cause of it, which was, that a white 
 man belonging to the estate came to her hut one morning before she was up, and she 
 suffered his embraces almost instantly after her black husband had quitted her. — 
 Treatise on Tropical Diseases, &c. Fourtli Edition, p 111. London, 1804. 
 
 But the most extraordinary case of monstrosity, involving the questions of superfcEta- 
 tion and paternity, is said to have occurred at Alexandria, in f-gypt. A Fellah woman 
 was delivered of a dicephalous monster, of which one head was while, and apparently 
 about the eighth month of uterine life, while the other was black, possessing in other 
 respects the negro conformation, and this head was fully developed. The monster was 
 born dead, and the mother died soon after her delivery. The change in the color of the 
 skin commenced at the neck of the black head, and was found, by an eminent physician, 
 to be due to the existence of a coloring matter similar to that found in the skin of the 
 negro race. The husband of the woman was a Fellah, whose skin was of a brownish 
 color. There were negro laborers in the port, but it coulil not be ascertained whether 
 the woman had had intercourse with any of them. It is therefore impossible to say 
 whether this was or was not a case of impregnation about the same time by two men 
 of different races. — L Union M^dicale. Paris, 5 Acdt, 1S48. Quoted from Dr. Taylor's 
 Medical Jurisprudence. Fourth Edition, p. 547. London, 1852.
 
 314 SUPERFCETATION. MISSED LABOR. 
 
 being at least three weeks younger than the negro ; thus corroborating the 
 woman's opinion, as to the time between the two conditions.! 
 
 The third class of cases must also be explained on the suppo- 
 sition of a twin pregnancy ; two ova having been impregnated at 
 nearly tlie same time by different men. But with regard to those 
 instances where a woman gives birth to a mature child, and three 
 or four months afterwards to a second — the uterus not being 
 double — no explanation but that of superfcetation can be given. 
 Professor Eisenmann, of Strasbourg, relates the history of a 
 woman who was delivered of a second child 140 days after the 
 birth of the first, both having been mature : she subsequently 
 bore many other children, and after her death the uterus was 
 proved to be single. 
 
 Dr. Maton has recorded the case of an Italian lady who was 
 delivered on the 12th November, 1807, of a male, child, which 
 " had every appearance of health at the time of his birth," though 
 he lived nine days only. On the 2d February, 1808 — not quite 
 three calendar months afterwards — this lady gave birth to another 
 male infant, completely formed and apparently in good health ; 
 and who lived for three months, when he died of measles.^ 
 
 Dr. Tyler Smith states, that in the early part of the year 1856 
 lie saw the following example : 
 
 A young married lady, pregnant for the first time, miscarried at the end 
 of the fifth month; and some hours afterwards a small clot was discharged, 
 inclosing a perfectly fresh and healthy ovum of about one n)onth. There 
 were no signs of a double uterus in this case : the patient had menstruated 
 regularly during the time she had been pregnant, and was unwell three weeks 
 before she aborted.^ 
 
 With regard to some of the reported cases of superfcetation 
 there can be no doubt but that they have been so named im- 
 properly. The mistake has arisen from the uterus having been 
 double or divided into two cornua ; conception having occurred 
 first in one division, and then in the other. Professor Knssmaul, 
 in his excellent treatise on uterine malformation,^ does not seem 
 
 1 American Journal of the Medical Sciences. 'Sew Series. Vol. xvii, p. 549. 
 Pliila.leliiliia, April, 1819. 
 
 ^ Medical Transactions, published by the College of Physicians in London. Vol. iv, 
 p. IGl. London, IS! 3. 
 
 3 The Lancet. London, I'ith April, ISfiG. 
 
 * Von dem Mangel, der VerUUmniernng und Verdopplung der Gel/aimutter, von der 
 Nachempfangniss, und der Ueberwanderung des Eies. Von Adolf Kussmaul, M.D., 
 p. 3, &c. Wurzburg, 185'J.
 
 DOUBLE UTERI. 
 
 315 
 
 inclined to agree with Rathke, that the uterus is formed partly 
 out of the genital canal and partly by the fusion of the two 
 oviducts. Such a mode of formation would account for a womb 
 which is double at its upper part and single below ; but it fails to 
 explain the cases where the uterus and vagina are both com- 
 pletely bifid. Consequently, Kussmaul believes with Serres, 
 Geoffroy St. Hilaire, and others, that the uterus and vagina and 
 bladder are all originally bifid. In many of the lower animals 
 the uterus is permanently double-horned. And in the human 
 
 FiQ. 13. 
 
 UTERUS DIVIDED BY A PARTITION AND HAVING A DOUBLE OS. THE VAGINA 
 
 IS SINGLE. (After Cruveilhier. ) 
 
 subject, until the beginning of the fourth month of intra-uterine 
 life the womb is always distinctly bifid ; but its dividing septum 
 commonly disappears in the sixth month. Where, however, 
 arrest of development occurs before this absorption of the septum 
 takes place, the uterus remains a double organ throughout life, 
 its cavities being separated from each other by a distinct wall. 
 
 Instead of being simply divided by a septum the uterus is oc- 
 casionally more distinctly bifid. Some duplex uteri have the
 
 316 
 
 SUPERFOETATION. MISSED LABOR. 
 
 separation only at the upper part ; the two horns becoming fused 
 together into one cervix, so as to present one orifice. In other 
 instances, the two halves lie far apart above, but come into appo- 
 sition below ; tlie two cervical canals and orifices, however, re- 
 maining perfectly distinct, while the vagina is also divided. But 
 it is worth remembering, that whatever the exact form of these 
 uterine malformations may be, yet the essential organs of genera- 
 
 FiG. 14. 
 
 SECTION OF THE SAME UTERUS. 
 
 The drawing was made at the expiration of a pregnancy in which the (oetus had been developed iu 
 
 the left cavity. 
 
 tion are found as in the normal state. In other words, though 
 the uterus and vagina be double, the ovaries and oviducts are 
 unaltered, either as regards position or number. 
 
 A remarkable case of impregnation of both horns, and conse- 
 quent production of twins in the uterus bicornis, has been re- 
 corded by Dr. Generali, and is quoted by Dr. Alexander Henry 
 in his excellent essay on this subject. The chief points may be 
 thus stated : 
 
 Gaetana Bovatti, of Modena, had had six difficult instrumental labors. 
 In 1816, she was prefruant for the seventh time ; and there was noticed a 
 well-marked furrow along the median line of the uterus, which gave rise to
 
 DOUBLE UTERI. 
 
 317 
 
 the suspicion of a double pregnancy. On the 15th February, 1817, she was 
 delivered of an apparently full-prown male child; the placenta came away 
 naturally, but there was no lochial di.^charge. The abdomen was reduced in 
 size on only one side, and foetal movements were felt on the other. This 
 state continued until the 14th March, when she was delivered of a second 
 male infant of equal development with the firjt. In 1822, she became preg- 
 nant for the last time, and was delivered of a female infant. In September, 
 1847, this woman died of apoplexy. The uterus, on examination, was found 
 to be double : the neck was of the usual form, but the body was divided into 
 two parts, each being furnished with a Fallopian tube.' 
 
 Fig. 15. 
 
 BIFID OR DOUBLE-HORNED UTERUS. (After Moreau.) 
 
 The woman from whom this drawins was takf n, had conceived alternately in each half of the uterus, 
 and died after her second delivery m tlie Haris Maternile from metro-peritonitis The vagina was origi- 
 nally divided throufihout its whole length by a septum, but in eonseiiuence of rupture during delivery, 
 there remained only a narrow band and a double cicatrix at the upper part of the canal. 
 
 Another decided case may be subjoined. It occurred in the 
 practice of one of the pupils of the Maternite of Paris, and the 
 history is as follows : 
 
 A woman was on the point of labor in the fifth month of her seventh preg- 
 nancy ; a continual flow of blood, three weeks before, caused her to forebode 
 miscarriage. The labor proceeded slowly, the head of the foetus passed the 
 OS uteri, but could only be extracted by aid of the fingers, and the infant 
 
 1 The London Journal of Medicine. Vol. i, p. 1105. 1849.
 
 318 SUPERFCETATION. MISSED LABOR. 
 
 was born dead and livid. The umbilical cord was broken at the moment of 
 delivery. Madame Dejean was waiting impatiently for the return of the 
 pains and the expulsion of the placenta, when, all at once, a mass of blood, 
 partly fluid and partly coagulated, issued forth, and brought with it an em- 
 bryo, supposed to be in its third month, inanifesthiy si<j7is of life. The 
 former loetus was eijiht inchesand a half in length, the latter only three and 
 a half: the superfoetation was evident. Madame Dejean ascertained by ex- 
 amination, that the vagina and utero-vaginal orifice were single, as well as 
 the cervix uteri ; but that there existed two cervico uttrtne oi-ijices, each cor- 
 responding with a distinct uterus. These two orifices were perfectly distinct 
 and open, one on the right, the other on the left side ; they were of a dif- 
 ferent size. The birth of the second infant was almost imuiediately followed 
 by the expulsion of the placenta belonging to the first : while the other came 
 away an hour afterwards. One afterbirth was four inches in diameter, the 
 other three ; both were nearly circular, and the cords were attached to their 
 centres. It is easy to suppose that a second impregnation may have taken 
 place two months after the first, inasmuch as the body alone of the uterus is 
 occupied in the ^rai half of pregnancy; and it is quite evident that the mis- 
 carriage was occasioned by the considerable distension of the two uteri, of 
 which one only had been distended in previous pregnancies.^ 
 
 The facts of another example have been recorded by Tiede- 
 mann. The principal points of interest run thus: 
 
 A young woman, during her labor, was visited by two physicians, both of 
 whom examined her. One stated that she was not pregnant, and that the 
 OS tincse was firm and closed : while the other asserted that the os was open 
 and the head already engaged in it. This difference of opinion caused a 
 discussion, which led to a further and more careful examination, when it was 
 found that there were two vaginse and a double uterus. 
 
 An interesting case of double uterus, with simultaneous ges- 
 tation, was related to the Fellows of the Obstetrical Society of 
 London in June, 1862, by Mr. Grace : 
 
 Mr. Grace was summoned by his father to see a patient in labor for the 
 fourth time. Her age was twenty-six. Twice previously there had been 
 premature birth; the third child did not live. When first seen by Mr. 
 Grace, labor had been going on for fifteen hours ; the waters had escaped. 
 On examination, a hand was found presenting in the vagina, with the os 
 uteri about half dilated; but lying posterior to this, another os was dis- 
 covered, with the head of a child presenting. The septum between the two 
 was half an inch thick, and extended up as far as could be reached. The 
 anterior os was dilated, the child turned, and delivery effected. The pla- 
 centa then followed. The child was dead, and apparently seven months old. 
 The posterior os was next dilated, turning effected, and a live child extracted, 
 which survived only a few hours. The placenta of the second child was ex- 
 
 1 A Practical Treatise on the Diseases of the Uterus and its Appendages. By Madame 
 Boivin and Prof. Dug^s. Translated by G. 0. Hetning. Note, p. 20. London, 1834.
 
 THE POSSIBILITY OF S U PE R F(ET ATI N. 319 
 
 pelled without difficulty. Both children were females equal in development. 
 No flooding or other complication interfered with the perfect recovery of the 
 patient.^ 
 
 The question still remains to be answered, — Is there any posi- 
 tive physical obstacle to the occurrence of superfoetation where 
 the uterus is not double or bilobed ? It seems certain that there 
 is not; or, at all events, not until after the termination of the 
 third month of pregnancy. The opposite view has chiefly been 
 maintained by those who assert that ovulation never occurs during 
 pregnancy, who believe that the os uteri gets plugged directly 
 after impregnation, and who have also been unacquainted with 
 the true structure of the decidua. That ovulation during preg- 
 nancy is an exceptional circumstance — notwithstanding Scanzoni 
 believes its occurrence to be the law — is extremely probable ; but 
 this is very ditierent to saying that it never takes place. As a 
 rule, a woman does not experience any menstrual discharge 
 during gestation ; yet no one denies that this is a rule to which 
 there are many exceptions. And as we sometimes see that the 
 external signs of ovulation are manifested, why should we argue 
 that those which are naturally unseen are absent ? With regard 
 to the supposed obstruction of the cervical canal it is now, I be- 
 lieve, generally accepted as proved that the mucous plug of preg- 
 nancy is similar to the mucus found in the cervix in the unim- 
 pregnated non-menstruating uterus; through which plug the 
 active spermatozoa must make their way in ordinary fecundation, 
 and which therefore can be no obstacle. Then, the observations 
 Avhich have been already made on the structure and growth of 
 the gravid uterus have shown that the uterus does not become 
 closed until the ovum attains such a size as to force the decidua 
 reflexa into close and firm apposition with the decidua vera ; so 
 that until this happens — about the third month — there is a suffi- 
 ciently free communication between the ovary and the vagina, 
 or in other words between the ovules and the semen. As Dr. J. 
 Matthews Duncan remarks, this explanation will account for all 
 the authentic cases of superfoetation.^ For if we suppose in an 
 instance of this kind, that the first child is born prematurely, 
 but within the limits of viability, we thus gain two months ; and 
 
 1 Transactions of the Obstetrical Society of London. Vol. iv, p. 138. London, ISfi". 
 ^ Monthly Journal of Medical kiciences. Vol. xvi, p. 331. Edinburgh, 1853.
 
 320 SUPERFCETATION. MISSED LABOR. 
 
 if inipregnation may take place between two and three months 
 after conception, we have thus four or five months of interval 
 accounted for between the births of successive viable infants. 
 
 As illustrating the application of the foregoing remarks, atten- 
 tion may be directed to the following case : 
 
 In 1862, Dr. George Harley and the author were requested to draw up a 
 report on a preparation of supposed twin abortion which had been exhibited 
 to the Obstetrical Society by Dr. Langmore. The patient's history was this : 
 Mrs. B — , aged 88, has had nine children, the youngest being three years 
 old. Has never had twins. The catamenia were on for the last time in 
 January, 1862, and they ceased on the 20th. On the 22d Mny, when she 
 was probably about four months advanced in pregnancy, she noticed a slight 
 vaginal discharge; a fortnight previously havjng had shivering and a con- 
 tinued feeling of coldness in the abdomen. In the evening pains came on, 
 and a foetus, apparently of about four months' gestation, was expelled. It 
 was flattened, and mure or less atrophied; and on examination immediately 
 afterwards, it was apparent that it had been (feud some time. Serious hem- 
 orrhage set in, and therefore Dr. Langmore, who, up to this time had been 
 in charge of the case, summoned Dr. Piiestley for consultation. This gen- 
 tleman removed the placenta, which corresponded in size with the foetus 
 expelled. As the flooding was not checked by this proceeding, Dr. Priestley 
 again introduced his finger into the uterus; when, by depressing the organ 
 with the hand applied over the pubes, he reached a smooth and soft body, 
 which was adherent to the upper part of the cavity, but was removed with- 
 out much difficulty. On withdrawing this body it was found to consist of a 
 second bag of membranes. The chorion and amnion were unruptured, 
 healthy, and transparent; and through them an embryo of about five or six 
 weeks could be plainly seen, floating in clear liquor an)nii. The embryo 
 appeared fresh and perfect, not at all atrophied, and minute vessels could be 
 distinguished ramifying on its dorsal surface. There was a little fresh blood- 
 clot, adherent here and there to the villi of the chorion ; and as thi.« was not 
 reujoved before putting the preparation into spirit, it became hardened and 
 incorporated with the villi. There were, however, none of the appearances 
 of ordinary apoplectic ovum. The decidua of this second ovum came away 
 separately, and was healthy ; there was no indurations in its substance, but 
 here and there it was infiltrated with fresh blood. 
 
 When the preparation came into the possession of Dr. Harley and the 
 author it had been in spirit for thirteen days. The first foetus was of about 
 the fourth month of utero-gestation. It was a male, the penis and scrotum 
 being distinct; it measured five and a half inches in length from the occiput 
 to the heel. The eyelids were separable. Mouth, lips, and tongue, perfectly 
 distinct. The ears were tolerably advanced in formation, the meatus being 
 distinct. The nails were already defined. The placenta was pale and exsan- 
 guine in some portions, in others dark and filled with clotted blood. The 
 membranes and cord were distinct. The cause of death appeared to have 
 been strangulation from twisting of the cord. 
 
 In the second preparation the membranes were found unruptured, but 
 opaque; and through them an ovum could be indistinctly seen fluating in 
 liquor amnii. A portion of the chorion villi was imbedded in blood-clot, but 
 this could be separated, where it was attempted, in one small portion only.
 
 MISSED LABOR. 321 
 
 The whole seemed healthy, allowing for the changes produced by the spirit. 
 The sac of the n)enibranes measured two and one-eighth inches. On opening 
 the bag a small euibryo, in a good state of preservation, was discovered. It 
 measured five-eighths of an inch in length and five-sixteenths in breadth. 
 The head, with the eye, was perfectly distinct. So, also, were the branchial 
 clefts. The legs and arms already projected from the trunk. The interior 
 of the sac was at one spot unusually vascular. 
 
 After a careful examination of the preparation, the examiners came to 
 the conclusion that it was in all probability an example of superfoetation. 
 And they say that they did so for this reason : " If the second, healthy, six 
 weeks' ovum were the product of the same conception as the first four 
 months' foetus, which had been dead some thiie when expelled, then we 
 must believe that although the latter perished some days before its expul- 
 sion, and manifested symptoms of putrefaction, yet the small, second ovum 
 died when six weeks old, was retained fur about ten weeks afterwards, and, 
 nevertheless, when removed, was perfectly healthy, and did not present any 
 trace of decomposition. We cannot subscribe to this improbable view. As, 
 theoretically, we see no physical obstacle to the occurrence of superfoeta- 
 tion, during: the first three months of pregnancy, so we think the specimen 
 now reported upon proves, so far as anything of the sort can prove, that 
 superfoetation is a positive fact."^ 
 
 I would only remark, in conclusion, that although it is impor- 
 tant there should be a general recognition of the truth of the 
 doctrine of superfoetation, yet it is equally necessary for the phy- 
 sician to avoid being over-credulous. Without doubt, supertoeta- 
 tion is of rare occurrence, the genuine recorded cases of it being 
 few. But because, in medical literature, many true and false 
 narratives are mixed up together, we are not justified in reject- 
 ing the whole. The labor of sifting the grains of wheat from 
 the bushel of chafl'may be great; but, unlike Gratiano's reasons, 
 they are worth the search. 
 
 2. Missed Labor. — More uncommon and extraordinary, per- 
 haps, than either extra-uterine pregnancy or superfoetation, is 
 the abnormal condition now to be mentioned. When, Irom 
 some cause which has not hitherto been explained, the pains of 
 parturition do not come on efiiciently at the proper period, but 
 the mature foetus dies and remains included in the uterine cavity, 
 without directly destroying the mother, we have an example of 
 what is termed missed labor. This curious phenomenon is of very 
 rare occurrence in the human subject; although it may be con- 
 jectured that Celsus is alluding to it in the twenty-ninth chapter 
 of his seventh book, where directions are given for extracting 
 
 ' Transactions of tlie Obstetrical Society of London. Vol. iv, p. 165. London, 1863. 
 
 21
 
 322 SUPERFCETATION. MISSED LABOR. 
 
 the foetus when it has died in the uterus and cannot be born 
 spontaneously. "Whether this conjecture be well founded or 
 not, however, I am only acquainted with the records of some 
 twenty, or four and twenty indubitable examples of this remark- 
 able casualty in woman ;^ but it seems to be much more fre- 
 quently met with in cows, mares, and other domestic animals. 
 In the Museum of the Royal College of Surgeons of Eng- 
 land, there are several preparations illustrating this condition. 
 Amongst others there is the os uteri of a cow, whose uterus had 
 contained twin calves (almost fully developed) for nearly two 
 years; and another dissection showing a portion of the horn of 
 the uterus of a sheep, containing a part of the lamb which had 
 been retained in the uterus bej'ond the ordinary period of gesta- 
 tion, and which had become adherent to the surrounding uter- 
 ine wall. 
 
 Judging from the examples which have been published of 
 missed labor in the human subject, it would appear that the 
 uterus either remains perfectly passive at the completion of the 
 full term of gestation, or inefficient pains come on for a time and 
 then cease altogether; while any attempts which may be made 
 to excite contractions by ergot, galvanism, artiiieial dilatation of 
 the OS uteri, &c., seem to faih The womb indeed becomes a 
 
 1 In addition to some examples to be presently mentioned, the reader may be re- 
 ferred to the following: ^lorgagni alliules to one case from Nebelins, in his wt)rk ])e 
 Sedibiis et Causis Morbornm : Epistola xlviii, art. 41. Edit. -^nda. Tomns 2ndus, p. 
 200. Patavii, 1765. — In Lovvthorps Abridgment of the Philosophical Transactions, 
 Fifth Edition, vol iii, p. 2"2.3. London, 1749, is a case where some of the tissues of the 
 foetus were voided by the anus years after cot\ception. So many bones, indeed, came 
 away that "everybody thought that there must have been three foetuses buried in the 
 womb aril that time." — Dr. Dan. Schulz reports the case of a fcetus retained in the titenis 
 for nine years. The history is to be found in the Conimentarii de Rebus in Scientia 
 Naturali et Medicina Gestis, vol. xvi, p. 309. Lijisite, 1770. — Gahn has collected the 
 histories of many strange cases in his dissertation De Partu Seroiiiio, pp. 12 to 16. Up- 
 saliae, 1770. Many of the supposed examples of missed labor, however, are really in- 
 stances of extra-uterine firegnaiicy.- — Voigtel speaks of an embryo remaining forty years 
 in the womb, in his Handbuch der Pathologischen Anatomic. Band iii, p. 518. Halle, 
 1805 — In J?chmidt"s Jahrbucher, 9th November, 164S, Dr. Vondorfer relates the case of 
 a woman, forty-nine years old. with whom the pains of labor came on, and ceased after 
 continuing for some days. At the end of eleven years the patient died from symptoms 
 of purulent infection; and at the autopsy the remains of the putrefied foetus, with its 
 immerous bones, were found in the uterus. — Dr Rae jNIenzies records an instance in the 
 Glasgow Medical Journal, vol. i, p. 129, lb53. — Dr. Montgomery met with one instance, 
 which he has narrated in the second edition of his classical work on The Signs of Preg- 
 nancy, p. 5bl9. London, 1856. — Or. McClintock reports a case of his own, with the 
 notes of others coinmimicated to him, in the Dublin Quarterly Journal of Medical Science, 
 vol. xxxvii, pp. 51 and 3(i7. Dublin, 1S64 — Sir Jantes Simpson and Dr Keiller each 
 relate<l a case to the Obstetrical Society of Edinburgh, on the 12th July, 1S65, the par- 
 ticuiars of which are tiiven in the Edinburgh Medical Journal, pp. 575, 576. Decem- 
 ber, 18(i5 — And lastly. Dr. Halley described a case at the Obstetrical Society of Lf^n- 
 don, on 5th June, 1867, a report of which appears in the Lancet, p. 72. 20th July, 1867.
 
 MISSED LABOR. 323 
 
 mere sac, like the cyst formed around an extra-uterine foetus ; 
 and its walls may ulcerate so as to permit of the passage of the 
 decomposed foetal bones and tissues into the peritoneal cavity, 
 or into the bladder, or into the bowel. Meanwhile, however, 
 the woman's health suffers greatly. The horribly oft'ensive pu- 
 trid discharge, which follows upon the decomposition of the 
 foetus, alwaj's sets up severe constitutional disturbance; while the 
 patient is foitunate if ichorhsemia, or metritis, or peritonitis can 
 be warded oft'. 
 
 Dr. Oldham has met with one case which deserves to be known, 
 inasmuch as prior to its occurrence very little attention had been 
 devoted to the subject in this country : 
 
 The subject of this history was a pregnant woman aged forty-one, who ex- 
 pected to be confined in June, 1845; at which time a gush of blood from 
 the uterus took place, with some pain, but without any other sign of labor. 
 The breasts became distended with milk. Ergot of rye, galvanism, and some 
 attempts at artificial dilatation were in vain had recourse to, in order to ex- 
 cite the paralyzed uterus. The foetus decomposed, and a great many of its 
 bones were removed through the os uteri. The patient died three months 
 after she had missed her labor. A preparation of the uterus was shown at 
 one of the meetings of the Pathological Society. By this specimen it was 
 seen that the uterus was contracted, and the anterior wall of its body almost 
 entirely absorbed. The remainder of the foetal bones, closely packed into 
 an ovoid mass, were found in a cyst; which was bounded in front by the ab- 
 dominal walls and urinary bladder; above, by omentum and small intestine, 
 held together by false membrane; and behind and below by the posterior 
 wall of the uterus, the cervix, and the os. The bladder was also thinning at 
 one part, as though some of the foetal bones would have soon passed through it.^ 
 
 A more extraordinary instance occurred some years ago in 
 Oceoquan, Virginia, and has been reported by Dr. M. L. Weems : 
 
 A mulatto, about twenty-five years old, the mother of three or"four children, 
 having completed the ninth month of her pregnancy, was taken in labor in 
 the spring of 1827. Severe pains continued for two or three days, and then 
 ceased ; leaving her undelivered. From this time she continued, regularly, 
 about every four weeks, to experience a return of the pains; which would 
 generally last for two days, and then leave her as befoie This state of things 
 continued until June, 1828, when an empiric determined to open the uterus 
 by an incision through the abdomen. On performing this operation, the 
 uterus was found to contain the remains of a foetus in a half dissolved state, 
 many of its bones being detached and bare : a large proportion of the soft 
 parts had previously putrefied, and come away by the vagina. On removing 
 the remains of the foetus, the internal surface of the uterus, for several inches 
 
 ^ Proceedings of the Pathological Society. Vol. i, p. 130. London, 1S4G. Also the 
 Guy's Hospital Reports. Second Series. Vol. v, p. 105. London, 1S47.
 
 324 SUPEKFCETATION. MISSED LABOR. 
 
 around the os uteri, was found lined by a crust of osseous matter, which 
 formed a smooth and perfectly continuous surface, except at the os uteri, 
 where there was an opening sufficiently large to admit the finger. The crust 
 was about half a line thick, possessed considerable strength, and adhered 
 firmly to the uterus; from which it was with difficulty removed in sumll fl;ikes. 
 The uterus sh(jwed no disposition to contract; but the woman did well for 
 ten days, when — after an error in diet — she was seized with peritonitis and 
 died. No post-mortem examination was made.^ 
 
 Tlie foregoing case is particularly interesting; for though 
 Morgagni, Baillie, and others, have related instances in which 
 the substance of the unimpregnated uterus has been converted 
 into bone, yet I know of only one other example of such a change 
 occurring during gestation. This instance is recorded by Dr. 
 John Caldwell,^ and is remarkable because not only was the 
 greater part of the uterus ossified, but the foetus itself had also 
 undergone the same cliange. It is true that Dr. R. B. Cheston^ 
 has given the history of a curious case in which the fcetus was 
 retained in the mother's abdomen, inclosed in an osseous sac, for 
 fifty-two years after the expiration of the usual period of gesta- 
 tion ; but it seems probable that in this instance the uterus rup- 
 tured during labor, and that the bony covering was subsequently 
 formed around the child as it lay in the abdominal cavity. 
 
 AVith regard to the cause of missed labor we know nothing. 
 I have a theory, that in some cases at least it may be due to the 
 unibilical cord being twisted twice or thrice round the child's 
 neck. Let the cord be coiled only once round this part, and it 
 is astonishing how ineflicient the pains of labor are rendered. 
 As to treatment also, but little can be said. Such remedies as 
 hip baths, vaginal injections of the solution of permanganate of 
 potash, rest, and nourishing food are obviously indicated. If 
 symptoms of blood-poisoning set in, the efi'ects of the sulphite of 
 magnesia should be tried. Where any of the foetal bones can 
 be felt presenting at the mouth of the uterus, they ought to be 
 carefully extracted. And lastly, iinder favorable circumstances 
 it is certainly justifiable to dilate the os uteri with sponge tents, 
 and then to remove as many of the bones, &c., as can be got at, 
 without the employment of undue force. 
 
 1 Tlie American Journal of tlie Medical Sciences. Vol. xviii, p 257. Philadelpliin, 
 1 8.36. 
 
 2 The E(linbur<jh Medical and Snrgical Joninal. Vol. ii, p. 22. Edinburgh, 180G. 
 ' MedicoChirurgical Transactions. Vol. v, p. 104. London, 1814. — The ])repara- 
 
 tion (No. 2720) is in the pathological department of the Museum of the Royal College 
 of Surgeons of England.
 
 DISEASES COEXISTENT WITH PREGNANCJy. 825 
 
 CHAPTER IX. 
 
 THE DISEASES WHICH MAY COEXIST WITH PREGNANCY, AND THEIR 
 RECIPROCAL INFLUENCE. 
 
 1. The state of pregnancy not always a happy one — The fears of the recently 
 
 MARRIED GIRL — ThE ANXIETIES OF THE POOR. — 2. ThE INFLUENCE OP MENTAL 
 
 DISORDERS — Melancholia the most frequent form — The consequences op 
 
 PREGNANCY OCCURRING IN A WOMAN ALREADY INSANE. — 3. PARALYTIC AFFECTIONS 
 DO NOT HINDER CONCEPTION — DISEASE OF THE BRAIN HAS NO EFFECT ON THE 
 PROGRESS OF LABOR — The AMOUNT OF INFLUENCE WHICH THE THREE NERVOUS 
 CENTRES EXERT UPON THE UTERUS DURING PARTURITION — 4. PREGNANCY SELDOM 
 OF BENEFIT TO EPILEPTICS. — 5. ChOREA IN CONNECTION WITH PREGNANCY. — 6. ThE 
 NECESSITY FOR CAUTION IN RECOMMENDING MARRIAGE FOR YOUNG HYSTERICAL 
 
 WOMEN — The influence of hysteria on pregnancy AND DELIVERY. — 7. The 
 
 OCCURRENCE OF TETANUS AFTER ABORTION. — 8. The EFFECT OF PREGNANCY ON 
 THE PROGRESS OF PHTHISIS — ThE EFFECT OF PULMONARY CONSUMPTION IN HINDER- 
 ING CONCEPTION. — 9. The effect op pneumonia on the COURSE OF GESTATION — 
 
 The fatality of this disease to pregnant women. — 10. The heart nor.mally 
 
 IN A state of hypertrophy DURING PREGNANCY — SYMPATHETIC OR NERVOUS 
 
 thr0bb1n6s of the aorta. — 11. carcinoma of the labia and cervix uteri. — 
 12. The treatment of syphilis during pregnancy. — 13. The epidemic and 
 infectious maladies which may complicate pregnancy. — 14. general obser- 
 VATIONS ON THE THERAPEUTICS OF PREGNANCY — ThE INFLUENCE OF BLOODLETTING 
 
 — Cathartics and purgatives — Diaphoretics — Narcotics and sedatives — 
 counter-irritation — tonics and stimulants, etc. 
 
 1. The state of pregnancy though a happy one for the great 
 majority of women, is not so for alL In the delicate and re- 
 cently married girl, the general constitutional uneasiness which 
 this condition induces, together with the novelty of her position, 
 tends not a little to foster and increase the vague fears which 
 are naturally entertained as to the pains and perils of parturi- 
 tion ; fears, which have not unfrequently been seen to embitter 
 almost the whole period of gestation. So also, the prudent 
 mother maintaining a family on limited means experiences no 
 small amount of solicitude as to the manner in which another 
 child is to be provided for; this inquietude perhaps attaining an 
 importance with w^hich those only can thoroughly sympathize 
 who know what it is to feel the res angusta dovii. And then — 
 not to mention the unmarried girl, whose pregnancy only serves
 
 326 DISEASES COEXISTENT WITH PREGNANCY. 
 
 to reveal her dishonor — there are those who, having grown-up 
 sons and daughters, and having been unfruitful for some few 
 years, become unexpectedly pregnant just perhaps as they were 
 looking for "the change of life;" and who, strange to say, really 
 feel greatly ashamed of their condition. If, after a time, the 
 sentiment of humiliation be conquered and allowed to pass 
 away, it is often only that it may be replaced by an exaggerated 
 remembrance of past suffering, and a firm conviction tliat the 
 trial which awaits them will end fatally; or perhaps the melan- 
 choly feeling takes the form of a fixed and ever-present idea, 
 that the oftspring will be malformed and hideous. Suppose, 
 that to these mental disturbances there-be superadded physical 
 suffering — e. g., that arising from some form of dyspepsia. 
 Surely, the effect upon the patient's constitution can be pictured 
 without much difficulty. Indeed, under these circumstances, 
 sensitive ladies have sometimes so foolishly tortured themselves, 
 that at the termination of their condition by parturition, their 
 protracted vexation and pain has culminated in an attack of 
 puerperal mania. If it be allowed, as it fortunately can be, that 
 matters very seldom proceed to this extremity, yet it is undeni- 
 able that they very generally place the pregnant woman in a 
 most unfavorable position for withstanding the ill effects of any 
 m.orbid processes to which her system may become exposed ; and 
 that they always modify these processes in a marked degree. 
 
 2. Granting that these remarks are correct, it will excite no 
 astonishment to find that mental disorders, either slight or grave, 
 not very uncommonly demand the cautious attention of the 
 physician during the progress of gestation. This is especially 
 the case with women who have any predisposition to insanity; 
 such individuals being particularly susceptible to its attacks, 
 either during pregnancy or immediately after delivery. In 
 mild cases, the disease merely impresses a peculiar character on 
 the patient's actions and physiognomy, without depriving her of 
 the power of self-control; wdiereas in the more severe instances 
 there are the ordinary well-marked symptoms of an established 
 disordered intellect. It should be remembered, however, that 
 the difference between these two classes is usually only one of 
 degree ; the affection being the same in both. 
 
 Multiparas and women beyond the age of twenty five are
 
 INFLUENCE OF MENTAL DISORDERS. 327 
 
 probably more liable to attacks of insanity during pregnancy 
 than primiparous young females. An hereditary tendency, 
 former attacks of mental alienation, constitutional weakness, 
 excessive irritability of the uterine organs, prolonged mental 
 excitement, and sudden fright, are among the chief predisposing 
 causes. Although the reason for its being so cannot be satis- 
 factorily defined, yet there is little doubt but that this distress- 
 ing malady is more common in France than in Great Britain ; 
 while in both countries, the cases of insanity arising during preg- 
 nancy are much smaller in number than those which occur after 
 delivery. Single women seem to suffer more frequently than 
 the married; shame, neglect of friends, and perhaps the cruelty 
 of the seducer being no sedatives to nervous irritability and ex- 
 citement. It does not follow because a woman is attacked with 
 temporary insanity during one pregnancy, that she will there- 
 fore necessarily suffer in the same way in another ; but there is 
 certainly a fear that she may do so. Dr. Burrows, in his Com- 
 mentaries on Insanity^ asserts that in some women insanity 
 occurs contemporaneously with conception, and returns with 
 every impregnation. Some become insane at various periods 
 of gestation; others at the time of quickening oidy. The char- 
 acter of the derangement during pregnancy is almost always 
 that of genuine insanity, not the delirium of the puerperal state. 
 The same strange and inexplicable anomalies have, it is reported, 
 been once in a way observed in the insanity of pregnancy, as have 
 been found to occur in the mania which follows delivery. Thus, 
 it has been asserted that women who have lost their reason for 
 a time when carrying male children, have continued quite 
 healthy when pregnant with females. Kow although I cannot 
 believe for one moment that these circumstances have stood at 
 all in the relation of cause and effect, yet there are not wanting 
 authorities who appear to think that there has been something 
 more than mere accident in the sequence of events. Even 
 Esquirol has said, that some females have puerperal mania after 
 giving birth to a male infant, whereas they have remained 
 exempt from this malady after confinement with a daughter. 
 So also in other instances, delirium has manifested itself only 
 after every second labor. And again, in a third class, the dis- 
 ease has set in during the third or fifth month of each period of 
 lactation without any discoverable exciting cause. Possibly,
 
 328 DISEASES COEXISTENT WITH PREGNANCY, 
 
 however, the process of suckling has induced a condition of 
 cerebral anfemia, the women being originally of weak and irri- 
 table constitutions. 
 
 Of the various forms of insanity, malancholia is that which 
 most frequently afflicts the pregnant woman. The symptoms 
 are in no way modified by the condition of the generative organs; 
 and hence they need not be described in these pages. The diag- 
 nosis between extreme mental dejection and true melancholia is 
 often sufficiently difficult to test the sagacity of the physician. 
 One simple mode of distinguishing between the two, which 
 merits attention, has been pointed out by Dr. L. V. Marc^,' and 
 it is this : That the tendency to despondency, and all the result- 
 ing modifications of character and intelligence which are met 
 with at the commencement of pregnancy, become less and less 
 marked after the third month of gestation, and especially as the 
 time of labor draws nigh ; whereas in examples of mental de- 
 rangement exactly the reverse occurs. Thus, putting aside those 
 cases where conception seems to give, as it were, the signal for 
 intellectual derangement, it is found that insanity seldom begins 
 till the third month has passed, and commonly does not do so 
 till after the sixth; while in general, moreover, the patient does 
 not in any way improve during the continuance of gestation. 
 
 Remotely allied to these cases of monomania are those long- 
 ings of pregnant women which sometimes lead to the commis- 
 sion of crime. The delusions of this nature can generally be 
 conquered ; and no doubt as a rule, they are overcome. But 
 every now and then the public is startled by finding some lady 
 of position accused of shoplifting, and whose only excuse is that 
 she is irresponsible on account of her pregnancy. This plea 
 must always be received with great caution. It is impossible to 
 lay down any general rules on the subject. Every case must be 
 thoroughly inquired into, without any regard to the social posi- 
 tion of the accused. It should be remembered, however, that 
 the question to be solved is generally this : Has the theft been 
 so contrived and so attempted to be concealed, and has the stolen 
 property been so used or disposed of, as to show that the accused 
 is a responsible agent or not ? There may be no dispute as to 
 her having urgent longings. The point is, — could she not resist 
 
 1 Traill ile la Folie des Femmes Enceintes, des Nouvelles Accouchees, et des Nour- 
 rices, p. A2. Paris, 1858.
 
 TENDENCY TO SUICIDE. 329 
 
 them ? For it can never be allowed that the moral or legal ob- 
 ligation of a woman to withstand temptation is removed by 
 pregnancy. 
 
 Where insanity comes on during gestation without any special 
 cause, and when there is no strong hereditary predisposition or 
 powerful moral influence to maintain the diseased action, ameli- 
 oration of all the symptoms very often occurs spontaneously a 
 few days, or even hours, after delivery; this amendment being 
 followed by complete recovery within a variable period of time. 
 Why, in one instance, parturition should cure mental derange- 
 ment, whereas in another it may appear as the cause of acute 
 mania, is a problem difficult to solve. The fact, however, being 
 as stated, it follows that during the attack active medical treat- 
 ment ought not to be resorted to. The physician should content 
 himself with seeing that the functions of the bowels, liver, kid- 
 neys, skin, &c., are properly performed; that the patient takes a 
 due amount of nourishment, without overtaxing her digestive 
 organs; and that she has quiet sleep at night. Tonics, gentle 
 aperients, sedatives, and narcotics, with moderate daily exercise 
 in the open air, are all useful agents. In many instances, re- 
 moval from home and the influence of relatives is required ; ex- 
 ceptionally, the reverse has to be recommended, the presence 
 and conversation of judicious friends proving beneficial. One 
 point must, however, be specially remembered, or the most fright- 
 ful consequences may ensue ; viz., that inasmuch as the morbid 
 state almost always gives rise to the greatest irritability and des- 
 pondency duringthe whole progress of the disease, so these afflicted 
 patients require constant care to pi'fevent them from attempting 
 self destruction. They wxmld ap[)ear, moreover, to be peculiarly 
 liable to become affected with sudden uncontrollable impulses to 
 commit suicide; in this respect differing from the majority of 
 melancholies, who generally destroy themselves, or try to do so, 
 after long and careful premeditation, and after displaying the 
 greatest cunning in their preparations for eluding suspicion. 
 After delivery has safely taken place, the infant should on no 
 account be left alone in the mother's charge, until it is quite 
 certain that a favorable and permanent change has taken place ; 
 though it is quite proper at short intervals and under surveil- 
 lance to trust her with the child — not to suckle it, save in a few 
 special cases — in order to try and arouse a new and healthy train
 
 330 DISEASES COEXISTENT WITH PREGNANCY. 
 
 of feelings. The expression "permanent change" is used ad- 
 visedly, for tlie disease sometimes recurs. As a case in point it 
 may be mentioned, that in 1841 a woman was discharged from 
 St. Luke's Hospital apparently cured ; but experiencing a fright 
 soon afterwards, the mind again became aifected, and in one of 
 the paroxysms she destroyed both her infant and herself. And 
 then, supposing the patient to be so fortunate as to be cured, she 
 should be carefully forewarned of the risk — even if it be but 
 small — of another pregnancy ; for it may not unreasonably be 
 anticipated that the cause recurring, the effect will follow. 
 
 In certain instances it unfortunately happens that delivery, 
 instead of exerting a beneficial influence on the progress of the 
 insanity, seems rather to aggravate the symptoms. Thus, a 
 woman was admitted into the private asylum at Bethnal Green, 
 who had been attacked with melancholia immediately after quick- 
 ening. She had a strong desire to destroy herself and her three 
 children. The disease continued unrelieved during the remain- 
 ing term of pregnancy ; and became much worse after delivery. 
 In a second example, at the same institution, the cerebral affec- 
 tion manifested itself in strangeness of conduct a month before 
 parturition ; perfect incoherence and great depression persisting 
 after this event. Yet cases of this class are not always to be re- 
 garded as hopeless ; for cures have sometimes been effected after 
 the lapse of several months. But they teach us the important 
 fact, that in no case of mania combined with pregnancy is it ad- 
 visable to prematurely terminate the latter in order to relieve the 
 former. It has happened more than once that when insanity has 
 occurred during the state of gestation, abortion has been induced 
 as a means of cure ; and, as far as I can learn, the results have 
 been most deplorable. On the contrary, by adopting a simple 
 expectant mode of treatment the lives of both mother and infant 
 will be unendangered ; while hopes may be entertained that the 
 mental powers of the patient will be ultimately restored. 
 
 So far we have been considering the influence of pregnancy 
 as an exciting cause of mental derangement ; but another propo- 
 sition may likewise be discussed with some advantage. What, 
 then, are the consequences which flow from pregnancy occurring 
 in a woman already insane? Does it lead to the cure or aggra- 
 vation of the mental disorder ? If we seek for replies to these 
 questions in the writings of those physicians who have given
 
 MENTAL DISEASE AGGRAVATED BY PREGNANCY. 331 
 
 especial attention to the subject of lunacy, we shall obtain only 
 directly contrary opinions. Thus, guided by the results which 
 have followed in only a few cases, we find some writers confirm- 
 ing the vulgar opinion that pregnane}^ cures insanity. But the 
 practitioners who have had the largest experience — men who 
 have not only seen but who have observed, and whose remarks 
 are universally received with the greatest respect — take a much 
 more cautious view of this question. For example, Esquirol, in 
 recapitulating the facts taught him by unwearied and careful 
 observation, says — "Pregnancy, parturition, and lactation are 
 means by which Nature has sometimes cured insanity ; but I 
 regard these cures as rare. I have often seen pregnancy and 
 labor eft'ect no change in the demented, with the exception of 
 rendering them more calm. 1 have also known a lady, who, 
 during five consecutive pregnancies, became deranged, and was 
 cured each time by the accouchement. But in spite of this ex- 
 ample and of many others often quoted, and notwithstanding 
 the opinions of many physicians, I regard as exceptional cases 
 the cures of insanity by marriage, pregnancy, and parturition ; 
 so often have I seen the madness persist in spite of, and even be 
 aggravated by, these means. It is only necessary to visit the 
 Saipetriere to see more than a hundred insane women, though 
 they each have gone through the process of marriage, pregnancy, 
 and delivery."^ 
 
 More recent authors, especially Marce and Morel, entertain 
 similar views ; and it seems to me, that reasoning from relevant 
 facts, the opinion of these authorities must be regarded as correct. 
 We have seen how very impressible the nervous system is ren- 
 dered in most pregnant women, how the disposition often becomes 
 altered, how the sympathetic disorders which are almost a part 
 of the state of gestation depress the vital powers, and what a 
 shock the pains of labor with the hemorrhage which accompanies 
 delivery may inflict upon the whole system. Are we warranted, 
 then, in inferring that these actions can impress a salutary change 
 on a pre-existing morbid state ? I believe not ; but rather, on the 
 contrary, that as a general rule, which the exceptions serve to 
 prove, they are calculated to aggravate the mental disorder. 
 Facts alone, however, can satisfactorily decide this question, and 
 
 1 Des Maladies Mental es, sous les rapports Medical, Hygienique, et Medico-legal. 
 Tome ii, p. 392. Paris, 1S38.
 
 332 DISEASES COEXISTENT WITH PREGNANCY. 
 
 .to them appeal is made. From hospital practice or from the 
 writings of different authors, Dr. Marcd has collected the histories 
 of nineteen cases of pregnancy occurring in insane women. ^ The 
 great importance of the question under consideration justifies a 
 brief analysis of these : 
 
 In one case, a woman thirty-two years of a<re was safely delivered at the 
 end of her first pregnancy. After her second labor she was attacked with 
 mania, which continued one month. Three weeks before her third accouche- 
 ment, she again became insane, and has since remained so. A fouith preo;- 
 nancy with a labor remarkable for a complete absence of any suffering did 
 not ameliorate her condition. 
 
 The second patient was thirty-five years old, and had two attacks of insanity 
 in two years ; the first arising without any appreciable cause, the second at 
 the end of a confinement. She seems to have got well, but two years subse- 
 quently (in 1832) the disease reappeared in the form of melancholia with 
 stupor; being occasioned by the fear of cholera. While so afflicted she 
 became pregnant. Gestation, delivery, and lactation for two months only 
 aggravated the disease. At the end of two years some svnjptoms of dementia 
 had shown themselves, when a new pregnancy occurred, followed by delivery 
 at the full term. The dementia became more marked, and the patient re- 
 mained incurable at Charenton. 
 
 Tn a third case pregnancy and labor occurred during a third attack of 
 mania. The woman, twenty-five years old, became demented without any 
 remission in the progress of the disease. 
 
 In a fourth instance, a young won)an became pregnant while in the Sal- 
 petri^re, suff'ering from attacks of stupor alternately with excitement. She 
 was delivered during a period of stupor after a labor of sis hours; the pains 
 having been so slight that she scarcely uttered a cry even during the last 
 quarter of an hour. The mental disease was in no way modified. 
 
 The fifth example is curious from the fact that the patient became insane 
 when she was nineteen years of age, and that in spite of her malady con- 
 tinuing she was married at twenty-one. She had three children with(jut her 
 condition being improved ; and she was an inmate of the Salpetriere at the 
 time the report was written. 
 
 The age of the sixth patient was thirty-nine. She suff'ered from partial 
 delirium with hallucinations ; and in no way improved after pregnancy and 
 a natural labor. The seventh case was of a similar description. 
 
 Then there are five examples which can only be alluded to briefly, since 
 the facts are not reported in detail. One was delivered in the asylum of St. 
 Jacques of Nantes, without her mental disease being at all modified : two 
 were in the Salpetriere under the care of M. Mitivie at the time of the re- 
 port, one being twenty-eight years of age, the other thirty-five, and both in- 
 curable, though they were delivered in the hospital some years ago : in one 
 case pregnancy occurred after the persistence of hallucinations for two years, 
 but no improvement followed the birth of a fine healthy boy : and the filth 
 patient was under the care of M. Morel, who states that the morbid condition 
 of the mind was modified neither by the state of pregnancy nor by parturition. 
 
 1 Traill tie la Folie ties Femnies Enceintes, &c., pp. 81 to 119. Paris, 1858.
 
 MENTAL DISEASE AGGRAVATED BY PREGNANCY. 333 
 
 And finally, there are five instances in which a cure took place at a longer 
 or shorter interval after delivery. There is one in which there was such con- 
 siderable amelioration of the symptoms at the end of the third month of 
 pregnancy, that she was then discharged from the asylum, and unfortunately 
 lost sight of. And there is another recorded by M. Weill, in which reason 
 was regained during two successive pregnancies, though the patient after- 
 wards became an incurable lunatic. 
 
 The foregoing review cannot, it seems to me, do otherwise than 
 lead us to agree with Dr. Marc^ in opposing the practice of those 
 who advise pregnancy in the cases of insane women, when ordi- 
 nary remedies fail to effect any good. It is the more necessary 
 to be positive upon this point, because popular prejudice is in 
 favor of the view that pregnancy is not only a cure for insanity, 
 but for all chronic nervous disorders ; and the physician, without 
 taking the initiative, may nevertheless by his silence be thought 
 to authorize the practice which flows from the prevalence of this 
 opinion. The error has arisen through the circumstance daily 
 taught by common experience, that women who marry and by 
 childbearing carry out the law of Nature, usually enjoy better and 
 more even health than such as lead a life of celibacy, or who 
 marry and remain unfruitful. But because marriage unquestion- 
 ably serves to maintain the balance of physical and mental vigor, 
 it by no means follows that it will equally avail to cure or even 
 mitigate disease. While writing these remarks I have in my rec- 
 ollection the case of a young ladyof fortune, who was of such 
 an excitable disposition, and suftered so frequently from attacks 
 of aggravated hysteria, that at times she positively required con- 
 trol. After consulting for nervous disorders of one kind or 
 another almost every medical man of note in the metropolis, her 
 relations were strongly advised to try the eflect of matrimony. 
 Money, it is usually allowed, can procure everything ; and in this 
 instance it certainly enabled its possessor to secure a husband. 
 After the marriage ceremony " the happy pair" lived together for 
 nearly two years, when " incompatibility of temper" necessitated 
 a separation. The lady was the mother of one child, which she 
 seemed to dislike the sight of, and which was cruelly neglected ; 
 and she was five or six months advanced in pregnancy with a 
 second infant when I saw her. Though unfit for any decent 
 society, liable to attacks of irritability and despondency sad to 
 witness, and in such a state generally that no one would say she 
 was of sound mind, yet she could scarcely be called insane in the
 
 334 DISEASES COEXISTENT WITH PREGNANCY. 
 
 ordinary acceptation of tlie term. Still it seemed to me certain 
 at the time, that by whatever expression her condition was then 
 designated, confirmed dementia could be the only ultimate result. 
 Again, some time in the year 1859, I attended a case in consul- 
 tation with Mr. Francis Odling, where there was a history some- 
 what similar to the foregoing as respects disease and marriage and 
 separation ; though happily the symptoms were less severe, the 
 offspring was better cared for, and there appeared a probability 
 of a more favorable termination. But the point I wish to insist 
 upon is, that in neither of these examples did marriage do aught 
 but aggravate the morbid symptoms ; while it materially increased 
 the ditficulty of managing the patients in a social point of view, 
 and subjected the poor little helpless children to unnatural neg- 
 lect in infimcy, with the miserable prospect of inheriting the 
 mental weakness of the parents. 
 
 When fecundation takes place in insane women, the period 
 of gestation is generally passed through in a quiet manner, and 
 is not marked by any special peculiarities. In only two of the 
 cases which have been referred to did the act of quickening give 
 rise to any fresh delusions. One of the patients declared that 
 she had a tapeworm in her stomach, whose movements she felt; 
 while the other woman believed that there was a serpent in her 
 abdomen, which at the time of her delivery would spring upon 
 the surrounding persons and destroy them. The histories of 
 these and sim.ilar cases also show that the labors of insane women 
 are, generally speaking, remarkably easy; the pain and sufiering 
 being so slight that no indication of uneasiness even may be 
 given. This circumstance makes it necessary that such women 
 should be narrowly watched as the time of delivery draws nigh ; 
 since otherwise the lives of both mother and infant may be sac- 
 rificed for want of due attention. Again, too, let me urge that 
 the suicidal and homicidal tendencies of the parent be not for- 
 gotten. The woman is often impelled by an almost irresistible 
 desire to destroy' both herself and child. And though she may 
 for a time be able to withstand this influence, yet unless closely 
 watched day and night, her power of resistance will fail her at 
 some opportune moment; and then the loss of two lives will be 
 the penalty for the neglect of the attendants. 
 
 3. The i^aralytic affections dependent upon disease of the brain
 
 PARALYTIC AFFECTIONS. 335 
 
 and medulla oblongata need not act so as to prevent pregnancy. 
 I have myself seen two instances of long standing hemiplegia, in 
 which utero-gestation for a time proceeded as under ordinary 
 circumstances; and it may be believed that such cases are far 
 from uncommon. Hemiplegia, involving the face and tongue 
 and extremities, is the ordinary form of cerebral paralysis; the 
 disease rarely assuming the condition of paraplegia, which de- 
 pends, as a rule, on some injury of the spinal cord or its mem- 
 branes. When paraplegia arises during the latter months of 
 gestation, the paralysis may be due to the pressure of the gravid 
 uterus upon the obturator nerve and the sacral plexus. 
 
 The fact is well known that paralysis is sometimes a functional 
 disorder ; or, in other words,- no organic change exists in any of 
 the nervous structures which can be recognized. Intemperance, 
 cold, excessive venery, &c., seem occasionally to produce this 
 form; and very rarely it is probable that pregnancy has a simi- 
 lar effect. At all events we know, that during the term of utero- 
 gestation, particularly if it be complicated with albuminuria, it 
 is not very uncommon to find patients affected with amaurosis, 
 or with deafness : which conditions persist only until after de- 
 livery. A few remarkable instances are recorded in which more 
 marked paralysis arises. Thus, Dr. Lever mentions the case of 
 a lady who was attacked with hemiplegia in four successive preg- 
 nancies. The symptoms always came on very soon after the 
 commencement of gestation ; they were modified by treatment, 
 but not removed ; and were only cured by delivery. — About the 
 year 1857, I was consulted by a lady whose lower extremities 
 became gradually paralyzed rather before the sixth month of 
 gestation ; so that when seen one month afterwards she could 
 neither stand nor walk, and was exceedingly debilitated. Medi- 
 cines and nourishing diet improved the health, but not the par- 
 alysis. A week prior to labor she suffered from retention of 
 urine, as well as from an inability to retain the contents of the 
 bowel. Five weeks after parturition she had entirely recovered. 
 The cure appeared to be permanent; chiefiy I believe in conse- 
 quence of the great care which was taken to keep up the general 
 health, and her adherence to my urgent advice that she should 
 lead a life of celibacy. In this instance it appeared to me, that 
 the paralytic affection was not dependent upon the pressure of 
 the gravid uterus, since the mischief commenced at too early a
 
 336 DISEASES COEXISTENT WITH PREGNANCY. 
 
 period for tins cause to act so powerfully. It rather seemed to 
 be owing to "an irritation springing from various sensitive 
 nerves;" and to be allied to that form of paraplegia which is 
 sometimes due to disease, and particularly to displacement, of 
 the virgin uterus. Lisfranc, Nonat, Romberg and others have 
 related several cases of this kind of paralysis following disease 
 of the womb, which were only cured by the relief of uterine dis- 
 turbance. An instance reported by Dr. Brown-Sdquard may be 
 quoted as an example : 
 
 In the year 1855, a young lady consulted this eminent p^^ysiologist for 
 what she called an extreine weakness; but which was really a paraplegia, 
 almost complete at each menstrual pi^riod. There was no diminution of any 
 kind of sensibility; no paralysis of the bladder or rectum; no symptom of 
 hysteria. Dysuienorrhoea, bearing-down pains, with a very sensitive and 
 congested and anteflexed condition of the uterus alone existed. In a few 
 days after the use of a bandage to support the womb, a great amelioiation 
 was evident; and in less than two weeks the paralysis had entirely ceased. 
 It had lasted six months; and had been treated in vain by strychnia, gal- 
 vanism, shower-baths, steel, and other tonics.^ 
 
 The connection and reciprocal influence which exists between 
 the brain and uterus is often so well marked, that it might be 
 thought disease of the former would have an injurious influence 
 on the progress of parturition. Daily experience teaches us, that 
 mental impressions may suspend the pains of labor, and some- 
 times suppress the menstrual flow; while conversely, irritation 
 of the ovarian or uterine nerves during pregnancy or the process 
 of delivery, has excited an attack of convulsions or apoplexy or 
 mania. But on examining the question more closely, it will be 
 found that our speculations upon this head are without founda- 
 tion. The uterus resembles the heart in more than one respect. 
 Thus, it is a large hollow muscle; its contractions are mainly 
 regulated by the ganglionic system of nerves; and its action is 
 rhythmic, three periods being observable, viz., one of contraction, 
 one of relaxation, and one of repose. The amount of influence 
 which the three nervous centres exert upon the uterus during 
 parturition is uncertain; some difference of opinion existing 
 upon this, as on many other points connected with neural physi- 
 ology. It seems, however, quite clear that the influence of the 
 cerebrum need not be taken into much account: for we find that 
 
 1 The Lancet, p. 415. London, 2Sth April, 1860.
 
 EPILEPSY. 337 
 
 uterine contractions occur just the same when all cerebral influ- 
 ences are withdrawn as when they are uninterfered with. The 
 occurrence of labor in cases of hemiplegia, of complete paraplegia, 
 of convulsions, as well as in the temporary unconsciousness pro- 
 duced by anaesthetics, proves this sufiiciently. That the spinal 
 system furnishes the uterus with nerves is certain from the many 
 reflex relations of this organ. To take only one instance, we 
 find that powerful contractions may generally be induced by the 
 excitement of the mammary nerves, as happens when a child is 
 placed at the breast. But it is probable that the largest supply 
 of nervous force is derived from the ganglionic system ; and this 
 is shown by the process of parturition taking place when all 
 spinal influence appears to be abrogated. Dr. Farre records the 
 following example of this fact : 
 
 A woman was attacked with paraplegia in the eighth month of preg- 
 nancy. She had neither sensation nor motion in any part below the umbili- 
 cus. No reflex movements whatever could be produced by tickling the soles 
 of the feet. The feces passed involuntarily, and the urine was drawn off 
 daily. About the ninth month, her medical attendant, when about to pass 
 the catheter, found a full grown foetus in the bed (dead). The uterus was 
 contracted, and the placenta in the vagina. The woman was entirely ignorant 
 of what had occurred. Scanzoni and Chaussier relate similar examples of 
 birth taking place notwithstanding complete paralysis of the sensitive and 
 motor functions of the lower half of the body. In Chaussier's case the pres- 
 sure was occasioned by a hydatid cyst which involved the cord on a level 
 with the first dorsal vertebra.-^ 
 
 The powerful influence of the sympathetic ganglia and nerves 
 is further shown in the uterine contractions which are sometimes 
 manifested after death ; as when delivery spontaneously takes 
 place some time subsequently to the cessation of the maternal 
 life. Hence it seems probable, that while the cerebro-spinal 
 fibres maintain the relations of the uterus with other organs, the 
 ganglionic system regulates the contractions of this viscus. 
 
 4. The hope has occasionally been entertained that pregnancy 
 might exert a favorable influence upon patients liable to fits of 
 epilepsy^ if only by suspending the attacks during the continuance 
 of gestation. Such expectations have very generally ended in 
 disappointment. This result might be anticipated, if it were 
 
 ' Cyclopnpclia of Anatomy and Physiology. Article, Uterus and its Appendages. 
 Vol. V, p. 676. London, 1859. 
 
 22
 
 338 DISEASES COEXISTENT WITH PREGNANCY. 
 
 merely remembered that irritation of the female organs of gener- 
 ation sometimes alone suffices to excite this disease ; so that not 
 a few authors — as Sauvages, Prichard, and others — speak espe- 
 cially of the Epilepsia Uterina. M. Malgaigne even mentions a 
 remarkable instance in which the first epileptic attack came on 
 during pregnancy, and the woman continued ever afterwards a 
 sufferer from frequent seizures. The cases, however, where ges- 
 tation actually provokes this disease must be few in number. 
 Dr. Copland alludes to the history of a young lady, who was for 
 a long period under his care on account of slight epileptic fits, 
 connected with irregularity of the uterine functions and bowels. 
 After marriage, she experienced a gradual amendment for some 
 time ; but her first labor was followed by a severe attack of 
 puerperal mania. 
 
 On the other hand, in studying fully the causes of epilepsy, it 
 does seem as if celibacy actually predisposed some women to 
 sufter from this disease; and hence, since the year 1691, when 
 Lanzoni recorded a cure by marriage, not a few physicians and 
 patients have hoped for a similar result from this remedy. Dr. 
 Sieveking refers to one of his patients, a widow of thirty-eight, 
 who stated that she had been afflicted with fits for as long as she 
 could recollect ; but had been freer from them since marriage 
 and childbirth than formerly. Nevertheless, while allowing that 
 marriage tends to relieve many disorders of the sexual functions 
 in women, yet this author very judiciously^ remarks, that as it is 
 certain "the marital act itself may become an exciting cause 
 of epilepsy, and as we know that the hereditary influence of the 
 disease is great, we ought not to counsel epileptics to marry ; as 
 well on account of their partners, as on account of their ofifepring, 
 unless the long time that has elapsed since the occurrence of a 
 paroxysm, justifies a hope that the morbid taint is quiescent, if 
 not extinct."^ This advice is substantially the same as that given 
 by Dr. Herpin ; who remarks that he is acquainted with the 
 histories of two young men and two women who married many 
 years after they had been cured, while up to the date of his 
 writing they had none of them had reason to regret taking such 
 a step.^ 
 
 Supposing an epileptic to become pregnant, the question of 
 
 1 On Epilepsy and Epileptiform Seizures, p. 113. London, 1858. 
 
 2 Du Prognostic et du Traitement Curatif de TEpilepsie, p. 523. Paris, 1852.
 
 CHOREA. 339 
 
 course arises as to the power of medicine to afford relief. Un- 
 fortunately, no special remedy can be recommended as likely to 
 do much good ; but a certain amount of benefit will accrue from 
 making every endeavor to improve the patient's general health, 
 and also from adiiiinistering such agents as are calculated to 
 give tone to the nervous system. Hence, a simple but nutritious 
 diet, must be allowed ; with plenty of milk, cream, and two raw 
 eggs daily. Intoxicating drinks of all kinds are, as a general 
 rule, to be forbidden. The patient ought to take exercise in the 
 open air ; she should avoid late hours ; and she must be warned 
 of the consequences of exposing herself to anything calculated 
 to produce mental excitement. Then, hypophosphite of soda or 
 lime, cod-liver oil, large doses of tincture of henbane, bark, 
 quinine, zinc, or one or other of the mild preparations of steel 
 should be prescribed. Recollecting that epileptics improve for 
 a time under every new plan of treatment, we must so husband 
 our resources as to be able to vary the remedies; while every- 
 thing should be done to make the suft'erer place confidence in 
 her physician. Faith and hope will often accomplish very much 
 when all the drugs in the Pharmacopoeia prove valueless, more 
 especially in disorders of the nervous system. Finally, it is not 
 to be forgotten that the tendency to epilepsy is frequently handed 
 down from parent to offspring. Hence, a mother who sufi'ers from 
 attacks of this malady ought not to be permitted to increase her 
 child's unavoidable predisposition to the same by suckling it. 
 A strong and healthy wet-nurse is, if possible, to be procured ; 
 while the infant must be reared with the greatest attention to its 
 physical and mental health. 
 
 5. Of the nervous affections which may complicate pregnancy, 
 cliorea is also one which demands some attention. The chief 
 features of this disease consist — to use the definition of Romberg 
 — in combined movements of one or more groups of muscles, in- 
 dependent of cerebral influence, increasing in violence when pre- 
 determined movements are attempted, and more or less inter- 
 fering with the latter. 
 
 Chorea is rare after puberty, being most commonly seen in 
 patients between six or eight and fifteen years of age. But oc- 
 casionally it affects adult women, and is not very unfrequently 
 found in connection with pregnancy. It is remarkable, that in
 
 340 DISEASES COEXISTENT WITH PREGNANCY. 
 
 tliese cases the sufferers have rarely been troubled with the dis- 
 ease in early life ; while it seldom occurs before the second month 
 of gestation, and still more infrequently after the fourth. The 
 attacks can sometimes be relieved by the employment of suitable 
 remedies ; but often they are very obstinate, and resist all treat- 
 ment until after delivery. Moreover, primiparous women appear 
 to be more liable to chorea than the multiparous, for of twenty 
 recorded examples the patient was in her first pregnancy in no 
 less than seventeen. It is also quite exceptional for it to set in 
 after deliver}^ In the majority of instances both sides of the body 
 are affected, though sometimes the disease is unilateral. So, 
 also, the upper extremities are attacked alone in some women; 
 and the same is the case with the lower limbs, thouffh Ronibero; 
 makes the contrary assertion. But undoubtedly, as a general 
 rule, the chorea of pregnant females is bilateral. " The intensity 
 of the movements," says Romberg, "is very marked, and they 
 are often complicated with convulsions of an epileptic character. 
 Many complain of a sense of numbness in the affected parts. 
 The brain is almost invariably aflected ; and this is shown by 
 headache, vertigo, a wild expression of the features, rolling eyes, 
 unconnected speech, loss of memory, and great irritability."^ 
 
 The symptoms and progress of this disorder when coexistent 
 with pregnancy are often remarkable. As the best method of 
 fixing the chief facts upon the memory of the reader, three or 
 four of the most interesting cases recorded will be quoted. The 
 first to be mentioned, shows well how violent the attacks some- 
 times prove : 
 
 A Jewess had sufFeved from chorea as a girl, and been successfully treated 
 by Peter Frank. Fifteen years afterwards she married, and became preg- 
 nant ; when an attack of chorea set in, more intense than Frank had ever 
 witnessed during a practice of fifty years. The spasmodic movements con- 
 tinued day and night : there was perfect consciousness, yet the behavior was 
 most violent. Tiie integuments were covered with boils and gangrenous 
 spots. None of the remedies employed had any eflPect. A miscarriage took 
 place at the fifth month, and health was restored at the same time.^ 
 
 Dr. Ingleby, in a course of Clinical Lectures, alludes to the 
 
 1 A Manual of tlip Nervous Diseases of Man. Translated and Edited for the Syden- 
 ham Society, by E. H. Sieveking, M D., p. 63. I>ondon, 1853. 
 
 2 Frank's (Josephus) Praxeos, Medicie iiiiiversie priccepta. Tomus I, p. 348. Lip- 
 siis, lb41.
 
 CHOREA. 341 
 
 histories of five examples wliicli were all fatal. One of this gen- 
 tleman's most remarkable cases was the following : 
 
 A female in the last month of frestation, had been suifering for six weeks 
 from a violent headache. Soon after a venesection convulsions of the facial 
 muscles supervened, which were communicated to the left arm ; and which — 
 after a second bleeding — spread over the greater part of the body. On the 
 evening of the fifth day, the disease attained an alarming height ; the patient 
 spoke loud, rapidly, and almost unceasingly, though her consciousness was 
 unimpaired ; and the movements were so violent and universal, that it was 
 necessary to hold her down by force. As, at the same time, parturient pains 
 set in, it was thought advisable to rupture the membranes; upon which a 
 dead child was born. The spasmodic symptoms, however, were in no way 
 diminished ; and after a short sleep, produced by opium, the movements 
 became so much aggravated, that six people were scarcely able to restrain her. 
 Twenty-four hours later death ensued, with all the symptoms of extreme ex- 
 haustion.' 
 
 Dr. Lever has reported the following interesting example of 
 this affection, commencing at an early period of pregnancy. The 
 chief points in the medical history need only be quoted : 
 
 Mrs. was married at the age of nineteen. She was of a cheerful and 
 
 lively disposition, had enjoyed good health, and the uterine functions had 
 been performed with regularity and without pain. A few months before 
 marriage or just afterwards — it cannot be said which, owing to Dr. Lever's 
 style being more poetical than distinct — she suffered once or twice from 
 hysteric attacks; but conception took place "ere the torch of Hymen was 
 extinguished." For the first two months the symptoms of pregnancy pre- 
 sented no special peculiarity; being chiefly mechanical, with gastric irrita- 
 bility. But at the commencement of the third month, a perceptible alteration 
 took place in her manner ; she became irritable and peevish, convulsive 
 movements were observed about the muscles of the face, and these were fol- 
 lowed in a week by a tossing of the head to and fro. The right arm next 
 became convulsed, then the left, and afterwards the left and right leg. 
 During the progress of the case, her mode of speech altered ; her sentences 
 were short; she hesitated before replying to a question, and when an answer 
 was given she seemed to shoot it out. In spite of purgatives, zinc, iro\i, 
 arsenic, digitalis, colchicum, nux vomica, bark, quinine, musk, ammonia, and 
 the shower bath, no improvement took place; and she continued in the same 
 condition until the close of gestation, when her memory seemed weakened, 
 and fears were entertained lest she should become imbecile. At the proper 
 period labor set in, and after an easy time she was delivered of a live girl. 
 When the uterine pains were present, the convulsive movements ceased; but 
 in the intervals they were distressing. Delivery was succeeded by a long 
 and quiet sleep. The patient was better on waking ; the symptoms gradually 
 subsided ; and at the end of a month no trace of chorea was left. The supply 
 of milk was copious, and she weaned her infant at the seventh month. The 
 
 1 The Lancet, p. 783. London, February 22, 1840.
 
 342 DISEASES COEXISTENT WITH PREGNANCY. 
 
 child at the time of the report was seventeen years old, of a slender figure, 
 quick and irritable, and impatient of rebuke. At the age of twelve she had 
 a slight attack of chorea, induced by fright ; but the attack was soon removed, 
 and at the time of removal the catameuia appeared, and afterwards continued 
 regular.' 
 
 Dr. Robert Lee gives an account of a young woman, in the 
 sixth month of her second pregnancy, who died of chorea on 
 the 29th August, 1840, in St. George's Hospital: 
 
 The symptoms were at first slight, and were apparently produced by a 
 fright. The convulsive movements, however, became so violent, that it was 
 found necessary to put on a strait waistcoat, and fix her down to the bed. 
 Forty-seven hours before death the contents of the uterus were expelled. 
 On examining the body after death, the brain and spinal cord were perfectly 
 healthy. There were some small vegetations on the mitral valve. The riiiht 
 kidney and ureter were wanting; the supra-renal capsule was present. The 
 uterus was in a natural state. The corpus luteum was unusually small, and 
 the coats of the Graafian vesicle could scarcely be seen within the yelluw 
 matter. Dr. Lee asks the pertinent question, — Whether, when the treat- 
 ment failed to relieve the symptoms, and they became violent and dangerous, 
 would it have been advisable to induce premature labor ?^ 
 
 Dr. J. Matthews Duncan relates two cases of partial chorea, 
 which need not be farther mentioned than to say that they are 
 interestino; for these reasons : 
 
 The lower limbs were the parts afi'ected with the involuntary movements. 
 The attacks were periodical in their character, the movements occuriing in 
 one case only in the evening and early part of the night, and in the other 
 being troublesome merely in the night, unless the patient sat in one position 
 for a long time. The treatment consisted chiefly in the administration of 
 steel and opiates; and both patients got well after a few weeks of medical 
 care, and at least two months before delivery,^ 
 
 And lastly, Dr. Lawson Tait has favored me with the partic- 
 ulars of the following case, which well illustrates the dangerous 
 nature of this disease : 
 
 E. T., a delicate blonde, suffered frequently from rheumatic fever during 
 childhood; the last attack, wheu in her sixteenth year, ending in chorea, 
 ■which continued several months. She married at the age of twenty-two. 
 Durins her Jirst pregnancy, chorea set in at the fourth month; it ceased, as 
 she said, " the moment the infant was born." In the second pregnancy, the 
 chorea came on earlier, and was more violent; but it stopped with parturition. 
 
 ' Guy's Hospital Reports. Second Series. Vol. v, p. 4. London, 1847. 
 
 2 Clinical Midwifery. Second edition, p. 112. London, 1848. 
 
 3 Ediiiburgli Medical and Surgical Journal. Vol. lxx.\i, p. 35. Edinburgh, 1854.
 
 CHOREA. 343 
 
 With the tJiird gestation, the diseased movements commenced before she 
 knew positively that she was pregnant; abortion at the third month was 
 fijllowed by a cure. Pregnancy at once occurred for the fourth time, and 
 chorea manifested itself immediately. When Dr. Lawson Tait saw her, on 
 19th June, 1867, the pregnancy had advanced to about 3 J months. The 
 movements were extremely violent ; the tongue was much bitten, sleep was 
 impossible, and the urine contained sugar. As the disease became aggra- 
 vated, abortion was induced on the 26th. The movements ceased for many 
 hours, but then returned with augmented severity. She was kept under the 
 influence of chloroform for twenty-four hours; but death took place on the 
 29th. with symptoms of apoplexy. 
 
 At the autopsy, on examining the brain, there was found a clot formed by 
 blood effu.sed from the anterior part of the velum interpositum, towards 
 the left side. The heart was healthy. There were no indications of any ill 
 consequences from the abortion. No appearance of disease in any other 
 organ. 
 
 The treatment of chorea is not of necessity to be materially 
 modified because of the state of gestation. Hence as in the St. 
 Vitus's dance of childhood, the chief indications are to regulate 
 the bowels, to subdue irritation, and to strengthen the system. 
 "When purgatives are required, they must, as will by and by ap- 
 pear, be well chosen ; drastic cathartics, preparations of aloes, 
 and large doses of senna, being inadmissible. Opiates prove 
 beneficial in many, if not in all cases; but especially are they 
 useful when the urine contains sugar, as it sometimes does in 
 these cases. Remembering that during sleep the irregular actions 
 of the muscles usually cease, we may often advantageously give 
 the sufferer the great benefit of tranquil repose by the aid ot 
 chloroform. The tonics which do most good are of the ferrugin- 
 ous kind; and few preparations of this class act better than the 
 ofiieinal wine of citrate of iron, the citrate of iron and ammonia, 
 the saccharated carbonate of iron, the citrate of iron and quinia, 
 or the reduced iron. Sometimes, the arseniate of iron, in doses 
 varying from the one-twelfth to the fourth of a grain, proves use- 
 ful. Where any fear of abortion or premature labor is entertained, 
 it is perhaps advisable to trust to the h3'pophosj)hite of soda or 
 lime with bark, instead of employing any preparation of steel. 
 When cod-liver oil can be digested, it proves of singular service ; 
 but it is useless trying it if nausea be induced. I am inclined to 
 think that the light-brown oil of Dr. de Jongh is more easily 
 taken for a long time than most other varieties. Of course, with 
 any of these measures it will be necessary that the patient be 
 allowed a good nourishing diet, milk or cocoa being taken in the
 
 344 DISEASES COEXISTENT WITH PREGNANCY. 
 
 place of tea and coffee; that she he advised to take moderate ex- 
 ercise in the open air, if her condition permit ; and that mental 
 excitement he guarded against as much as possihle. With re- 
 gard to shower or douche haths it may be said, that it will usually 
 be better to try and do without them ; though ordinary tepid 
 baths, especially if made as salt as sea-water and administered 
 so as to give no shock to the system, will often be of advantage. 
 And then, supposing all our efforts fail to give relief, I entertain 
 no doubt but that abortion or premature labor should be induced ; 
 taking care, however, not to wait so long before resorting to the 
 necessary proceedings that the patient's strength is exhausted. 
 
 6. An author may well congratulate himself when he can with 
 justice assume that such a disorder as Jiysteria needs no descrip- 
 tion at his hands. For who can accurately paint the features of 
 this protean malady ? What writer, however ready with his pen, 
 can detail a tithe of the symptoms presented by those afflicted 
 with this disease ? Every example of it is a study to the most 
 experienced practitioner. Not only are no two cases alike, but 
 each case presents ever-varying phenomena. For hysterical 
 women — as Sydenham admirably says — observe no mean in any- 
 thing ; they are constaint only to inconstancy. 
 
 Taking it for granted, then, that most of my readers are ac- 
 quainted with the principal forms and varieties of tins disease, 
 and referring those less enlightened to the wards of our hospitals 
 and to special books upon the subject, I sliall here confine my- 
 self — as is my province — to the consideration simpl}' of two ques- 
 tions. The first is, as to the propriety of recommending marriage 
 for young hysterical females? Since the daj's of Hippocrates 
 innumerable writers have replied to this inquiry in the affirma- 
 tive ; and with certain reservations the answer must be allowed 
 to be correct. Hysteria originates during the period of sexual 
 maturity. A morbid sexual state, either physical or mental, 
 often — to say the least — lies at the root of it; for the disease is 
 very seldom witnessed in young women whose uterine functions 
 are perfectly normal, or in sucli as are hap})ily married.' Its vic- 
 tims are young single girls suffering from chlorosis, ovaritis, 
 
 ' We know that Hindoo women are married prior to the appearance of the catame- 
 nia; and it is said, though I know not with how much trutli, that hysteria is almost un- 
 known among tliem.
 
 HYSTERIA. 345 
 
 amenorrlioea, leucorrhcBa, or dysmenorrhoea ; women who are 
 united to men that they dislike, though they probably have to 
 hide their unhappiness from the world ; or females who have be- 
 come widows during the prime of life. If, then, we allow that 
 a happ3^ marriage is the grand remed}^ for very many hysterical 
 diseases, we ought to take care only to recommend this step when 
 all bodily disease has been removed ; and when there appears to 
 be something more than a mere chance that it will benefit the 
 particular case before us. In other words it may be said, that 
 general principles must not be relied upon too implicitly in the 
 consideration of this subject. The remarks of Mandeville on 
 the responsibility of physicians advising marriage as a remedy 
 are worthy of notice, though they are not altogether in accord- 
 ance with the views here advocated. lie says: "But I never 
 prescribe an uncertain Remedy, that may jDrove worse than the 
 Disease; for not to speak of the many Inconveniences the advis- 
 ing it often puts People to (prcetercpiara quod januam aperit 
 nequitipe), in the first place it may fail, and then there are two 
 People made unhappy instead of one ; Secondly, it may hut half 
 cure the Woman, who, lingering under the Remainder of lier dis- 
 ease, may have half a dozen children, that shall all inherit it. A 
 Physician has a publick Trust reposed in him : His Prescriptions 
 b}^ assisting some, ought never to prejudice others."' 
 
 The seco7id point which remains to be spoken of is as to the 
 influence of hysteria on pregnancy and delivery. On this head I 
 have not much information to impart. But it seems that when 
 a woman suffers from aggravated hysteria during the period of 
 gestation, there is some reason to fear that the parturient state 
 may be followed by an attack of puerperal mania. Thus the 
 following observation is made by Dr. Burrows: "I have seen 
 two cases where hysterical symptoms attended during pregnancy, 
 and the patients almost immediately on delivery became insane." 
 And again he remarks: "Puerperal delirium consequent on 
 labor is sometimes predicated, though not absolutely developed, 
 during gestation. If while pregnant there attend frequent hys- 
 ieric affections, preternatural susceptibility, unaccountable exu- 
 berance or depression of spirits, morbid aptitude to exaggerate 
 every trivial occurrence and attach to it great importance, sus- 
 
 ^ A Treatise on the Hypochondriack and Hysterick Diseases. Third Edition, p. 307. 
 London, 1730.
 
 346 DISEASES COEXISTENT WITH PREGNANCY. 
 
 picion, irritability, or febrile excitation, or, what is still more in- 
 dicative, a soporous state, with a very quick pulse, then the super- 
 vention of delirium on labor may be dreaded."^ Dr. Gooch re- 
 lates the history of a lady unusually subject to the common forms 
 of hysteria, who was delivered at the seventh month of a dead 
 child, and who subsequently suffered from catalepsy and mono- 
 mania. The following is an outline of the case: 
 
 Mrs. is twenty-nine years of atre. She has long been unusually subject 
 
 to the common forms of hysteria. Her husband says he has often seen her 
 become apparently insensible whilst sitting at the dinner-table, the state of 
 unconsciousness lasting several minutes. She married nine years ago, has 
 been pregnant many times, but has only borne one living child. A few days 
 after her hist delivery, of a dead child, at the seventh month, she was seized 
 with violent pain in the left side of the head and face, which subsided under 
 the use of hemlock; but she continued to suffer from flatulence, a quick 
 weak pulse, and much mental depression. One evening she told her hus- 
 band that she had never properly discharged her duties as a wife, and that 
 her death would be a happy release both to him and her. The next morning 
 she made an unsuccessful attenjpt to cut lier throat; and afterwards was very 
 violent. Soon she became cataleptic, and lost all consciousness. She had 
 three paroxysms of cataleptic symptoms; the first attack lasting fourteen 
 hours, the second for twelve hours, and the third for nine hours. The delir- 
 ium then assumed the ordinary form of melancholia. Three months from 
 her delivery she was well enough to resume her domestic duties.^ 
 
 7. "Women have suffered from tetanus setting in after abortion 
 just as they have done so after the termination of natural labor, 
 or after lesions of the unimpregnated uterus. Fortunately, this 
 fatal disease is very rare under either of these circumstances. 
 Thus, in a table of 171 published examples of tetanus collected 
 by Dr. Laurie,^ there is only one case in which it was due to 
 abortion, and one in which retained placenta is said to have 
 been the source; while in fifty-two instances found by the same 
 gentleman in the Records of the Glasgow Infirmary, there is not 
 one report of its occurrence in obstetrical practice. Other cases 
 are, however, to be discovered scattered through the various 
 British and foreign periodicals. In an essay on puerperal tet- 
 anus, Sir James Simpson has brought together the histories of 
 seven undoubted instances of this disorder following early mis- 
 
 1 Commentaries on the Causes, Forms, Symptoms, and Treatment, Moral and Medi- 
 cal, of Insanity, pp. .364 and 366. London, liS'J8. 
 
 2 An Aoconnt of some of the most Important Diseases peculiar to Women, p. 112. 
 Second Editi(jn. London, 1S31. 
 
 8 Glasgow Medical Journal. Vol, i, p. 339. Glasgow, 1854.
 
 TETANUS. 34:7 
 
 carriage, in all of which death occurred ; as well as sixteen 
 similar examples of this affection succeeding to parturition at 
 or near the full time, thirteen of which ended fatally.^ When 
 tetanus has supervened upon abortion it seems to have generally 
 happened after the sudden cessation of the discharge from the 
 use of astringents or of the plug ; this cessation having been 
 followed by exposure to cold. So when it takes place after de- 
 livery, the abrupt suppression of the lochia from the influence 
 of cold or damp seems to have been the starting-point of the 
 disease. 
 
 The instance of tetanus following a retained placenta which 
 was just referred to occurred in the practice of Dr. Store r, and 
 presents some instructive features. The chief facts which are to 
 be gleaned from the report are these : 
 
 On the 20th September, 1841, Mrs. C , aged thirty-eight, was de- 
 livered of her third child after a natural labor. The umbilical cord was 
 large, and so feeble that on passing the finger along it to the attachment ia 
 the placenta it separated at its origin. The placenta, which was very firm, 
 was situated high up on the anterior face of the uterus ; and it adhered 
 throughout its whole extent with such force to that organ, that Dr. Storer 
 could not detach it in the slightest degree. Having made such efforts as 
 were thought proper without any success, the patient was left. On the 22d 
 September, the bowels were freely opened by a dose of castor oil and an 
 enema; but there was no appearance of the placenta being detached. On 
 the 23d the lochia were quite offensive, and vaginal injections of chamomile 
 tea were ordered. But little change took place in the appearance of the 
 patient on the 24th and 25th ; except that repeated chills were noticed on 
 the former of these days, which were followed by a slight secretion of milk, 
 and upon that and the following day the child was nursed. On the morning 
 of the 26th, the commencement of the sixth day, Dr. S. removed a small 
 fragment of the placenta, which had been thrown into the vagina, and feel- 
 ing more beyond it which could not be seized, a dose of ergot was given. 
 After a second dose two masses of placenta similar to the first passed away. 
 On the 27th the pulse for the first time since delivery was upwards of 100, 
 small and wiry; the patient complained of pain in the head, considerable 
 stiffness of the jaws, and a difficulty in swallowing. These symptoms rapidly 
 increased, and at eleven o'clock P. M., the tip of the tongue could scarcely 
 be protruded between the teeth. The muscles of the neck and jaws had 
 become much more painful, the respiration was laborious, and at irregular 
 intervals there were tetanic spasms. On the morning of the 28th it was 
 found that she had passed a very restless night; the muscles of the jaw were 
 so rigid that the mouth could not be opened in the slightest degree; while 
 the merest touch appeared to distress her, and to hasten the spasmodic action 
 which was every few minutes present. The head was thrown backward upon 
 
 ^ Edinburgh Monthly Journal of Medical Science, p. 97. February, 1854. Repub- 
 lished in The Obstetric Memoirs and Contributions, vol. ii, p. 49. Edinburgh, 1856.
 
 348 DISEASES COEXISTENT WITH PREGNANCY. 
 
 the pillow, and so firmly contracted were the muscles of the neck, that when 
 her hand was placed at the back of her occiput, the whole body was brought 
 forward, the neck not being flexed in the slightest degree. When the spasms 
 were present, the suffering appeared to be extreme; and the paroxysms in- 
 creased in frequency and severity until about midnight of this, the eighth 
 day, when she sank exhausted by opisthotonos. — No post-mortem examina- 
 tion was allowed to be niade. It may be observed that there were no symp- 
 toms of metro-peritonitis.^ 
 
 An interesting example of intermittent tetanus occurring dur- 
 ing pregnancy has been published by Dr. Trevor Morris. This 
 gentleman says : 
 
 Mrs. S , aged twenty-two, in her second pregnancy, was placed under 
 
 my care for her confinement, which she expected to take place in July, 18(32. 
 I saw her early in April, when she was tolerably well. She had had some 
 little time before what she calls "dead ague." There is a previou.s history 
 of her having had, at the age of fourteen, fits brought on by excessive fright, 
 and during which she had bitten her tongue. 
 
 On April 19th, at seven p. M., I was hurriedly sent for to see her. T found 
 her on the floor; the limbs and trunk in a state of rigid spasm ; frothing at 
 the mouth ; jaw locked; fingers firmly clenched on the palm ; body curved 
 forwards, &c. In this state of emprosthotonos she remained about half an 
 hour, when the spasm yielded, but only to assume after a few minutes the 
 form of opisthotonos, which was most perfect, and which lasted for half or 
 three-quarters of an hour, when she gradually recovered, with merely an oc- 
 casional sob. On questioning her, I found that the first indication of the 
 approaching seizure was a numbness in her legs, which felt as if they would 
 not support her, obliging her to sit or lie down ; and on subsequent occasions 
 she would exclaim, "My legs are going!" From the moment of attack to 
 its termination all consciousness was lost; severe congestive pain of the head 
 followed, which lasted some time. She had had previous threatenings on 
 two or three consecutive days, and always at the same hour. As I found 
 her bowels were constipated, I ordered her ten grains of calomel at night, 
 and a warm aperient draught for the following morning, which brought away 
 some scybala at the first action. She was to take six grains of quinine half 
 an hour before the expected time of attack, or earlier should symptoms de- 
 mand it. Being over-anxious to avert it, she took the draught before symp- 
 toms actually connected with the approaching attack appeared. It was, 
 however, much modified, as was also the consequent congestive headache. 
 As her tongue was coated, I ordered her dilute nitric acid with nitric ether 
 and tincture of orange-peel, and she was again to taKe the draught in the 
 evening as usual, which this time prevented a recurrence. She now took 
 two grains of quinine three times a day. She had one or two other attacks 
 from neglecting this precaution, but by a little attention from time to time 
 future ones were averted. She went her full time, and was delivered of a 
 living child on July 15th. 
 
 Such cases as these must be rare, as this is the first that I have seen or 
 heard of during a residence of five years in a malarious district. There are 
 
 1 American Journal of the Medical Sciences. Vol. xxix, p. 97. Philadelphia, 1842.
 
 TETANUS. 349 
 
 in this case traces of hysteria and epilepsy combined, as evidenced by pi'e- 
 vious history; perfect unconsciousness during the attack ; no renieuibrance 
 of it; sobbing at its conclusion, though ending neither in sleep nor crying. 
 In each attack the form of eniprosthotonos was that first assumed, then that 
 of opisthotonos. The patient made a good recovery, is now well, and cer- 
 tainly anything but an hysterical subject.^ 
 
 The treatment of tetanus occurring during gestation, or after 
 parturition, has to be conducted according to the same rules 
 which influence the practitioner in attem.pting to cure tliis aiiec- 
 tion when it arises independently of childbearing. I shall there- 
 fore only make one remark on this head. The disease essentially 
 consists in an exalted reflex excitability of the spinal system. 
 Consequently, our eflbrts must be directed towards diminishing 
 this state by keeping the patient in the most perfect quietude, and 
 by the exhibition of antispasmodics and narcotics. The subcu- 
 taneous injection of the officinal solution of atropia is deserving 
 of trial; not more than two minims (gr. ^\) being employed at 
 first. The extract of Calabar beau (Extractum Physostigmatis, 
 gr. Jj to I) is also a remedy from which much may be expected. 
 Chloroform, in consequence of its direct sedative action upon the 
 reflex nervous system and upon muscular contractility, is invalu- 
 able. This agent is not recommended as a last resource. It 
 has been employed successfully in cases of traumatic tetanus ; 
 and though, of course, it has often failed, yet perhaps — as Sir 
 James Simpson suggests — some of the failures have arisen from 
 the patient not having been kept sufficiently deeply and con- 
 tinuously under its influence. The effects of this drug may have 
 to be sustained even for many days ; which with care may be 
 done without danger. In an apparently hopeless case of convul- 
 sions in an infant of only six weeks old, Sir James Simpson em- 
 ployed chloroform almost continuously for thirteen days ; using 
 in this time as much as one hundred ounces of the drus". The 
 disease yielded ; and a few months afterwards the little patient 
 was a strong and healthy child. When the heart's action is at 
 all feeble I much prefer a mixture of equal parts of chloroform 
 and pure ether, to the former agent by itself. Moreover, if the 
 induction of anaesthesia fails to save life, it at least aftbrds the 
 blessing of relief from the most frightful suflering ; and it is not 
 possible to over-estimate the importance of assuaging the agony 
 
 1 The Lancet, p. 331. 27th September, 1862.
 
 350 DISEASES COEXISTENT WITH PREGNANCY. 
 
 to which the tetanic spasms give rise. Though many years have 
 elapsed since the following passages were written, yet the advice 
 inculcated may still be enforced with advantage : " Nay further, 
 I esteem it the office of a physician," says Lord Bacon, " not only 
 to restore health, but to mitigate pain and dolors ; and not only 
 when such mitigation may conduce to recovery, but when it may 
 serve to make a fair and easy passage : for it is no small felicity 
 which Augustus Caesar was wont to wish to himself, that same 
 Euflumasia ; and which was specially noted in the death of An- 
 toninus Pius, whose death was after the fashion and semblance of 
 a kindly and pleasant sleep. So it is written of Epicurus, that 
 after his disease was judged desperate, Jie drowned his stomach 
 and senses with a large drauglit and ingurgitation of wine ; where- 
 upon, the epigram was made, Hinc stygias ebrius hausit aquas ; 
 he was not sober enough to taste any bitterness of the Stygian 
 water. But the physicians contrariwise do make a kind of scruple 
 and religion to stay with the patient after the disease is deplored ; 
 whereas, in my judgment, they ought both to inquire the skill 
 and to give the attendances for the facilitating and assuaging of 
 the pains and agonies of death. "^ 
 
 8. It has been generally admitted until the last few years, that 
 when pregnancy occurred in a phi his ical patient the progress of the 
 consuynption ivas retarded; hut that after delivery the organic lesion 
 proceeded more rapidly^ and death more speedily ensued. The 
 theory has been this : That as during pregnancy all the powers 
 of the system are concentrated upon the uterus, so this organ 
 prevents or retards disease in all other parts of the animal 
 economy. This doctrine was advocated by most authorities of 
 note, until Dr. A. Grisolle published some observations showing 
 that it is quite untenable.^ This gentleman's essay is so elabor- 
 ate, and his arguments appear so well-founded, that I am sure a 
 brief analysis of his memoir will be useful. Dr. Grisolle's views 
 are based upon the histories of twenty-seven cases of phthisis 
 occurring during pregnancy. In twenty-four of these the or- 
 ganic disease began during utero-gestation, at a period more or 
 
 ' The Advancement of Learning. Book the Second. Spedding and Heath's collected 
 edition of Bacon's Works. Vol. iii, p. 375. London. 1857. 
 
 ^ Archives Generates de M6decine. Quatri^me Serie. Tome xxii, p. 4L Paris, 
 lb50.
 
 PHTHISIS. 351 
 
 less near its commencement; while in only three did the ra- 
 tional signs of tubercle exist prior to pregnancy, though the dis- 
 ease did not actually manifest itself until a later period. In none 
 of these cases was the pulmonary afl'ection retarded : on the con- 
 trary, it made rapid progress. 
 
 When we reflect on the profound influence which pulmonary 
 tubercles exert on the constitution, as well as on the uterine 
 disorders which so generally supei-vene at an advanced period of 
 the disease, we can readily understand wh}^ conception should 
 rarely take place in phthisical women. In almost all the cases 
 in which phthisis coexists with pregnancy, it is found that the 
 latter has occurred first, and that it is in a more or less advanced 
 period of its course that pulmonary tubercles have suddenly mani- 
 fested their presence. Thus, there is no antagonism between 
 pregnancy and phthisis ; but gestation does not modify nor exert 
 any tardative eflect on the pulmonary lesion. The phenomena 
 of the disorder are developed with the same regularity and con- 
 stancy. Pregnancy does not increase the violence nor frequency 
 of certain accidental symptoms of phthisis ; for the dyspnoea is 
 not more painful, there is no increased tendency to diarrlioea, 
 neither is haemoptysis more frequent. But in all the cases the 
 actual duration of the disease was shortened; for in all, the dis- 
 ease terminated at from the eighth to the fifteenth month from 
 the commencement of the symptoms, while its mean duration 
 was only nine and a half months. These results then, that there 
 is no essential difference in the symptoms between the phthisis 
 of pregnant and non-pregnant women, and that pregnancy, in- 
 stead of prolonging life, hastens the progress of the organic 
 lesion, seem to be clearly established ; and it is difficult to im- 
 agine with respect to the last fact — how the opposite hypothesis 
 ever became current. The system weakened by loss of appetite, 
 diminished power of assimilation, night sweats, diarrhoea, copi- 
 ous expectoration, and hectic fever, can hardly be thought to be 
 in such a favorable position as to be better able to support two 
 lives than one. But the history of medicine shows that not un- 
 frequently when the plain common-sense truth stares us in the 
 face, we prefer turning aside in order to advocate or establish a 
 theory, the only charm of whicli is its improbability. 
 
 "With respect to the second current opinion, that the puerperal 
 state accelerates tuberculization, and consequently hastens death,
 
 352 DISEASES COEXISTENT WITH PREGNANCY. 
 
 it need only be said that in practice such is ascertained to he the 
 exception, not the rule. Dr. Grisolle found that twelve women, 
 some of wiiom at the time of delivery w^ere in the second, but 
 the majority in the third stage of phthisis, continued to struggle, 
 on an average, for four months afterwards against the progress 
 of the disease ; while in all, the symptoms w^ere those observed 
 in ordinary cases. In ten other phthisical females wdio were 
 only in the first, or at the commencement of the second stage, 
 the progress of the disease after delivery was slow in three ; 
 there was a notable aggravation in two ; while the general symp- 
 toms manifested a sensible amelioration in the other five. Hence, 
 if we wish to draw any rule from these-cases it nmst be — that the 
 organic disease is often mitigated after delivery, provided it has 
 not reached an advanced stage. 
 
 But it may be asked, if neither pregnancy nor the puerperal 
 state have that influence upon the progress of phthisis which 
 many have attributed to them, what is the opposite state of mat- 
 ters 'I In other words, to w^hat extent does phthisis modify the 
 course of pregnancy and the sequelae of parturition ? There can, 
 it would seem, be little doubt but that in the majority of instances 
 tuberculization does not materially influence the progress of 
 pregnancy. Yery many cases have now been carefully watched 
 where the pulmonary disease had even reached its third stage, and 
 yet gestation has proceeded uninterruptedly to the full term. 
 The more closely I have investigated this question the more con- 
 vinced do I feel, that a pregnant woman suflering from any low- 
 ering chronic disease is not less likely to carry her foetus for 
 nine months than one who is strong and healthy. The opposite 
 opinion has gained supporters from the fact of no suflicient dis- 
 tinction being drawn betw^een a diseased embryo and a diseased 
 mother. The latter may sufl:"er from chronic heart or lung dis- 
 ease, hepatic or renal afiections, scrofula, cancer, diabetes, &c., 
 without the former being appreciably aftected during its intra- 
 uterine life. In this respect there is a marked diflerence between 
 chronic and acute diseases ; for wdiereas, perhaps, in a large 
 number of cases of phthisis coexistent with pregnancy, prema- 
 ture labor would only occur in one-sixth of the whole, in pneu- 
 monia it would probably do so in three-fourths, or even more. 
 In the one case we have a disease coming on so gradually, that 
 the system may be said not to feel any shock ; in the other, there
 
 PNEUMONIA. 353 
 
 is sudden and severe constitutional disturbance, more allied to 
 tliat which results from a dangerous accident or a capital opera- 
 tion. 
 
 The only influence of pulmonary consumption on the process 
 of parturition would appear to be that it shortens the duration 
 of the suffering, and lessens the violence of the pains; so that 
 the lahor is seldom extended beyond four hours. The simple 
 explanation of this circumstance is obviously, that the relaxed 
 and flabby tissues offer diminished resistance to the passage of 
 the child. The lacteal secretion has generally been found to be 
 freely established shortly after labor; but forasmuch as suckling 
 would be very injurious to a consumptive mother, and would 
 probably produce both present and future disastrous results in 
 the infant, it has not usually been allowed beyond the first few 
 days. When tbe mother has insisted upon nursing, the milk 
 has either very mucb diminished in quantity, or has entirely 
 ceased to be secreted within a period varying from one to four 
 weeks ; and lactation for this short time has materially aggravated 
 the maternal disease, while the infants have also been great suf- 
 ferers. Indeed, of almost all children, those born of a phthisical 
 parent most imperatively demand that they should be reared by 
 a young and vigorous and healthy wet nurse ; for otherwise they 
 are almost sure to sufter early from mal-nutrition in a marked 
 degree, and at a later period to fall victims to some form of tu- 
 bercular disease. 
 
 9. The question next arises as to the influence which an attack 
 of pneumonia may exert upon the progress of gestation ? The 
 most common result undoubtedly is the termination of the preg- 
 nancy by the expulsion of the foetus. This effect takes place 
 possibly in three out of four cases. How can such a fact be ex- 
 plained? It cannot be owing to the violence of the cough, as 
 some suppose, because women aft'ected with severe bronchitis, or 
 with asthma, do not abort. It is not probable that it is produced 
 by the intensity of the fever or by the inflammation pe7- se, because 
 a similar result does not happen in nearly the same proportion of 
 cases of encephalitis, pleurisy, hepatitis, or enteritis. Neither 
 does it seem to be accounted for by the importance of the organ 
 affected ; since in pulmonary phthisis we have not a like eftect. 
 ISTo doubt the suddenness as well as the severity of the attack may 
 
 23
 
 354 DISEASES COEXISTENT WITH PREGNANCY. 
 
 have a very unfavorable influence upon the state of pregnancy; 
 but obviously, from the foregoing observations, not sufiicient 
 alone to account for the circumstance under consideration. The 
 true explanation is I believe to be found in the condition of the 
 blood in acute inflammation of the lungs. JSTow it is well known 
 that in this disease there is either a great deficiency of chloride 
 of sodium in, or a total absence of this salt from, the urine ; and 
 it has been proved, that such a diminution or absence conclusively 
 indicates that the circulating fluid contains less than the normal 
 quantity. The two cliief facts which may be adduced as favoring 
 my view are these. First, that in the textures of the embryo, a 
 large proportion of fixed chloride is present. Thus, Lehmann 
 examined the femur of a six months' foetus, and found 11.138 
 per cent, of chloride in tlie ash, while he could only obtain from 
 that of adult bones 0.7 to 1.5 per cent. So also it is probable 
 that there is a determination of chloride of sodium to the tissues 
 of the gradually increasing uterus ; but at all events the re- 
 searches of Voigt show us that there is a considerable quantity 
 of this salt in the liquor amnii, which salt diminishes as gestation 
 advances. Secondly, Mulder and various observers have noticed 
 a diminution of chloride of sodium in the blood in cases of 
 cholera ; and it so happens that this disease appears to give rise 
 to premature expulsion of the foetus just as often as pneumonia 
 does. Dr. Bouchut has shown that in fifty-two cases of cholera 
 occurring in pregnant women, twenty-five aborted in consequence 
 of the disease; while he infers that the same result would in all 
 probability have taken place in a larger number had it not been 
 prevented by the early death of the patients. Moreover, with a 
 few exceptions, abortion took place only in those cases in which 
 the disease lasted over twenty-four hours ; when, consequently, 
 the altered condition of tlie blood would be fully appreciated 
 by the various tissues. The objectors to this hypothesis may 
 reasonably urge, that the absence of fixed chlorides from the 
 urine occurs in many acute inflammatory diseases besides pneu- 
 monia. But the answer to this assertion seems to be, that in in- 
 flammation of other organs this diminution is scarcely to the 
 same extent as it is with inflammation of the lungs; while we 
 also know that abortion does occur in all these cases, though it 
 is most common in the pulmonary disease. 
 
 It only remains to be noticed that pneumonia is much more
 
 HYPERTROPHY OP THE HEART. 355 
 
 fatal to pregnant than to non-pregnant women. It is also con- 
 siderably more dangerous when it produces abortion than when 
 it does not interrupt gestation. And furtlier, when the morbid 
 action sets in at a time near the natural period of labor, it has a 
 most disastrous effect upon the foetus ; which is usually either 
 born dead, or in so feeble a condition that it cannot be kept 
 alive beyond a few hours after birth. 
 
 10. More than thirty years ago Dr. Larcher, arrived at the 
 conclusion that the heart is normally in a state of hypertrophy 
 during gestation, although his views have only recently been 
 fully published.^ This gentleman's investigations were pursued 
 at the Maternity Hospital of Paris ; and were based upon the 
 circumstance that in 130 post-mortem examinations of women 
 who had died mostly from puerperal fever there was not found 
 a single exception to this rule. The walls of the left ventricle 
 were increased by at least a fourth or a third in thickness, while 
 at the same time their texture was firmer and their color brighter. 
 The rio:ht ventricle and the auricles were found to have retained 
 their normal thickness. Twenty years later Dr. Beau examined 
 the question anew; while at his suggestion M. Ducrest, Interne 
 of the Maternity, carefully ncjted the heart's condition in 100 
 other women, and confirmed Dr. Larcher's statements. 
 
 Within certain limits this condition is of course compatible 
 with the maintenance of perfect health ; but it may also be re- 
 ceived as the explanation of that predisposition to congestion of 
 the different viscera which often marks the state of gestation. 
 Probably, as a general rule the hypertrophy gradually but slowly 
 disappears after parturition ; though in exceptional instances it 
 may be otherwise, especially when pregnancy recurs frequently 
 and at short intervals. There seems some reason to believe that 
 this change is the cause of those permanent lesions in the organs 
 of the circulation which are not unfrequently met with in women 
 who have borne many children in the space of a few years, or 
 while in a bad state of health. So also it is said that the bron- 
 chitis which is so common during gestation derives much of its 
 character from the persistence of this condition of the heart. 
 And again, it may account for the various forms of hemorrhage 
 
 1 Archives Centrales de Medecine. 5"* Serie. Tome xiii, pp. 291-306. Paris, 1859.
 
 356 DISEASES COEXISTENT WITH PREGNANCY. 
 
 that often occur in pregnancy; as epistaxis, life mopty sis, and 
 apoplexy. 
 
 Sympathetic or nervous throbbings of the aorta not unfre- 
 quently cause much annoyance in the early and uiiddle periods 
 of pregnancy. The throb has generally a jerking and abrupt 
 character; it seems to occupy the whole line of the vessels, 
 rather than to be circumscribed ; and its maximum of intensity 
 is often found about the umbilical region. In the advanced 
 stages, palpitation combined with dyspnoea has generally a me- 
 chanical cause ; that is to say, it depends upon the pressure of 
 the gravid uterus upon the large vessels of the abdomen. The 
 womb also pushes the diaphragm upwards ; while by prevent- 
 ing its descent easy respiration is interfered with. 
 
 11. The fact has been established by the observations of several 
 physicians, that carcinoma of the lips and cervix of the uterus does 
 not prevent conception. Even when the disease has reached the 
 stage of ulceration, and the watery and sanguineous discharges 
 are abundant, an ovule may become fertilized. Under the same 
 circumstances it is also certain, that the ovum may be gradually 
 developed and retained in utero until the completion of the 
 natural term of gestation ; abortion or premature expulsion of 
 the fcetus being an exceptional occurrence. When the pregnancy 
 proceeds uninterruptedly nearly or quite to the full term, the 
 labor is commonly found to be difficult and tedious, and invari- 
 ably very hazardous to the mother ; while the consequences to 
 the child are often very disastrous. If the disease should form 
 any serious obstacle to the passage of the infant, and especially 
 if the difficulty be such as cannot be overcome by the cautious 
 use of the knife or of obstetric instruments, rupture of the uterus 
 is the common result. Moreover, supposing delivery to be safely 
 accomplished, the process of parturition seems decidedly to give 
 an impetus to the destructive tendency of the cancer, particularly 
 by exciting inflammation and softening. 
 
 These remarks will be best proved by a short reference to cer- 
 tain statistics : 
 
 In lookino; throuirh the few English and French treatises or essays devoted 
 to the subject of abortion, carcinoma of the uterus is scarcely mentioned as 
 a cause. In our periodical literature numerous examples of obstructed hibor, 
 at the full term, from cancer of the cervix uteri are related ; but none of mis-
 
 CANCER OF THE UTERUS. 357 
 
 carriage from this disease. Of thirty cases of cancer and seven of cauliflower 
 excrescence with pregnancy, reported by Puchelt, tive died undelivered, four 
 of them with ruptured uterus. Of the thirty-two delivered naturally or by art, 
 sixteen pprished during or soon after labor ; thirteen survived their accouche- 
 ment; while of three the issue is unknown. In these thirty-seven cases, 
 only ten of the children were born alive ; seventeen were still born ; five were 
 undelivered; and of five no account of the viab lity of the infants is given. 
 Of twenty examples advanced to the full term of pregnancy, with four to the 
 end of the seventh month, collected by Dr. Menzies, of Glasgow, four of the 
 women died undelivered, and ten within the puerperal month ; while of the 
 ten that survived longer, labor occurred in one at the end of the seventh 
 month, and in five the disease implicated only a portion of the circumference 
 of the OS. In one of these the disease consisted merely of four or five small 
 tubercles, and the subject of it recovered from three successive labors, in 
 which she bore one dead and two living children. In three of these twenty- 
 four cases the cervix was lacerated; in one a large disc was detached from 
 the lower part of the uterus during parturition, and the mother survived six 
 months; in two the body of the uterus gave way, and the patients died soon 
 after delivery ; in another rupture produced death before delivery could be 
 efi'ected; while in one the woman died undelivered, from low peritonitis, 
 seventeen months after the commencement of gestation, without the rigid os 
 uteri having yielded to the feeble muscular contractions. From the twenty- 
 four cases twenty-six children resulted ; of whom eight were alive, eleven 
 were stillborn, four were undelivered, and of three the fate is unknown. 
 
 The treatment of pregnancy when complicated with uterine 
 cancer is surrounded with difficulties, so that it is almost impos- 
 sible to lay down any very precise rules for the guidance of the 
 obstetrician. Probably the favorite proceeding with most prac- 
 titioners is the induction of abortion ; or, at a later period, of 
 prematare labor. The former is had recourse to if the disease 
 be in an advanced stage, or if it implicate the whole of the os 
 uteri; while the latter is resorted to between the thirty second 
 and thirty-sixth week where the aflection is less extensive. But 
 I doubt very much the prudence of adopting this practice in the 
 majority of instances. As Dr. Menzies remarks, — "There are 
 serious objections to following this counsel in all cases. It will 
 frequently be found that the cervix is so narrowed or entirely 
 obliterated by the cancerous deposit, that the membranes cannot 
 be reached without inflicting such laceration and contusion as 
 may induce hemorrhage or inflammation. If the disease is ex- 
 tensive, the contraction great, and pregnancy advanced to the 
 seventh month, delivery must be accomplished with such diffi- 
 culty and danger, as should cause us to hesitate in accelerating 
 a crisis, whereby our patient may be deprived of two months at 
 least of her existence. It is, moreover, a well-established fact
 
 358 DISEASES COEXISTENT WITH PREGNANCY. 
 
 that parturition accelerates the destructive action of the disease, 
 while pregnancy appears to impede it ; hence in cancer far ad- 
 vanced, where great loss of structure has rendered the os more 
 patent, and the passage of the head comparatively easy, prema- 
 ture delivery would likewise hasten the fatal issue. I think, 
 however, that in some cases where the scirrhus has not made 
 much progress. Dr. Kiwisch's plan of inducing abortion, as modi- 
 fied by Dr. Tyler Smith, would afibrd us a means of prolonging 
 life, further than would be attained by allowing the pregnancy 
 to be matured."^ 
 
 In an example of multiple medullary cancer, complicated with 
 pregnancy advanced to the fifth month, which I saw with Dr. 
 Thane in July, 1862, it was thought advisable to make the uterus 
 expel its contents prematurely, chiefly with the view of in- 
 creasing the mother's comfort. Of course, in this instance, the 
 proceeding was not contraindicated by any feeling for the child ; 
 as owing to the increasing amount of cancerous deposit in the 
 recto-vaginal septum, it was certain that a live infant could never 
 be given birth to through the natural passages.^ 
 
 Supposing that the pregnancy has gone on until the full term, 
 and that the natural efforts appear insufficient to accomplish de- 
 livery, assistance must be afforded at a somewhat early period to 
 avoid the risk of rupture of the uterus, or of exhaustion from 
 failure of the woman's already diminished vital powers. Under 
 these circumstances turning has been performed in several in- 
 stances; but in all, according to Dr. Menzies, with the loss of 
 both mother and child. The application of the forceps has been 
 recommended by many writers ; but the use of this instrument 
 is clearly inadmissible unless the os be dilated, the pelvis well- 
 formed, and the deposit thin and elastic. Of course these are just 
 the instances where sufficient space is afforded spontaneously, 
 and hence where delivery can take place without any artificial 
 aid. Craniotomy succeeds well for the mother in some carefully 
 selected cases ; or possibly cephalotripsy might be advantageously 
 had recourse to. But then it must be recollected, that if the os 
 uteri be rigid and contracted from induration of its tissues, there 
 
 1 A Case of Pregnanoy complirated with Carcinoma of the Uterus, in which Gestation 
 was prolonged to the Seventeenth Month By P. Rae Menzies, M.D., &c. The Glasgt w 
 Medical Journal, vol. i, p. 138 Glasgow. 1854. 
 
 ■■^ 'I'liis c;ase is reported at length in the Transactions of the Obstetrical Society of 
 London, vol. iv, p. '213. London, 1^63.
 
 CANCER OF THE UTERUS. 359 
 
 is great danger of laceration occurring, even from drawing a 
 mnch-mutilated child through the diseased maternal passages. 
 Moreover, many men may conscientiously object to sacrifice the 
 existence of a healthy infant for the mere chance of giving a few 
 weeks of suffering to a woman afflicted with a fatal disease. 
 Hence it is a subject for congratulation that the life of the child 
 can often be spared by means which do not materially, if at all, 
 prove detrimental to the mother. This desirable end is to be 
 attained by resorting to vaginal hysterotomy. After the nec- 
 essary incisions have been made into the os and cervix uteri, we 
 may either trust to the natural efforts to complete the labor, or 
 we may apply the long forceps, or we may even turn and deliver 
 the infant by the feet. When performing the operation of hys- 
 terotomy it is as well to remember that the safest plan is to make 
 four incisions ; viz., one obliquely and anteriorly on each side, and 
 two obliquely and posteriorly. In this manner the surgeon will 
 avoid the risk of wounding the uterine arteries, which run tor- 
 tuously upwards on the sides of the womb. 
 
 Where the carcinomatous infiltration proves so extensive as 
 entirely to prevent delivery jjer vias naturales, it only remains for 
 the surgeon to extract the child, if alive, by the Csesarean section. 
 In two or three instances, in this country, the infant has been 
 saved by this proceeding, when it has been had recourse to under 
 these circumstances ; while in three comparatively recent cases, 
 the mother has lived for some months after the operation. In 
 fact, she has quite recovered from the latter, but has subsequently 
 succumbed to the original disease. It is indeed remarkable, that 
 of late 3'ears those cases of Cesarean section appear to have done 
 the best where this operation has been performed on account of 
 uterine cancer obstructing labor at, or near, the full term. The 
 explanation may possibly be this: That after the removal of the 
 fcetus through an incision into the healthy uterus, two opposite 
 processes — as first pointed out by Dr. West— are called into play. 
 The one action consists in the rapid removal and disintegration 
 of the uterine tissue; the other, in the repair of the wound Avhicli 
 has been made by the surgeon. It is difficult to understand how 
 two such antagonistic operations can take place, in the same 
 organ, at the same time. But where the uterine walls are dis- 
 eased, when perhaps owing to cancerous infiltration the normal 
 process of fatty degeneration after labor is impeded or prevented,
 
 360 DISEASES COEXISTENT WITH PREGNANCY. 
 
 then it seems by no means improbable that the action of repair 
 may go on unimpeded. In such a case, the uterus when emptied 
 of its contents contracts firmly ; and as under this force the edges 
 of the wound must be compressed together, the process of union 
 seems a comparatively simple act. 
 
 12. The effect of syphilis upon the course of gestation has been 
 so fully discussed in the cliapter on abortion, that only a few 
 words need now be added on the subject of treatment. On this 
 head then it may be said positively that the use of appropriate 
 remedies must not be postponed until after delivery. Syphilis is 
 the disease of all others which is most likely to produce death of 
 the foetus and miscarriage ; while I entertain no doubt whatever, 
 but tliat the proper treatment is in a certain degree harmless. 
 
 In the case of primary sores the inunction of small quantities 
 of mercurial ointment, night and morning, or less frequently, ac- 
 cording to circumstances, until the mouth is gently touched, will 
 produce the most beneficial effects; while if gestation be not ad- 
 vanced beyond the end of the sixth month, the cure may safely 
 be hastened by the simultaneous employment of the mercurial 
 vapor bath. For the removal of secondary or constitutional 
 syphilis I have great faith in the perchloride of mercury, in doses 
 of one-sixteenth to one-eighth of a grain, thrice daily. The only 
 inconvenience attached to the use of this remedy is the length of 
 time for which it is necessary to persevere with it. Except in the 
 advanced periods of pregnancy the mercurial vapor bath can also 
 be advised in these instances. — One hint more may prove useful. 
 The accoucheur has occasionally to attend a woman in labor who 
 is suffering from primary ulcers on the genitals. To save the in- 
 fant in its passage and himself in his manipulations from infec- 
 tion, he should touch each sore thoroughly with the solid nitrate 
 of silver; so as to give it a temporary impermeable coating, or 
 to alter the secretion on its surface. For his own greater security 
 also, I would advise him either to wear an oiled-silk glove, or to 
 adopt my own practice and paint the hand with the officinal flex- 
 ible collodion. By this last means akind of elastic artificial cuticle 
 is formed, which is impermeable to fluid until it cracks ; and this 
 it will not do for some few hours, if only moderate care be taken. 
 
 13. This chapter would be incomplete without a few words on
 
 EPIDEMIC AND INFECTIOUS DISEASES. 361 
 
 the epidemic and infectious maladies which may complicate preg- 
 nancy. It is probably in reference to disorders of this class that 
 Hippocrates says in one of his aphorisms that acute diseases are 
 fatal to pregnant women. However this may be, the remark is 
 still often made that during widespread epidemics, a smaller 
 relative proportion of pregnant women have been attacked than 
 of others ; but that when they suffer, they do so very severely. 
 Gardien positively expresses this opinion, for he says — " Les 
 femmes enceintes sont moins expos^es a gagner les maladies cou- 
 tagieuses, mais lorqu'elles en sont atteintes, elles succombent plus 
 promptement."^ This proposition is not altogether true. For 
 example, in the epidemics of influenza, pregnancy formed no 
 barrier to its invasion ; and the disease ran its course in the ordi- 
 nary way, being neither more nor less severe than usual. The 
 same remark applies to cholera ; with the exception that it very 
 often, as has been already mentioned, produces abortion. M. 
 Bouchut, in analyzing fifty-two observations made upon pregnant 
 women attacked with this disease, shows that twenty-five aborted 
 in consequence. Of these twenty-five women, sixteen recovered ; 
 while of the twenty-seven who did not miscarry, only six recov- 
 ered. But it must be noted that, of the women who recovered 
 after aborting, only four had the disease in a rapid and danger- 
 ous form ; while in the twenty-one who died undelivered, the 
 disorder was short and severe, so that it may fairly be said there 
 was scarcely time for the uterus to expel its contents. Appa- 
 rently unmindful of this circumstance, M. Devilliers, Jr., has 
 argued that abortion produces a favorable efiect upon the termi- 
 nation of cholera ; and he has consequently recommended the 
 provocation of miscarriage as a means of diminishing the fatality 
 of this disease. 
 
 The eruptive fevers are all particularly dangerous to w^omen 
 who have been recently delivered, whether the labor have been 
 premature or at the full term. A patient attacked with small- 
 pox, measles, scarlet fever, or erysipelas within one week of the 
 birth of her child will rarely recover. The occurrence of either 
 of these diseases during pregnancy is less to be feared. Often 
 the fever runs a natural course, as if there were no complication. 
 By no means as a rule is abortion induced ; though when it hap- 
 
 1 Traite Complet d'Acroucliemens, et des Rlaladies des Filles, des Femmes, et des 
 Enfans. Deuxieme Edition. Tome ii, p. 29. Paris, IS16.
 
 362 DISEASES COEXISTENT WITH PREGNANCY, 
 
 pens the case assumes a somewhat more serious aspect. Proba- 
 bly small-pox is the most to be dreaded of this class of disorders ; 
 the confluent form appearing to be uniformly fatal to the foetus, 
 and not unfrequently to the parent. If the discrete variety occur 
 towards the end of gestation, the child will often be born alive; 
 while it may also be healthy, or the body will be already covered 
 with variolous pustules, or the poison may be incubating so that 
 the disease will appear a few days after birth. The fact has been 
 already alluded to that a pregnant woman may be exposed to tlie 
 contagion of variola, and, owing to her system being protected 
 by vaccination or by an attack of the disease at a former period, 
 she can escape unharmed ; the foetus in utero alone suflering. 
 So if she be pregnant with twins it has happened, that while one 
 foetus has become affected with this eruptive fever, the other has 
 escaped. A pregnant woman residing in a district where small- 
 pox is prevalent, should be vaccinated or revaccinated. This is 
 advisable, partly to lessen the risk to herself; but particularly 
 because there is reason to believe, that the protective influence 
 of vaccination, successfully performed during the time of gesta- 
 tion, extends to the foetus. 
 
 Dr. Montgomery believed he had seen sufiicient to satisfy him 
 that pregnancy does, at least occasionally, prevent or delay the 
 development of infectious disease until after parturition, although 
 the infection may have been previously caught. In his work (p. 
 44) there are related three corroborative examples. Thus : 
 
 Mrs. W., when in the ninth n)onth of pregnancy, was much about her 
 brother, who was dangerously ill of malignant scarlet fever. She seemed to 
 have escaped the danger completely ; but the day after delivery she was 
 covered with the disease, and in a few days died. Between the time of her 
 exposure to the contagion and the delivery, there had intervened three weeks; 
 during which time she appeared to be quite well. 
 
 Again, a Mrs. F. was in the eighth month of pregnancy, when she assid- 
 uously attended upon her husband, who was suffering from typhus fever. 
 After his recovery, she went to her father's house, some fifty miles from 
 town, where she was delivered in due time ; but i mi mediately after labor she 
 was seized with typhus fever, of which she died in eight days. Between five 
 and six weeks had elapsed from the time of Mr. F.'s illness to her labor, dur- 
 ing wliich interval she appeared in perfect health. 
 
 'J'he third case was one of erysipelas, occurring in a young lady who was 
 delivered on the Tith November, 1854, after a favorable labor. I'revious to 
 the birth of the child she complained of soreness of the abdomen, which 
 afterwards persif^ted. On the ]4th, the insteps of both feet were covered 
 with well-developed erysipelas, and the abdominal pain then began to subside, 
 and in two or three days quite ceased. Dr. Montgomery was informed that
 
 THERAPEUTICS OF PREGNANCY. 363 
 
 some weeks before leaving home to visit Dublin for her confinement, her hus- 
 band had a severe attack of erysipelas, during which she had constantly 
 nursed him. Dr. Montgomery was of opinion that this lady caught the in- 
 fection from her husband during her close attendance upon him, that it re- 
 mained in abeyance until gestation was over, and was then developed. She 
 recovered well. 
 
 Only the first of the three foregoing cases is remarkable. And 
 too much importance must not be attached to this history ; for it 
 is by no means improbable that the poison was not derived from 
 the brother at all, but that subsequently Mrs. W. got exposed to 
 the influence of the disease without her knowledge. At all 
 events we know that the period of incubation in scarlet fever 
 varies from four to six days ; and as this period has certainly not 
 been lengthened in some instances, I do not think it likely that 
 it was prolonged in Dr. Montgomery's patient. Moreover, as I 
 have seen pregnant women attacked with smallpox after the 
 usual latent period of twelve days, and have not met with any 
 case where it could be supposed that the development of the 
 fever was -delayed by pregnancy, so my feeling of incredulity 
 becomes strengthened. With regard to the cases of typhus 
 fever and erysipelas our knowledge of the length of the period 
 of incubation is too imperfect to make the cases cited of any im- 
 portance. 
 
 14. In concluding this chapter with some general observations 
 on the therapeutics of inegnancy^ I shall be as brief as the nature 
 of the subject will allow. And at the outset it must be said, that 
 whatever may be the nature of the disease coexisting with gesta- 
 tion, the treatment should be mild and simple ; heroic remedies, 
 at least under these circumstances, being usually unadvisable. 
 The efforts of the physician must be directed rather to putting 
 tlie patient into the most favorable condition for bearing the 
 brunt of the disease, than to cutting short the morbid action. 
 Attention to all the laws of hj-giene is especially demanded. 
 The regulation of the sick-room ought not to be disregarded. 
 The strength is to be supported by such food as the digestive 
 organs can assimilate. And then, the practitioner, divesting 
 himself of the trammels of routine, must freely consider his pa- 
 tient's case from every possible point of view ; giving due weight 
 in summing up his evidence to her age, temperament, habit of 
 body, vital power, and the duration of the disorder. He may
 
 364 DISEASES COEXISTENT WITH PREGNANCY. 
 
 likewise advantageously bear in mind the season of the year, 
 and the nature of the prevailing epidemics. In this way he will 
 be putting himself in a position to quietly and cautiously aid 
 the curative processes; being unalarmed, even though he find 
 after making his diagnosis that the scientific term for tlie dis- 
 order he has to cope with ends in that wretched dissyllable itis. 
 
 The history of medicine teaches us that the ancients almost 
 prohibited bleeding during pregnancy; since they argued that 
 every ounce of blood taken away from the mother was so much 
 nourishment lost to the child. But there is undoubtedly a fashion 
 in therapeutics; for about the beginningof the sixteenth century 
 an abrupt reaction took place, and healthy pregnant females were 
 then freely subjected to phlebotomy, merely because they were 
 pregnant. In the last century, the French practitioners especi- 
 ally, bled almost every woman so soon as she became with child ; 
 repeating the operation when she had gone half the term, again 
 at the latter period of gestation, and a fourth time when labor came 
 on. In the present day a physician who ordered a pregnant wo- 
 man to lose blood would run a considerable chance of forfeiting 
 the confidence of his patient; for it is certain that neither the 
 bulk of the profession nor the public have now much faith in the 
 curative powers of bloodletting. About this fact it seems to me 
 there can be no dispute. It may possibly be shown that the dis- 
 like to bleeding is carried too far ; but that there is such a reluc- 
 tance cannot be contradicted. The probable quantity of blood 
 in the human body has been variously estimated by different 
 physiologists : until lately it would appear that the estimate 
 formed has been much too high. According to some recent and 
 trustworthy investigations by Welcker, the body of an adult 
 healthy male will probably contain about ten pounds of blood. 
 To read, however, of the terrible bleedings which were formerly 
 practised, one would think the blood constituted one-fourth of the 
 weight of the body, instead of one-fourteenth. The lancet was 
 not onl}- the remedy p^<r excellence for a large number of diseases, 
 but occasionally even the instrument by which a diagnosis had 
 to be made. The abuse of a weapon, however, can aflbrd no 
 argument against its use ; and therefore it is necessary to see if 
 there are any good reasons for discarding the practice of general 
 bloodletting in the intercurrent diseases of pregnancy. Although 
 it may be allowed, that in some few cases women suffer from a
 
 THERAPEUTICS OF PREGNANCY. 365 
 
 state of plethora during the term of iitero-gestation, yet I am 
 sure that generally the reverse is the case. This latter remark 
 is perhaps more particularly true of the inhahitants of large cities; 
 mao}^ of whom are either weakened by the ills wiiich belong to 
 poverty and a residence in unhealthy localities, or are enervated 
 by luxurious and idle habits. Mauriceau has termed pregnancy 
 a disease of nine months. "Without exactly indorsing this view, 
 it may certainly be said that it is not a time of excess of health. 
 The irritable condition of the nervous system, which is so com- 
 mon, is alone a proof of this. Moreover, though it is unneces- 
 sary to lay much stress upon the changes w^hich the blood — as 
 has been already pointed out — undergoes in its composition, yet 
 it may be observed that all chemists who have recently investi- 
 gated the question allow that the red globules diminish from the 
 beginning to the end of pregnancy ; and w^e know that bleeding, 
 in all instances, especially tends to lessen the proportion of these 
 elements. If to these points be added the proposition laid down 
 by Dr. Todd — " That the notion so long prevalent in the schools, 
 that acute disease can be prevented or cured by means which 
 depress and reduce vital and nervous power, is altogether falla- 
 cious,"^ I think we shall have sufficient evidence to make every 
 practitioner pause before opening the vein of a pregnant female. 
 Of course I am not here speaking of the relief of local conges- 
 tions by topical bloodletting. I believe, for example, that exces- 
 sive congestion of the uterus is a not unfrequent cause of some 
 of the special diseases of pregnancy, and that it may be best re- 
 lieved by the application of two or three leeches occasionally to 
 the lips of the womb. But this is quite beside the present ques- 
 tion, and indeed is merely referred to in order that my meaning 
 may not be misunderstood. 
 
 There is one other consideration of some weio;ht wdiich sus;- 
 gests itself before leaving this subject, and it is this, — that 
 bleeding may possibly, by inducing syncope, cause the death of 
 the foetus. The following case related by M. Depaul offers a 
 good illustration of the truth of this statement : 
 
 A young woman in the sixth month of her second pregnancy applied to 
 Dr. Depaul to be bled, as she stated that she suifered from giddiness and 
 severe headache. Eelying on these statements and on the condition of the 
 
 ' Clinical Lectures on Certain Acute Diseases. Preface. London, 1860.
 
 366 DISEASES COEXISTENT WITH PREGNANCY. 
 
 pulse, this oentlenian thought the loss of blood would be beneficial ; and after 
 having assured himself by the practice of auscultation that the foetus was 
 alive, he bled her. Having withdrawn ten ounces of blood, the vein was 
 about to be closed, when the patient fainted ; the state of syncope being so 
 complete that for some moments the respiration and circulation seemed com- 
 pletely suspended. She was taken from the chair on which she had been 
 sitting and placed in a horizontal position ; but although the usual remedies 
 were applied, twenty minutes elapsed before the circulation had resumed its 
 normal rhythm. From this time the active movements of the child ceased 
 to be fielt ; and five weeks afterward she was delivered of a dead child, which 
 it was concluded — from its condition — had died at the period of bleeding. 
 
 The following year this woman again became enceinte, and when the preg- 
 nancy had advanced to the end of the sixth month she once more applied to 
 be bled for the relief of giddiness and headache. The bleeding, practised 
 under the same conditions, was followed by the same accident. She fell into 
 a perfect swoon; and on recovery the foetal mo\iH3ments had ceased, while the 
 pulsations of the infant's heart, which had been previously heard, could not 
 now be detected. Some weeks afterwards she was delivered of a dead child. 
 This second unfortunate result, together with the history of the case, nnide 
 M. Depaul seek for further information ; and all he learned forced him to the 
 conclusion that the woman on the second application had simulated her head- 
 ache, &c., in order that she might be bled with the same result as on the first 
 occasion.^ 
 
 The employment of cathartics or purgatives in the transitory 
 disorders of pregnancy next demands attention. Medicines of 
 this class are chiefly used to remove the contents of the alimen- 
 tary canal, to diminish the quantity of the fluids of tlie body by 
 promoting secretion and exhalation from the intestinal surface, 
 to excite the liver and pancreas to increased action, and to affect 
 remote organs on the principle of revulsion. As a rule, different 
 purgatives act on different portions of the intestinal canal ; and 
 our object must be to employ such as principally affect the duo- 
 denum and other small intestines, rather than those which irritate 
 the rectum. Hence aloes, scammony, gamboge, colocynth, and 
 hellebore had better be avoided ; while all drastics, such as 
 croton oil or elaterium, prove very injurious. There can, how- 
 ever, be no harm in having recourse occasionally to castor oil, 
 rhubarb, taraxacum, purified ox bile, and the salts of soda or 
 potash, or to enemata of warm soap and water, gruel and oil, 
 &c. Senna is one of the drugs in common use which is gener- 
 ally considered harmless ; but I am sure that I have seen it do 
 mischief when administered during pregnancy, or when uterine 
 disease has existed. Such an effect is not suprising when we 
 
 ^ Ti-ait6 Tlieorique et Pratique d'Auscultation Obst^tricale, p. 269. Paris, 1847.
 
 THERAPEUTICS OF PREGNANCY. ~ 367 
 
 remember that this agent stimuhites the pelvic vessels, and has 
 a tendency to promote hemorrhoidal and menstrual discharges. 
 "Where active cathartics are deemed necessary, calomel or jalap 
 may be used, since they especially excite the action of the duo- 
 denum, and promote the discharge of bile. 
 
 Diaphoretics are valuable remedies, to which the obstetrician 
 may freely resort. To insure the action of the medicines of this 
 class, diluents — as tea, thin gruel, whey, and cold water — must 
 be freely given ; while external warmth ought to be carefully 
 applied. In the early months of pregnancy the hot water or 
 vapor bath may be prescribed without any fear of producing 
 abortion; but after the sixth month I should scarcely venture to 
 order these agents w^ithout some particular reason. 
 
 When narcotics or sedatives are given habitually to pregnant 
 women, they are said to exert an injurious eiiect upon tlie foetus 
 in utero. But this circumstance is not to prevent our cautiously 
 using medicines of these classes, where they are called for by the 
 presence of disease. To procure sleep, to allay pain and spasm, 
 to diminish vascular and nervous excitement, and to arrest ex- 
 cessive secretion, it is often indispensably necessary that hyos- 
 cyamus, camphor, belladonna, conium, hydrocyanic acid, ether, 
 chloroform, or opium should be administered. In prescribing 
 any of these drugs it is to be remembered that women are gen- 
 erally more susceptible to their influence than men ; and that 
 where there is much debility, with a disposition to miscarriage, 
 great caution will be requisite, since some of them may then 
 excite delivery. 
 
 Counter-irritation is resorted to in a large number of diseases, 
 and not very uncommonly without doing the slightest good. 
 Routine practitioners are especially fond of blisters ; but these 
 disagreeable agents should be but seldom employed under the 
 circumstances we are now considering. If it be certain that 
 counter-irritation is needed, sinapisms and turpentine stupes 
 and dry cupping will generally accomplish as much good as 
 vesicants, or those substances (tartar emetic and croton oil) 
 which produce pustular eruptions. 
 
 Tonics and stimulants may be employed in the intercurrent 
 diseases of pregnancy almost in the same way that they are 
 ordinarily used ; always excepting the various preparations of 
 steel, which, as a rule, are best avoided.
 
 368 DISEASES COEXISTENT WITH PREGNANCY. 
 
 Araonsfst the classes of medicines which should he avoided I 
 would place emetics, diuretics, and it need scarcely be said em- 
 menagogues. Of course a certain latitude must be allowed in 
 acting upon these observations ; since it is only possible to give 
 here general rules and hints. Particular cases will occasionally 
 happen, where the principles which have been inculcated must 
 be departed from. But the enlightened physician, who treats 
 disease according to the condition of his patient and the precise 
 nature of the morbid actions going on in her system, rather than 
 in conformity with a mere nosological arrangement — a system 
 in which each disorder has its appropriate remedy — will liave 
 little or no difficulty in understanding the extent to which he is 
 to follow the foregoing landmarks.
 
 SYMPATHETIC DISORDERS OF PREGNANCY. 3t)9 
 
 CHAPTER X. 
 
 THE SYMPATHETIC DISORDERS OF PREGNANCY, 
 
 Section' 1. — Disorders of' the Digestive Organs. — 1. Introduction. — 2. Capricious 
 APPETITE. — 3. Toothache. — 4. Salivation. — 5. Nausea and vomiting. — 6. Car- 
 
 DIALGIA. — 7. H^MATEMESIS. — 8. DiARRBfEA. — 9. CONSTIPATION. — 10. JauNDICE — 
 
 Hepatic hypertrophy — Acute atrophy of the liver. 
 
 Section 2. — Disorders of the organs of respiration and circulation. — 1. Dysp- 
 nea. — 2. Cough. — 3. Haemoptysis — 4. Palpitation op the heart. — 5. Faint- 
 ing. — 6. Enlargement of the thyroid gland. — 7. Morbid conditions of the 
 spleen. — 8. Varices— Haemorrhoids — Thrombus, or sanguineous tumor from 
 the rupture of the enlarged vaginal veins, etc. 
 
 Section 3. — Disorders of the nervous system. — 1. Cephalalgia. — 2. Sleepless- 
 ness. —3. Hypochondriasis. — 4. Nervous affections of the ears and eyes — 
 Amaurosis. — 5. Mastodynia. — 6. Pain of the right side — Myalgia. 
 
 Section 1. — The Disorders of the Digestive Organs. 
 
 1. Introduction. — Every physician who has devoted much 
 attention to the study of uterine diseases is aware that they give 
 rise to a great number of sympathetic disorders. From the first 
 catamenial period to the last, even when the menstrual function 
 is performed naturally and painles.'^ly, the excitement of the 
 sexual organs produces a marked effect upon the whole system. 
 It is scarcely surprising, therefore, that the wonderful changes 
 which result from fecundation should considerably influence all 
 the vital functions. 
 
 The effects induced bj' pregnancy vary very much in different 
 women. With some constitutions tlie peculiar excitement which 
 arises has only a directly beneficial influence ; causing all the 
 organs to act harmoniously and efficiently, and thereby producing 
 a more healthy condition than usuall}- exists at other times. In 
 many cases, however, more or less trouble.'^ome symptoms are 
 experienced. These are sometimes so slight as merely to pro- 
 duce a general feeling of discomfort; Avhile sometimes they are 
 so grave as materially to injure the general health, even if they 
 do not endanger life. 
 
 24
 
 370 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 The disorders of pregnancy arise chiefly from three sources, — 
 viz., from the important changes going on in the uterus pro- 
 ducing sympathetic influences and derangements in distant vis- 
 cera; from the pressure of the enlarged uterus upon the parts 
 near to or in contact with it; and from morbid states of the 
 sexual system. The amount of sympathetic irritation excited in 
 different organs varies much in diflerent women ; and unless 
 excessive, must not be regarded as unnatural. "It is a popular 
 observation, confirmed by experience," — says Denman — "that 
 those women are less subject to abortion, and ultimately fare 
 better, who have such symptoms as generally attend pregnancy, 
 than those who are exempt from them. The state of pregnancy 
 is then an altered, but cannot with propriety be called a morbid 
 state. But if the term disease be used on this occasion, with the 
 intention of giving a more intelligible explanation of the tem- 
 porary complaints to which women are then liable, or to denote 
 their irregularity, or an excessive degree of them, it may be re- 
 tained."^ 'No organ sympathizes more extensively with the uterus 
 than the stomach; and hence one of the earliest symptoms of 
 pregnancy is derangement of the functions of this viscus. Dys- 
 pepsia is the precursor of disordered nutrition ; for how can the 
 "life of the flesh" escape deterioration when the material from 
 which it is formed is imperfectly elaborated ? When it is remem- 
 bered, that the corpuscles naturally become diminished and the 
 watery portion of the blood increased, so soon as the system has 
 to supply materials for the development of a new being, it can 
 be easily understood how that which was at first a purely sym- 
 pathetic disorder at length becomes converted into a trouble- 
 some disease. The chlorotic condition to which the pregnant 
 woman thus gets reduced, partly explains many of the symptoms 
 — e. g., headache, vertigo, palpitation, dj^spnoea, and general 
 feebleness — from which she suffers at an advanced period of 
 gestation. And it is obvious, that such symptoms must become 
 aggravated by any lowering treatment ; while they can only be 
 lessened by animal food and milk and wine, with tonics and 
 similar remedies. 
 
 The corollary from these observations seems in part at least to 
 be, that great attention should be paid to the diet of pregnant 
 
 ^ Introduction to Midwifery Sixth Edition, p. 126. London, 1824
 
 DISORDERS OF DIGESTIVE ORG»ANS. 371 
 
 women ; which — while it is to be simple and light and nutritious 
 — ought to be specially adapted to the requirements of the par- 
 ti-cular individual, and the condition of her digestive organs. 
 In the way merely of a few common suggestions it may be said, 
 that improper indulgences in food are not to be sanctioned; that 
 highly-seasoned or very rich dishes are bad ; that tea and coffee 
 are to be used only in moderation, and in a great measuie as 
 vehicles for cream or plenty of milk; and that alcoholic stimu- 
 lants are by no means always, nor perhaps even generally, neces- 
 sary. It is often erroneously thought that an unusual supplj^ of 
 nourishment is required during pregnancy to support the strength 
 and aid the development of the foetus. Consequently, either an 
 increased amount of food is taken, or a change is abruptly made 
 from a plain and nourishing regimen to full and generous living. 
 Both of these errors are to be avoided. For by their adoption 
 we either give rise to a state of plethora, as injurious to the 
 mother as to the embryo ; or we produce debility and dyspepsia 
 and nausea and heartburn, &c., in the former, and in the Latter 
 constitutional feebleness, ^t^o argument is necessary to prove, 
 that the consequences must be the same to the infant, whether 
 the insufficient nourishment of the maternal system results from 
 want of food or from inability of the stomach to digest it. The 
 fact seems ofter> forgotten, that to allow an abundance of nitro- 
 genous food and stimulants is not always to impart permanent 
 power or even necessarily to give temporary strength ; for how 
 can healthy nutrition result if the digestive functions are taxed 
 bej'ond their powers, — if more food be eaten than can be prop- 
 erly digested and assimilated? Where the digestive powers are 
 good, however, and eating is not followed by oppression or lan- 
 guor, there can be no harm in satisfying the appetite with such 
 food as the patient may be accustomed to, and which she knows 
 from experience agrees with her. As a general rule, milk and 
 cream, lightly cooked and raw eggs, fish, poultry, mutton, beef 
 and game may be beneficially partaken of; remembering that 
 not only is variety in diet very important, but also that it is neces- 
 sary so to regulate the time of the different meals that the stomach 
 can enjoy proper intervals of rest. A too spare diet is, on the 
 other hand, no less injurious and reprehensible. Unhappily, 
 however, it cannot always be avoided. During "strikes" and 
 hard times many of the wives of the laboring classes sufter much
 
 372 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 from their inability to procure a due supply of wholesome food. 
 In consequence, they give birth to feeble and unhealthy children ; 
 who grow up stunted in growth and deficieut in both mental 
 and bodily vigor, unless they prematurely perish from some form 
 of tuberculous disease. 
 
 With delicate women it will sometimes be found advantageous 
 to advise them as to the nature of the ivater tliey should drink. 
 Hard water, or tliat which contains much lime and magnesia and 
 iron and sulphur, is no doubt injurious to the coats of the stomach 
 of many an invalid. The owners of racehorses are so well aware 
 of the importance of attention to this matter, that when the 
 animals are sent away from their stables to Epsom or Goodwood, 
 &c., the soft water to which they have been accustomed is often 
 forwarded with them ; for a trainer would no more allow "the 
 favorite" to have one drink of hard water when stabled on the 
 chalky downs, than he wouki let him remain a single day with- 
 out his gallop or without the most thorough grooming. Where 
 there is very great irritability of the stomach in pregnant women 
 small quantities of icy cold distilled water can sometimes be 
 taken, when the fluid direct from a spring will not be tolerated. 
 That which irritates the skin can hardly be expected to soothe a 
 mucous membrane. N^ow, for very fine skins pure soft water is 
 seen to be much better for use than that which is hard and coarse. 
 Indeed, no cosmetic will be required by the lady who washes in 
 distilled or in pure rain-water ; or even in water which has been 
 well boiled and filtered, provided that the impurity is due to the 
 presence of carbonate of lime. Whereas, however, all waters 
 from the chalk — which hold carbonate of lime in solution — may 
 be softened by boiling, tliose which are hardened by sulphate of 
 lime are rendered still harder by this means, to an extent pro- 
 portionate to the amount of the evaporation. It is not necessary 
 here to allude to the injurious properties of bad water, — i. e., that 
 containing decaying animal or vegetable matter, or that which is 
 rendered noxious by exposure to the effluvia from drains, or 
 which is poisoned by contact with lead — because we are all well 
 aware of the absolute necessity for prohibiting the use of such 
 dirty solutions of pestiferous matter. Since the mortality returns 
 of 1849 and 1854 unmistakably proved that a great excess in the 
 deaths from cholera occurred wherever bad water was supplied,
 
 DISORDEllS OF DltiESTIYE ORGANS. 373 
 
 any inattention to this point for the future would be almost un- 
 pardonable. 
 
 About the year 1850, M. Depaul revived the consideration of 
 the question as to the possibility of partially arresting the develop- 
 ment of the foetus by almost starving the mother ; so that, with- 
 out injuring its health, or shortening its intra-uterine existence, 
 the child when born might be small so as to pass through a con- 
 tracted pelvis. This gentleman relates two cases in favor of his 
 view that such a proceeding may sometimes be advantageously 
 resorted to. From these instances, as well as from a general con- 
 sideration of the subject, he draws the following conclusions: 
 
 (1) That bleeding and a low diet have an undeniable influence on the 
 development of the child during its intra-uterine existence. (2) This plan 
 can be adopted in malformations of the pelvis, and be substituted in some 
 instances for artificial premature labor. (H) It is applicable with no less ad- 
 vantage in those cases where, without a contracted pelvis, the extreme size 
 of the foetus has in preceding labors caused fatal difficulties. (4) The in- 
 fluence of a restricted diet, when the woman submits to it rigorously for a 
 sufficient length of time, is much more efficacious than that of bleeding. The 
 latter also cannot be often practised without comproniising the pregnancy. 
 (5) Bleeding should, however, be combined with a low diet. It is especially 
 useful in the last months of pregnancy. (6) This plan, judiciously em- 
 ployed, has no unfavorable influence either on the progress of pregnancy, on 
 the future health of the mother, or on the well-doing of the child. (7) It 
 is impossible to lav down a ligorous formula for its practice, for it should be 
 modified according to circumstances and the especial aim in view. And (8) 
 the treatment should be resorted to early, and ought to be persevered with 
 uninterruptedly till the end of pregnancy.' 
 
 Now the cases just alluded to of M. Depaul, those also related 
 by M. Delfraysse, — wlio administered small doses of iodine with 
 iodide of potassium during the last two months of gestation, with 
 the same intent, — and one recorded by Baron Dubois in 1855, 
 where scarcely any food was taken during the whole period of 
 pregnancy, are all very good examples of that j^ost hoc ergo 
 propter hoc kind of reasoning which is so often met with in med- 
 ical essays. Because a certain plan of treatment was adopted 
 with the mother in some half-dozen cases, and the child when 
 born was found to be small, therefore we are to admit the ex- 
 istence of cause and effect. But if these views of M. Depaul be 
 sound, all the experience of daily life must be valueless. Ask 
 
 1 L'Union Medicale. Tome iv, p. 22. Paris, lith January, 18-50.
 
 374 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 the practitioners who attended the poor Irish women during the 
 famine, if the infants were smaller than usual ? Does not the 
 union doctor deliver paupers, who have suffered great depriva- 
 tions and anxieties, of children as large — though thej may he 
 constitutionally weak — as those who first see light in the man- 
 sions of the great ? It has often heen noticed that women who 
 get thin during pregnancy give hirth to tlie fine-looking children. 
 In a case which was under my own care, the lady suffered severely 
 from nausea and vomiting during the greater part of the nine 
 months, so that she became quite attenuated and extremely 
 feeble. Yet her labor was tedious and difficult owing to the size 
 of the infant, wliich was found to weigh more than twelve pounds. 
 Look again at the infants born from mothers in advanced stages 
 of phthisis. Louis refers to the case of a w^oman whose lungs 
 contained a great number of tuberculous cavities and who died 
 in the last stage of marasmus, three weeks after having been de- 
 livered of an extremely robust infant. On the other hand, Den- 
 man asserts in his treatise, from which I have already quoted, 
 that, — " If the mother has little uneasiness, and grows corpulent 
 during pregnancy, the child is generally small." It seems un- 
 necessary then to say more against M. Depaul's cruel proceeding. 
 And, indeed, if we granted that the results obtained were as 
 favorable as could be desired, still the practice could have nothing 
 to recommend it in preference to the induction of premature 
 labor at some time after the expiration of the seventh month. 
 
 2. Capricious Appetite. — Want of appetite, or even a com- 
 plete disgust for food, is not uncommon during the earlier months 
 of pregnancy ; and when of long continuance gives rise to great 
 weakness and emaciation. As the dislike is chiefly towards 
 animal food, attempts must be made to nourish the system by 
 fresh vegetables, ripe fruits, eggs, light nutritious puddings, and 
 milk. 
 
 A more remarkable peculiarity is an irregular and depraved 
 appetite, sometimes described under the name of "pica," — prob- 
 ably from pica, a magpie, as this bird was supposed to live upon 
 clay. There is usually a distaste for wholesome food. The 
 longing for absurd or even disgusting articles of diet, is occa- 
 sionally carried to such an excess as to constitute a species of 
 monomania. The older writers seem to have taken a particular
 
 TOOTHACHE. 375 
 
 pleasure in detailing all the longings of pregnant women which 
 they could hear of; as well as in giving minute descriptions of 
 the extent to which these caprices were carried. Hence the 
 stories are numerous of daily meals made of chalk, brown paper, 
 charcoal, clay, cinders, dirt of all kinds, ginger, broken pebbles, 
 sealing-wax, slate-pencil, &c. Langius even mentions a woman, 
 who — to gratify her extremely disagreeable desires — killed her 
 husband, made a dinner oft' part of him while he was fresh, and 
 then pickled the remainder. 
 
 In most cases of disordered appetite it will be found that the 
 functions of the stomach are imperfectly performed, and that the 
 secretions of this viscus are in a vitiated condition. If we ex- 
 amine the patient's tongue it is seen to be coated with a thick 
 fur ; the mouth is filled with viscid saliva ; the breath is gener- 
 ally most ofiensive ; and complaint is either made of pyrosis, or 
 there are frequent eructations of an acid glairy fluid. Of course, 
 with these symptoms there can only coexist bodily weakness and 
 great mental depression. Consequently the physician's course 
 is clearly marked out. Instead of pandering or giving way to 
 the fancies of .the patient, she must be taught the necessity for 
 exercising a proper amount of self-denial ; inasmuch as compli- 
 ance with her whims only makes her more exacting. Attempts 
 have to be made to impart tone to the digestive organs ; and mild 
 alteratives, laxatives, pepsine, and simple vegetable tonics may 
 be administered according to the apparen.t requirements of the 
 system. Opiates sometimes prove useful by allaying gastrody- 
 nia ; while the preparations of bismuth are of great service where 
 there is water-brash. All violent medicines, whether purgative 
 or otherwise, are decidedly to be avoided; their exhibition being 
 fraught with equal danger to both the mother and fcetus. The 
 diet should also be bland and nutritious; soda-water or Seltzer 
 or Vichy water, with ice, will be found grateful ; exercise should 
 be taken daily in the open air ; and the patient's mind ought to 
 be kept occupied by change of scene, by persuading her to mix 
 in cheerful society, and by substituting healthy recreation for 
 listlessness and undue self-indulgence. 
 
 3. Toothache. — ITeuralgic pains in the dental nerves, especi- 
 ally in those of the upper jaw, are sometimes very troublesome. 
 They are most common iu the earlier months of gestation ; but
 
 376 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 occasionally frequent attacks of pain are experienced tbrougli 
 the whole period of pregnancy. The suffering, however, is not 
 always simply neuralgic; for acute caries of some of the teeth 
 may occur, giving rise to severe paroxysms of torture night and 
 day. Doubtless the existence of a decayed tooth prior to con- 
 ception will predispose the patient to attacks of this kind. 
 
 In all cases the mouth should be examined. If the suifering 
 be due to caries, and only one or two teeth are affected, they 
 should be extracted; provided the patient is strong enough to 
 bear the shock of the operation, if she is unwilling to allow an 
 ansesthetic to be employed. It is, however, only in exceptional 
 instances that there can be any objection to the inhalation of 
 chloroform ; or of what is better, a mixture of equal parts of 
 chloroform and pure ether. But if the pains are neuralgic, it 
 will be worse than useless to extract the teeth. Then we must 
 trust to efficient laxatives, tonics, good diet with wine or beer, 
 sedative fomentations, and the local application of chloroform. 
 I have found quinine combined with the ammoniated tincture 
 of valerian give lasting relief in cases attended with debility and 
 nervousness. Sometimes, the liquid extract of yellow cinchona 
 with phosphate or valerianate of zinc proves efficacious. In other 
 instances, when the blood has been watery, the valerianate of 
 iron, or the saccharated carbonate of iron, has done good. Seda- 
 tives are frequently needed to give temporary relief, and especi- 
 ally to prevent the mischief which arises from a series of restless 
 nights. Under these circumstances, a mixture of ether and 
 opium and Indian hemp may often be prescribed with advantage. 
 But where the distress is very great, the subcutaneous injection 
 of a quarter of a grain of morphia, dissolved in two or three 
 minims of distilled water, will give more rapid and sure relief 
 than when the same drug is exhibited by the stomach. I do not 
 think any advantage is gained by using the injection at the seat 
 of pain, while it is certainly sometimes inconvenient to do so. 
 Some authorities, however, have entertained a contrary opinion. 
 For example, Dr. R. H. Storer has recorded the following case : 
 
 A lady suffered for several weeks from severe neuraljiic pain throughout 
 the left half of the upper jaw. The pain was at times of a lancinating char- 
 acter, and at others dull. The general health was decidedly affected, as evi- 
 denced by the state of the circulatory, digestive, and nervous systems. The 
 teeth were all sound ; and there was no heat or swelling of the gums, nor
 
 SALIVATION. oU 
 
 increase of pain on pressing them. Anodynes, refrijrerants, emollient poul- 
 tices, and counter-irritants were successively resorted to without benefit. 
 After much solicitation, a tooth was extracted ; but the patient remained 
 unrelieved. On the following day, ten drops of a solution of bimeconate of 
 morphia were injected beneath the mucous membrane of the guui. The 
 pain ceased instantaneously, and it may be said permanently; inasmuch as 
 it had not returned at the end of five months, when the case was reported. 
 
 4, Salivation. — Hippocrates, and many writers since bis time, 
 have mentioned the occasional occurrence of sahvation as a sign 
 of pregnancy. Mauriceau alludes to increased spitting as a com- 
 mon symptom of pregnancy. Dewees says that almost all women 
 have more than an ordinary quantity of saliva during utero gesta- 
 tion. When salivation happens, it generally commences at an 
 early period ; and either ceases about the end of the third month, 
 or persists daring the whole term of gestation. In a few rare 
 instances it has continued for one or two months after delivery. 
 
 The salivary glands are usually found swollen and tender; the 
 buccal mucous membrane beino- also tumid and cono-ested. But 
 the gums are neither sore, spongy, nor ulcerated; and there is 
 no fetid odor from the mouth, as there is to such a marked ex- 
 tent in mercurial ptyalism. The amount of saliva secreted may 
 vary from a slight increase of the natural quantity, to three or 
 four quarts in the twenty-four hours ; the fluid is tenacious or 
 thin, and often has a rather unpleasant taste ; and the excessive 
 flow of it at night gives great annoyance, owdng to the necessity 
 for frequently emptying the mouth. In the few cases which I 
 have seen, the patient has suftered from troublesome constipa- 
 tion; and the stomach has been weak and irritable, giving rise 
 to a frequent sense of nausea with other d^yspeptic troubles. The 
 ill-effects which sometimes ensue are well seen in the following 
 characteristic case, recorded by Dewees. This author says : 
 
 I was called upon to prescribe for Mrs. J , who was advanced to the 
 
 fifth month of her pregnancy. At the second month she was attacked by a 
 profuse salivation ; she discharged daily from one to three quarts of saliva, 
 and was at the same time harassed by incessant nausea and frequent vomit- 
 ings : so irritable was the stomach, that it rejected, almost instantly, anything 
 that was put into it. She now became extremely debilitated — so much so as 
 to be unable to keep out of bed ; and when she did attempt to sit up, she 
 would almost instantly faint, if not instantly replaced. From a belief that 
 the afFection might be local, astringent gargles were freely employed, but 
 with marked disadvantage. A large blister was next applied at the back of 
 the neck, with decided but transient benefit — that is, the salivary discharge
 
 378 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 was less, the nausea diminished, and the voniitinti; became less frequent ; but 
 this favorable impression was but of three or four days' duration ; for after this 
 time all the unpleasant symptoms returned with their former severity. An 
 emetic of ipecacuanha was now exhibited, followed by a cathartic of rhubarb 
 and ma<i-ne.sia, without the smallest benefit; soda-water, lime-water and milk, 
 milk itself, &c , were in turn unavailingly employed. I now put my patient 
 upon a strictly animal diet, and ordered ten drops of laudanum morninir and 
 evening;, and fifteen at bed-time : this plan succeeded most perfectly in the 
 course of a few days; nausea and vomiting' ceased, and the discharsjje was 
 reduced to less than a pint per diem ; and perhaps the force of habit had no 
 inconsiderable apjency in the production of this quantity. The bowels during 
 this plan were kept open by the extract of butternut and rhubarb, in the 
 form of pills. The lady never had any return of this complaint in her sub- 
 sequent pregnancies.^ 
 
 Many patients are not as fortunate as -Mrs. J. with regard to 
 the non-return of the symptoms in subsequent pregnancies. 
 On the contrary, it will often be found that the same phenom- 
 ena recur asrain and ao-ain. I know of one ease where the first 
 appreciable symptom of pregnancy is salivation, which always 
 continues until after quickening. 
 
 The treatment of this affection demands a little caution. Ac- 
 cord! nij to some foreiarn writers the discharsre oua-ht not to be 
 suppressed, as the cure of it has been followed by apoplexy. 
 Our fears upon this point need not deter us, however, from at- 
 tempting to restrain the secretion when it is evidently deranging 
 the digestive organs and weakening the patient. The first point 
 is to attend to the functions of the bowels, a course of cooling 
 laxatives being always necessary. The application of small 
 blisters to the neck, or behind the ears, then appears more cal- 
 culated to do good than any other single remedy; and it has 
 seemed to me advisable to prevent the raw surfaces from heal- 
 ing for some short time by the use of irritating ointments. 
 Local applications to the mouth are seldom of use ; but inhala- 
 tions of the officinal vapors of conium or of creasote cannot 
 prove at all injurious. If any gargle is likely to do good, one 
 containing borax is the most promising in my estimation. The 
 following might be ordered experimentally: 
 
 Take of, — Glycerine of Borax, 2 fluid ounces; Rose-water, 6 fluid ounces. 
 Mix for a gargle. To be u.sed twice or thrice daily. 
 
 Sucking Weuhain lake ice gives temporary relief, and is grateful 
 
 1 A Treatise on the Diseases of Females. Tentli edition, p. '201. Philadelphia, 1854.
 
 NAUSEA AND VOMITING. 379 
 
 to tlie patient unless her teetli are decayed. With regard to med- 
 icines capable of acting directly upon the discharge, it can only 
 be said that none are known the effects of which are certain. I 
 think I have seen belUidonna do good ; either when taken in- 
 ternally, or applied over the region of the submaxillar}' gland. 
 I have tried the officinal arsenical solution, but as far as can be 
 remembered only in one instance with benefit. Chlorate of 
 potash, according to the following formula, might perhaps be 
 useful : 
 
 Take of.— Chlorate of Potash, 90 to 120 grains ; Liquid Extract of Yellow 
 Cinchona, 90 minims; Tincture of Hyoscyamus. 4 fluid drachms; Camphor 
 Water, to 8 fluid ounces. Mix and labol, — " One-eighth partj with a large 
 tablespoonful of water, every six or eight hours." 
 
 It need only be further remarked that the irritability of the 
 stomach, which appears sometimes to be the result of the ptya- 
 lism, will necessitate attention to the diet; and therefore the 
 rules which have already been laid down upon this subject have 
 to be attended to. The confession must also be made, that not 
 unfrequently all our efforts to check the secretion will only end 
 in disappointment. 
 
 5. ITausea and Vomiting. — These sympathetic disorders are 
 so common, that there are few women who do not sutler from 
 them during one stage or other of gestation. But it must be 
 remembered, that independently of pregnancy, vomiting is very 
 frequently witnessed in certain diseased conditions of the sexual 
 system. Thus morning sickness is occasionally troublesome in 
 dysmenorrhoea, in amenorrhcea, as well as when the catamenia 
 get irregular at " the change of life ; " it very often increases the 
 prostration of the sufferer and hastens death in carcinoma uteri; 
 and I have repeatedly seen it present in siniple irritation of the 
 ovaries, in acute and chronic ovaritis, in endometritis, in pelvic 
 cellulitis, as well as in peri-uterine hsematocele. La Motte refers 
 to a non-pregnant woman who vomited "sola actione coitus;" 
 and to two others who had violent sickness at each catamenial 
 period.^ 
 
 The phenomenon under consideration, when it occurs in con- 
 nection with pregnancy, may present itself during the first twelve 
 
 1 De Arte Obstetrica, pp. 54 and 75. Lugd. Batav., 1733.
 
 380 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 or sixteen weeks of gestation, or throughout the whole term, or 
 merely for the two or three latter months. In the first case it 
 usually sets in about the end of the third or fourth week, though 
 occasionally it begins within a day or two of conception. It is 
 generally assumed, but I know not with what degree of correct- 
 ness, that primiparous females suffer more frequently from vomit- 
 ing than others ; owing to the uterine tissues being more un- 
 yiehling in first pregnancies than they afterwards become. So 
 also some women assert that the}^ only have sickness when the 
 fcetus is of the male sex; a circumstance which they confess their 
 inability to explain, save by the feminine argument "that it is 
 so." The attacks of retching, in mild cases, give but little pain 
 or fixtigue ; though in more severe instances there is often ex- 
 haustion and considerable epigastric tenderness. It is not to be 
 forgotten that, in the great majority of cases, the stomach itself 
 is health}^ ; the sickness being caused by reflex irritation from 
 the gravid womb. 
 
 Speaking with some degree of latitude, it may be said that the 
 stomach only appears to be irritable during the early part of the 
 forenoon ; so that the patient, on rising from her bed, feels op- 
 pressed with nausea and usually makes an efibrt to vomit. From 
 this peculiarity, the attacks are often spoken of as " morning 
 sickness." The matters ejected consist chiefly of a glairy mu- 
 cus, mixed with a quantity of acid water; a little bile being 
 sometimes present. When the attack comes on after a meal, of 
 course the food is returned. The sickness does not take away 
 the appetite for breakfast, and frequently the nausea does not 
 return until the following day ; the attacks, perhaps, ceasing en- 
 tirely at the end of six or eight weeks, though ofttimes they con- 
 tinue until the period of quickening. 
 
 Unfortunately, it must be confessed that deviations from this 
 ordinary type are not very rare. Every physician meets with 
 instances where the irritability of the stomach is so extreme, that 
 dil'cctly any kind of food, or even plain water, is taken, it is re- 
 jected. In such cases the absence of all nutrition nmst lead to 
 symptoms which are very formidable. The patient soon becomes 
 feeble and exhausted; while there is daily increasing emaciation, 
 the wasting sometimes going on to an extraordinary degree. 
 The least exertion threatens to produce deadly syncope. There 
 is much suffering with uncontrollable restlessness ; the counte-
 
 NAUSEA AND VOMITING. 381 
 
 I 
 
 nance assumes an anxious expression, though many times no 
 manifestation of fear is apparent; the eyes get sunken while the 
 cheeks fall in ; and there is an oftensive sour odor in the breath. 
 Unless amelioration occur, which may sometimes suddenly hap- 
 pen when matters appear nearly at the worst, a perfect loathing 
 of all food and drink seems to set medical skill at defiance. Vio- 
 lent epigastric pains torment the sufferer; and the retchings often 
 persist, though the stomach be empty. The weakness is extreme. 
 At times there is disordered vision with hallucinations ; while 
 the system rallies and sinks again and again in the course of a 
 few hours, like the flickering flame of a nearly burnt-out taper. 
 But one step more, and a fatal result ensues ; the victim either 
 dying from sheer starvation, or from the rupture of a bloodvessel 
 during a violent fit of vomiting, or from a paroxysm of convul- 
 sions. Even to the last, however, the mind is often supported 
 by the hope of relief; and repeatedly the intellect remains per- 
 fectly clear till death closes the scene. Numerous fatal cases are 
 recorded, but I know of no author who has had the misfortune 
 to meet with so many as Baron Dubois; who stated, during a 
 discussion on this subject at the French Academy of Medicine 
 in 1852, that in the course of thirteen years he had met with 
 twenty in his own practice.^ 
 
 M. Dance is of opinion that when, during pregnancy, vomiting 
 is protracted beyond the ordinary period, it usually arises from a 
 morbid irritation of the uterus, which, together with the mem- 
 brana decidua, is in a state of inflammation. He has had an op- 
 portunity in two cases of testing this opinion by post-mortem ex- 
 aminatio)is. In the first of these the uterine parietes were found 
 thinned to almost a line and a half, soft and gorged with blood: 
 in the second, there was discovered pus and layers of coagulable 
 lymph between the decidua and internal surface of the uterus, 
 with other symptoms of inflammation. He recomm.ends the em- 
 ployment of decided antiphlogistic measures, applied as near as 
 possible to the uterus, and not to the stomach, which is only 
 sympathetically affected.^ But inasmuch as cupping, leeches, 
 blisters, and similar remedies were used in these instances with- 
 out the slightest benefit, the propriety of following M. Dance's 
 advice may not unreasonably be called in question. 
 
 1 Ranking and Radcliffe's Half-yearly Abstract of the Medical Sciences. Vol. xvi, p. 
 367. London, 1853. 
 
 2 Medico-Chirurgical Review. New Series. Vol. viii, p. 149. London, 1S29.
 
 382 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 According to Dr. Henry Bennet, the discovery of the frequent 
 existence of inflcimmatory ulceration of the neck of the uterus 
 during pregnancy is one of vital importance, inasmuch as it af- 
 fords a ready explanation of most of the accidents and morbid 
 sym[)toms of this period. From repeated investigations he has 
 ascertained that this condition "is of frequent occurrence, that 
 it is the keystone to the diseases of the pregnant state, and the 
 most general cause of laborious pregnancy, obstinate sickness, 
 moles, abortions, miscarriages, and hemorrhages."^ The inflam- 
 matory ulceration of the cervix will generally be found, on in- 
 quiring into tlie history, to have existed prior to the pregnancy; 
 for though this state is constantly the cause of sterility when it 
 attacks young married females at the onset of their married life, 
 yet it does not seem so uniformly to prevent conception in those 
 who have previously had children. The symptoms it gives rise 
 to are chiefly these : A continued and irritating pain in the 
 lower part of the back, as well as in the abdomen, and especially 
 in the ovarian regions; a feeling of aching or uneasiness down 
 the inside of the thighs; a more or less copious muco-purulent 
 vaginal discharge; a sensation of great pelvic weight and bearing- 
 down ; loss of appetite and strength and flesh ; headache, palpita- 
 tions, constipation, and troublesome sickness; with possibly a 
 gradually-increasing exhaustion, which may bring the patient to 
 the brink of the grave. On practising the touch, the ulcerated 
 OS uteri is found more open than is consistent with the period to 
 which gestation has advanced; while the lips are soft, instead of 
 being indurated as they are when the non-pregnant cervix is in- 
 flamed, and they have a velvety or even fungous pultaceous feel. 
 The vulva and vagina are extremely red and congested ; while 
 on examining with the speculum, the cervix is seen to be volu- 
 minous and tumid and of a livid hue, as well as more or less 
 covered with fungous granulations. The fungosity may be so 
 great as even to give rise to a fear of malignant ulceration ; while 
 the surface bleeds readily, the hemorrhage being sometimes peri- 
 odical so as to simulate menstruation. — The cure of all the fore- 
 going symptoms is not very difficult. The chief remedies are 
 free cauterization of the aflected surface with nitrate of silver ; or, 
 in bad cases, the careful application about every four days of the 
 
 1 On Inflammation of the Uterus: its Cervix and Appendages. Third edition, p. 15S. 
 London, lb53.
 
 NAUSEA AND VOMITING. 383 
 
 acid solution of nitrate of mercury. Benefit will arise from the 
 use of solutions of alum and sul})bate of ziuc, or of the diluted 
 solution of subacetate of lead, as injections. Then, with perfect 
 rest, a light diet, and simple vegetable tonics, all will do well. 
 
 Dr. Clay, of Manchester, believes that when obstinate vomiting 
 occurs during the latter months, it will very often be found due 
 to considerable congestive inflammation and great tenderness of 
 the OS and cervix uteri. He relates three cases as bearing out 
 his opinion. From them, as well as from his general experience, 
 he deduces these observations, which I cannot do better than 
 give in his own words : 
 
 That the irritable state of the stomach is purely symptomatic of that con- 
 dition of the OS and cervix uteri (that is) in these obstinate cases of the latter 
 months. That these cases diifer widely from, and must not be confounded 
 with, those of nausea and sickness of the early months, however severe; and 
 where the stomach itself particularly, and in some measure the entire digestive 
 functions are much derantred : and attention to the condition of the stomach 
 will in most, if not in all cases, be remedied by medicine and diet. That 
 diet or medicine have little or no effect in the severer cases above described, 
 iv the hitter months ; but that a position of the body calculated to relieve the 
 OS and cervix from pressure against the pelvic viscera, best accomplished by 
 lying on the back with the hips raised and head low, with food in very small 
 quantities given at long intervals. Lastly, and mainly, I rely on the appli- 
 cation of a few leeches, applied through the speculum, direct to the os and 
 cervix uteri, the seat of congestive inflammation, and consequently the cause 
 of general irritation and sympathetic action of the stomach and its conse- 
 quences. The leeches are to be repeated if any tenderness remains, and the 
 position strictly observed until the symptoms are entirely conquered.^ 
 
 In a few very rare instances, the attacks of vomiting are most 
 troublesome when the patient is in the recumbent posture. In 
 such. Dr. Clay suggests that there is some tenderness and con- 
 gestion of the uterine structure at or near the fundus uteri; and 
 he says that he has had one example of this kind, which was 
 soon relieved by stupes of warm turpentine and water, together 
 with the loss of a few ounces of blood from the arm. 
 
 There are, moreover, a few cases where the vomiting depends 
 upon some displacement of the uterus, such as retroversion or 
 anteversion, &c. In these a cure can be effected by replacing 
 the womb in its normal position. 
 
 We must now return to the consideration of the treatment 
 
 1 On the Severe and Obstinate Forms of Vomiting during the latter months of Preg- 
 nancy, p. 7. London. No date.
 
 384 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 necessary for those examples of purely sympathetic vomiting 
 from the state of pregnancy, where there is no morhid condition 
 of the nterine organs; a class of cases which I believe to be far 
 more common than any other. But first it should be observed 
 that when the morning sickness is merely slight, medical inter- 
 ference will seldom be called for. ]^ot a few practitioners con- 
 sider this disorder to have a beneficial tendency rather than 
 otherwise ; and certainly with the public it is a common belief 
 that women who do not suffer from it during the early months 
 are very apt to miscarry. Dr. Bedford goes so far as to lay down 
 this proposition : 
 
 That there is a strikino; connection between jhe absence of all o;astrie irri- 
 tation and miscarriage, is a fact about which I do not entertain the slightest 
 doubt; and on this assumption I have predicated a treatment, which I am 
 happy to inform you, has proved invariably successful. I could cite to you 
 more than one instance in which miscarriage has occurred under these cir- 
 cumstances, and having been consulted in a subsequent pregnancy, in which 
 the absence of nausea, &e., still persisted, I have been enabled to carry the 
 lady to her full term, and deliver her of a healthy child. The treatment is 
 extremely simple, and it is nothing more than an effort to assist Nature, and 
 relieve the uterus from the effects of extreme congestion. I order the pa- 
 tient to take from one-quarter to half a grain of ipecacuanha once, twice, or 
 thrice a day, as circumstances may indicate, for the purpose of producing 
 nausea, thus simulating as nearly as possible the course pursued by Nature, 
 when not contravened by influences which she cannot control. This course 
 of treatment is continued until about the fourth month of gestation, at 
 which time the nausea and vomiting usually attendant upon pregnancy, as a 
 general rule, cease. ^ 
 
 Supposing that the nausea and vomiting are having an evi- 
 dently injurious influence, as they frequently have, what is the 
 course to be pursued ? It may be answered that our purpose 
 must be threefold. First, to remove all irritating matters from 
 the primte viai, and promote healthy glandular secretion; sec- 
 ondly, to assist the action of the stomach by sedatives, tonics, 
 and a carefully-regulated diet; and thirdly, other means failing 
 and life being endangered, to remove the cause of the disturb- 
 ance by emptying the uterus. 
 
 Attempts tlien must firat be made to get the secretions of the 
 stomach and intestines, liver and pancreas into a healthy condi- 
 tion : for which purpose moderate doses of mercury and chalk, 
 
 ■ Clinical Lfctiires on the Diseases of Women and Children. Fourth Edition, p. 557. 
 New York, lb5G.
 
 NAUSEA AND VOMITING. 385 
 
 or of blue pill with henbane, or of taraxacum and sarsaparilla, 
 or of rhubarb and soda, or of the citrate of magnesia, may be 
 given. I have sometimes seen benefit, es[)ecially where the liver 
 has been inactive, from the administration of one-grain doses of 
 calomel, thrice daily. As soon as the gums have become slightly 
 touched, the sickness has ceased ; and by just keeping up a slight 
 influence for ten or fourteen days all tendency to relapse has been 
 warded otf. The functions of the stomach may also be assisted 
 with great hope of benefit by the administration of pig's pep- 
 sine, in from three- to five-grain doses, with the two chief meals 
 of the day. Should purgatives be needed, seidlitz powders, or 
 castor oil, or draughts containing the sulphate and carbonate of 
 magnesia, can be prescribed; or what is often better, a mixture 
 of diluted hydrocyanic acid, diluted nitro-hydrochloric acid, sul- 
 phate of magnesia, and camphor water. Where the stomach 
 rejects medicines, active aperient enemata should be used. The 
 following may be recommended as a good formula, the croton 
 oil being omitted unless the bowels are very costive : 
 
 Take of, — Castor Oil, 12 fluid drachms; Oil of Turpentine, 2 fluid drachms; 
 Croton Oil, 3 minims; Purified Ox Bile, 5 grains; Tincture of Assaf'oetida, 
 2 fluid drachms ; Gruel, 8 fluid ounces. Mix for an Enema. To be retained 
 for three or four hours. 
 
 When the evacuations have become healthy, we may — in the 
 second place — try the effect of some such medicine as the diluted 
 hydrocyanic acid ; giving it in doses of three to five minims, 
 either with infusion of calumba and bicarbonate of potash, or in 
 a common effervescing draught with citrate of ammonia, or in 
 some such way as the following : 
 
 Take of, — Diluted Phosphoric Acid, 90 minims; Diluted Hydrocyanic 
 Acid, 36 minims; Compound Tincture of Cardamoms, 6 fluid drachms; 
 Volatile Oil of Nutmeg, 12 minims; Water, to 6 fluid ounces. Mix and 
 label, — "One tablespoonful, with the same quantity of water, every six hours." 
 
 In many instances more powerful sedatives will be needed. 
 Resort must then be had to small doses of opium or morphia, 
 which often do great good. The extract of the former, in the 
 proportion of half a grain to two grains, with three of extract of 
 hyoscyamus, is a favorite remedy with me; as is also a mixture 
 of aromatic spirit of ammonia, compound tincture of chloroform, 
 
 25
 
 386 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 liquid extract of opium, five or ten drops of laurel water, and 
 compound infusion of orange peel. Certain quack preparations 
 are constantly advertised as having a reniarkablj' calming in- 
 fluence on the stomach ; but I trust few will be found to lower 
 the practice of medicine to such a mere mechanical art, as to 
 prescribe remedies with the composition and nice properties of 
 which they are utterly ignorant. As well might an expei'iment 
 be made with ITollovvay's pills and ointment. Sir James Simpson 
 speaks very strongly in favor of the salts of cerium, which appear 
 to have a "sedative-tonic" action, like those of silver and bis- 
 muth.^ It must be confessed that tliey have not unfrequently 
 caused me disappointment ; but at the same time I allow, that 
 they every now and then act most efficaciously. The oxalate of 
 cerium is generally to be preferred. The dose is from two to 
 three grains, repeated every three or four hours ; and it may be 
 given as a pill, or placed dry on the tongue with a small piece of 
 ice to assist in its deglutition. A solution of the nitrate of cerium 
 is sometimes prescribed ; but I have had no experience with this 
 preparation. Where the gastric irritability is very great, I often 
 combine three grains of oxalate of cerium with the eighth or 
 twelfth of a grain of morphia, and with advantage. Sir James 
 Simpson has also reported the cure of one severe case — after ice, 
 prussic acid, and half-grain opium pills had failed to give relief — 
 by allowing the lady to inhale some laudanum for a few minutes 
 from a small ether inhaler, hot water being applied to promote 
 its evaporation. Salicine is often a very useful drug, since it 
 allays sickness and promotes appetite and digestion. From three 
 to five grains may be administered thrice daily, with tincture of 
 orange-peel and water. Such agents as quinine or steel will sel- 
 dom be borne. And although they have been recommended, 
 yet I have never found any benefit in these cases from lemon- 
 juice, orange flower water, green tea, lukewarm gruel, assafcDtida, 
 creasote, nux vomica, camphor, conium, acetate of lead, or iodide 
 of potassium ; and only rarely I'rom the subnitrate of bismuth. 
 Every now and then a mixture like the following has seemed to 
 allay the vomiting : 
 
 Take of, — Carbonate of Magnesia, 40 grains; Subnitrate of Bismuth, GO 
 frrains ; Laurel Water, 30 mininis ; .Mucilage of' Trntiacantli, (5 fluid ounces. 
 Mix and label, — " One small tablespoouful every three or tuur hours." 
 
 ' Obstetric Memoirs and Contributions. Vol. i, p. 31'i. Edinburgh, 1850.
 
 NAUSEA AND VOMITING. 387 
 
 With regard to local applications to the epigastric region it 
 must be mentioned that blisters, sinapisms, compound liniment 
 of mustard, liniment of iodine, and turpentine stupes have their 
 advocates. A poultice made with three or four parts of linseed 
 meal, one of mustard, and a sufficiency of boiling water, may be 
 useful, if applied over the stomach for an hour every night or 
 morning. So also, the officinal camphor liniment, to which suffi- 
 cient chloroform has been added to produce a feeling of heat, can 
 be recommended; but it must be rubbed in every few hours, or 
 lint saturated with it may be kept applied as long as it can be 
 tolerated. Again, a piece of fine flannel saturated with a mixture 
 of laudanum and chloroform, and laid over the abdomen some- 
 times does good. An elegant and soothing preparation is made 
 by adding about one hundred grains of extract of belladonna to 
 an ounce of glycerine of starch ; the mixture being spread on 
 moist lint like a plaster. Equal portions of the officinal aconite, 
 belladonna, opium, and soap liniments form a good sedative ap- 
 plication, which may be gently rubbed in for a few minutes twice 
 a day. Other means failing, I have found a bladder of ice kept 
 over the epigastrium as long as it can be comfortably borne, give 
 relief. Such is also the case with the belladonna plaster, though 
 the resin it contains very frequently makes it too irritating to 
 allow of its being worn long enough ; with hot linseed meal 
 poultices sprinkled with tincture of belladonna or laudanum; and 
 with fomentations of a strong decoction of chamomile flowers and 
 poppy capsules. When, with disturbed innervation as the prin- 
 cipal cause of the vomiting, there has also been some slight mor- 
 bid action in the gastric mucous membrane, the constant wearing 
 of a wet compress over the whole of the belly has been very use- 
 ful. And lastly, it may be said that I have not seen any instance 
 where it has seemed advisable to apply cupping-glasses or leeches 
 to the walls of the abdomen; while the practice of venesection is 
 simply mentioned, in order to condemn it. 
 
 Xot only in cases where the cervix uteri has been tender, but 
 in other instances, I have found the use of medicated pessaries 
 give relief after various means had failed; and hence such as the 
 following may safely be tried : 
 
 Take of, — Extrnct of ]>e]lafl(jnna, 25 grains ; Extract of Hemlock, 80 
 grains; Iodide of Lead, 60 grains; Oil of Theobronia, 1 ounce; Olive Oil, 
 2 fluid drachms. Mix, divide into eight pessaries, and order one to be in- 
 troduced into the vagina every night.
 
 388 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 Where patients are verj reduced, or when the nights are rest- 
 less, from twelve to sixteen grains of extract of opium may be 
 substituted for the hemlock in the foregoing prescription. 
 
 Concerning the general treatment it should be recollected, that 
 perfect quiet and the recumbent posture will be indispensable 
 in bad cases. The diet ought to be light and nutritious; and if 
 necessary only very small quantities of liquid food must be given 
 at a time. It is obviously better to administer simply a teaspoon- 
 ful of milk and one of essence of beef alternately every half hour 
 when such are retained, than to give a teacupful and have the 
 whole returned. A little light wine often does good ; and there- 
 fore champagne may be allowed, or moselle, or sparkling carlo- 
 witz, or dry tokay, or claret, or hock, or a glass of sherry in a 
 little soda-water. In slight cases, where the sickness has only 
 occurred in the morning, I have more than once checked it by 
 directing a small cup of strong coffee, without milk or sugar, to 
 be taken about half an hour before rising from bed; this remedy 
 being also especially useful when an opiate has been given over 
 night. Sucking small lumps of ice will be found refreshing, 
 while it often alone serves to allay the irritability of the stom- 
 ach ; the ordinary cherry- water ice of the confectioners acts in a 
 like manner; and the same remark applies to milk and lime- 
 water, in equal proportions, made cold with ice, and given in 
 small quantities everj- three or four hours. Where all kinds of 
 ordinary food are rejected, the patient must be supported by 
 nutrient enemata; a favorite formula of mine consisting of three 
 fluid ounces of a strong solution of minced raw meat, half an 
 ounce of cream, an ounce of claret or two drachms of brandy, 
 and thirty drops of liquid extract of yellow cinchona. Such an 
 enema may be repeated every eight hours; from five to ten 
 minims of liquid extract of opium being added to it, if the rec- 
 tum is irritable. The use of enemata need not necessarily pre- 
 vent our recommending a modification of Liehig's Soup for 
 Invalids; since it will often be tolerated when every other kind 
 of food is rejected. It is thus made: 
 
 Take 1 lb. of newlj-'killcd beef or fowl, chop it fine, add eight fluid ounces 
 of soft or distilled water, four or six drops of pure hydrochloric acid, 30 to (iO 
 grains of common salt, and stir well together. After three hours the whole 
 is to be thrown on a conical hair sieve, and the fluid allowed to pass throush 
 with slight pressure. On the flesh residue in the sieve pour slowly two
 
 NAUSEA AND VOMITING. 389 
 
 ounces of distilled wnter, and let it run through while squeezing the meat. 
 There will be thus obtained about ten fluid ounces of cold juice (cold extract 
 of flesh), of a red color, and possessing a pleasant taste of soup; of which 
 from one tablespoonful to a wineglassful may be taken at pleasure. It must 
 not be warmed (at least, not to a greater extent than can be effected by par- 
 tially filling a bottle with it, and standing this in hot water), since it is 
 rendered muddy by heat or by alcohol, and deposits a thick coagulum of 
 albumen with the coloring matter of blood. If, from any special circum- 
 stance (such as a free secretion of gastric juice), it is deemed undesirable to 
 administer an acid, the soup may be well prepared by merely soaking the 
 minced meat in simple distilled water. When the flavor is thought dis- 
 agreeable it can be concealed by the addition of a little claret. 
 
 Moreover, in extreme cases the inunction of the finest sperm 
 oil, or sometimes of salad oil, or even of pure lard, over the 
 whole of the chest and abdomen once or twice daily does good. 
 The powerful smell of cod-liver oil often alone induces nausea, 
 otherwise it would be usefid. 
 
 Unfortunately, it occasionally happens that all the remedies 
 we cati think of fail to exert any beneficial influence. The pa- 
 tient is seen to grow weaker and more emaciated hour by hour. 
 Not only lias the prolonged want of nourishment to be contended 
 against ; but the mere act of vomiting, after a time, produces a 
 miserable sense of utter prostration. It then only remains — in 
 the tJiird place — to induce abortion ; care being taken not to 
 delay this proceeding too long, since it will in all probability 
 merely hasten death if signs of extreme exhaustion are present. 
 The minute details of the best method to be adopted for procur- 
 ing the expulsion of the foetus need not be given here. It is 
 sufiicient to say that the membranes are to be punctured so as 
 to allow the liquor amnii to drain off" quickly. For as soon as 
 this is done, the sickness will in almost all cases cease; while as 
 the pains of labor seldom set in within less than eighteen or 
 twenty-four hours, so there will be an opportunity for adminis- 
 tering nourishment several times before the patient's modicum 
 of strength is taxed by the occurrence of parturition, and may- 
 be of hemorrhage. It only remains again to express my opinion, 
 that this plan of treatment ought not to be resorted to without a 
 consultation between two or more practitioners. Moreover, the 
 necessity for destroying the product of conception, in order to 
 save the mother's life, should be fairly and fully explained to 
 the husband or relatives before resorting to the necessary steps.
 
 390 SYMPATHETIC DISOKDERS OF PREGNANCY. 
 
 6. Cardialgia. — Many women, especially such as are of a 
 nervous temperament, suffer much from heartburn during preg- 
 nancy, and often to a very distressing degree. Cardialgia may 
 exist alone, or it may be combined with pyrosis — water-brash. 
 To remedy these symptoms, any derangement of the abdominal 
 viscera which may be present must be removed; particular atten- 
 tion being paid to the general mode of living, the amount of 
 daily exercise, and the functions of the skin. Then one of the 
 simple bitter infusions, or bismuth and bicarbonate of soda, or 
 oxide of silver, or small doses of the mineral acids — especially 
 the diluted nitro-hydrochloric — are to be prescribed. Some such 
 form as this will possibly effect a cure : 
 
 Take of, — Diluted Nitro-hydrochloric Acid, 1 fluid drachm ; Diluted 
 Hydrocyanic Acid, 18 uiinims; Infusion of Chiretta, or Compound Infusion 
 of Gentian, to 8 fluid ounces. Mis and label, — •' One-sixth part three times 
 a day." 
 
 Benefit is sometimes derived from restricting the p-atient's 
 drink to lime-water and milk, or to soda-water and milk, or to 
 iced water; alcoholic stimulants of most kinds being unnecessary, 
 while all malt liquors and port wine and raw spirits are very 
 injurious. For food, white fish, mutton, chicken, and stale bread 
 should suflfice; with some digestible ripe fruit in the morning, in 
 the place of vegetables. Digestion can also often be aided with 
 advantage by the administration of pepsine with the two chief 
 meals of the day. 
 
 7. H^MATEiMESis. — A discharge of blood from the stomach, 
 during pregnancy, may occasionally take place without the ex- 
 istence of any appreciable disease of this viscus. Dr. Churchill 
 gays that the causes are probably to be found in a local or gen- 
 eral plethora; and that he has no doubt it is, in many instances, 
 a species of vicarious menstruation.' I have never, however, 
 met with any cases which could lead me to acquiesce in the latter 
 opinion. The entire theory of vicarious menstruation rests on 
 far too fragile a support, to allow of its being unnecessarily 
 strained to explain a simple phenomenon like this. The fact 
 would seem to be, that the gastric mucous coat is apt to get con- 
 gested quite independent of pregnancy. When it does so, one 
 
 1 On the Diseases of Women. Fifth Eiiition, p. 635. Dublin, 1864.
 
 DIARRHCEA. 391 
 
 or more capillary vessels may rupture ; just as happens, under 
 like circumstances, in the pituitary membrane lining the nasal 
 fossae. In this form of hsematemesis the attack is very seldom 
 dangerous, although it alarms the patient. Cold acidulous drinks, 
 ice and iced water, low diet, a large sinapism over the epigastric 
 region, an active purgative enema, a few doses of gallic acid, and 
 rest in bed for a day or two, will usually suffice to stop it. 
 
 8. DiARRHCEA. — Attacks of diarrhoea not uncommonly occur 
 alternately with constipation, or more rarely with morning sick- 
 ness. Some patients suiier habitually from looseness of the 
 bowels daring pregnancy; others are merely affected occasion- 
 ally, owing to indulgence in improper food; whilst a third class 
 appears liable to periodical attacks, setting in perhaps about 
 once a month. When the diari-hoea is allowed to continue un- 
 checked, it not only generally weakens the patient, but per- 
 chance may produce abortion by destroying the life of the foetus ; 
 or when the disorder is attended with tenesmus, it may directly 
 tend to bring on contractions of the uterus. Much more rarely, 
 however, the relaxation appears to do very little or no mischief, 
 but on the contrary seems to have a beneficial influence; since, 
 if attempts are made to check it, the s^^stem immediately resents 
 the uncalled-for interference. The following example, recorded 
 by old Peter Rommelius, proves the correctness of this obser- 
 vation : 
 
 A lady of spare habit and bilious temperament, as well as of a remarkably 
 placid disposition, was always seized with a diarrhoea immediately after con- 
 ception. With unfailing regularity the looseness returned every month 
 during the whole term of pregnancy, being often accompanied by violent 
 gastralgia. The advent of this periodical diarrhoea was always regarded by 
 the patient herself as an indubitable sign of pregnancy. The symptom con- 
 tinued at each period for seven or eight days ; while on each day there were 
 from fourteen to twenty-five copious alvine discharges. Although but little 
 food could be taken, a moderately good state of health was enjoyed. In her 
 first pregnancy medicines were exhibited with the intention of stopping the 
 diarrhoea ; but such unfavorable symptoms were produced, that it was neces- 
 sary to discontinue them. In the absence of pregnancy the catamenia were 
 natural and regular; whilst during the first week after conception there was 
 an abundant leucorrhoeal discharge, which became suspended as the diar- 
 rhoea got established. When the case was reported, the lady was the mother 
 of three healthy children.^ 
 
 ^ Miscellanea Curiosa, sive Ephemeridum Medico-Physicarum Gernianieariim Aca- 
 demic Naturae Curiosoium. Decuiia secuiida. Annus Qiiiiitus. P. 303. Nofiinberg-,*, 
 1687.
 
 392 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 The treatment of the diarrhoea of pregnancy must be cautiously 
 conducted. Of course, when the looseness appears to be in any 
 way beneficial, the practitioner will witlistand all importunities 
 for interference. Supposing, too, that the attack is slight, no 
 remedies beyond attention to the diet will be required ; for a cure 
 may generally be effected by keeping the patient for twenty-four 
 hours to moderate quantities of milk and arrowroot and rice. 
 If the symptoms show — as they not unfrequently do — that some 
 irritating matter is in the intestines, from two to four fluid drachms 
 of tincture of rhubarb, or half an ounce of castor oil, should be 
 ordered. Where the evacuations are offensive and acrid, indi- 
 cating derangement of the secretions, four or five grains of mer- 
 cury and chalk, repeated for three successive nights, will be 
 beneficial; while if the discharges are simply excessive, from five 
 to ten grains of Dover's powder can be combined with the mer- 
 cury and chalk, or we may administer some common astringent 
 mixture containing either logwood, kino, rhatany, tannin, or 
 catechu, &c. It should also be recollected that no agent so 
 speedily arrests the tenesmus and relieves the local pain as the 
 officinal opiate enema, or a suppository consisting of a grain of 
 extract of opium with twenty grains of the oil of theobroma. 
 
 9. Constipation. — This affection is only troublesome when it 
 has been allowed to continue for several days. It is indeed in- 
 credible the length of time that so^iie careless or indolent women 
 will go without an evacuation from tlie bowels ; and I have more 
 than once seen most serious symptoms produced, by the lower 
 part of the colon and rectum having become completely blocked 
 up with hardened fseces, owing to such neglect. 
 
 The symptoms produced by constipation are at first slight, 
 simple headache and general uneasiness being the most promi- 
 nent. Where a considerable accumulation of faeces has taken 
 place, these symptoms are much increased. Under such circum- 
 stances there is more or less fever, loss of appetite, sleeplessness, 
 distressing dreams, bearing-down pains, piles and nausea. If 
 we only question the patient carelessly, the cause of the suffering 
 may readily be overlooked ; since it has hajipened — as I have 
 before explained — that a small quantity of liquid matter escaping 
 by a channel formed through the mass or between the column 
 of hardened faeces and the side of the intestine, and discharojed
 
 CONSTIPATION. 393 
 
 daily, has led to the belief that the bowels were properly open. 
 In such instances a vaginal examination should be instituted, 
 when the rectum will be found distended and pressing into the 
 vagina, so as materially to diminish the calibre of this canal. 
 Among other inconveniences, this condition at the time of labor 
 has formed a positive obstruction to the passage of the child. 
 
 If with obstinate constipation there coexist severe vomiting, 
 then the umbilical and inguinal and crural regions must be care- 
 fully examined lest there be any protrusion of intestine. The 
 occurrence of hernia during pregnancy is not very rare. The 
 natural openings in the abdominal parietes are rendered more 
 and more lax as the walls become distended ; and it can easily 
 be understood how the enlarging uterus, by pressing upon the 
 intestines, facilitates the escape of a portion of the bowel or 
 omentum through either of the weak points. If a hernia be 
 found it should of course be reduced, and a proper truss put on 
 to prevent its descending again ; while if it be irreducible from 
 long standing, it is as well to give it support by a firm bandage 
 carefully applied. When the rupture is strangulated, an opera- 
 tion must be performed in the usual manner to divide the con- 
 striction, so as to permit the contents of the sac to be restored 
 to their normal position. 
 
 For the treatment of simple constipation medicines are seldom 
 necessary. It is generally advisable at all events to first try the 
 eflect of daily exercise, and regularity in soliciting intestinal ac- 
 tion ; together with the eating of brown bread, fresh vegetables, 
 ripe fruits, baked apples, figs, prunes soaked in olive oil, mul- 
 berry juice, marmalade, honey, or tamarinds. Where brown 
 bread is disliked or proves indigestible, the aerated bread will 
 be found more useful than the common household or fermented 
 bread, since it contains a peculiar agent which is absent in the 
 latter. This substance, named cerealin,is found in the external 
 coat of the wheat grain, and is torn away with the bran in the 
 ordinary process of grinding; the miller being careful to prevent 
 any mixture of the outer coat with the flour obtained from the 
 centre of the grain, since he knows that its presence will dimin- 
 ish the white color of the bread after fermentation. The action 
 of cerealin as a special digestive solvent of the conslituents of 
 the flour — gluten and starch — is particularly insisted upon by 
 Dr. Daugiish, who has introduced this new kind of bread ; this
 
 394 SYJI PATHETIC DISORDERS OF PREGNANCY. 
 
 gentleman asserting that its effect upon the gluten of wheat is 
 precisely similar to that of pepsine on the fibrine of meat. Pep- 
 sine acting alone on fibrine dissolves it, but does so very slowly; 
 while if lactic acid be added, solution takes place very rapidly. 
 In like manner the starch present with the gluten of wheat is 
 said to be acted upon by the cerealin, and to produce the neces- 
 sary lactic acid to assist in the solution of the gluten by cerealin. 
 Moreover, another advantage of the new bread is the absence of 
 the prejudicial matters — acetic acid and the yeast plant — im- 
 parted to ordinary bread by the process of fermentation. 
 
 To aid the digestion of animal food, pepsine — the digestive 
 principle of the gastric juice — can be administered ; by means of 
 which dyspepsia, attended with constipation, will often be re- 
 lieved. Sometimes the practitioner may direct the patient to 
 drink half a pint of cold water the last thing at night and again 
 early in the morning, with a good result ; or a glass of Seltzer 
 water had better be taken at night, with a tumblerful of equal 
 parts of milk and soda-water early in the morning. Then, in 
 more obstinate cases, the daily use of soap and water enemata is 
 to be recommended ; or the confection of senna with extract of 
 taraxacum and acid tartrate of potash in equal proportions — in 
 doses of a teaspoonful — twice or three times a week, may be ad- 
 vantageously prescribed. The ofiicinal solution of carbonate of 
 magnesia, in doses of two or three tablespoonfuls before break- 
 fast, is a valuable remedy. If there be much tympanites, a capital 
 carminative cathartic can thus be made : 
 
 Take of, — 3Ianna, 1 ounce ; Oil of Anise, 1 fluid drachm ; Distilled Water, 
 8 fluid ounces ; Carbonate of Magnesia, 220 grains ; Mix and label, — '' One 
 winegjassful every four or six hours, until relief is obtained." 
 
 In the same way one tablespoonful of castor oil, with two 
 drops of oil of peppermint and five or ten minims of tincture 
 of opium, will give relief; or rhubarb and quinine in the fol- 
 lowing manner may be useful if there be dyspepsia with the 
 flatulence : 
 
 Take of, — Tincture of Quinia, Tincture of Rhubarb, of each 1 fluid ounce. 
 Mix. One teaspoonful to be taken in a glass of sherry every day directly 
 after luncheon. 
 
 When, however, any accumulation of fseces has been allowed
 
 ICTERUS GRAVIDARUM. 395 
 
 to take place, active purgatives are absolutely required, and such 
 as this may be ordered : 
 
 Take of, — Purified Ox Bile, 12 grains; Carbonate of Magnesia, 30 grains; 
 Sulphate of Magnesia, 220 grains ; Tincture of Jalap, 2 fluid drachms; Com- 
 pound Tincture of CardainoufS, 4 fluid drachms: Cau)phor Water, to 4 fluid 
 ounces. Mix and hibel, — " Half of this mixture to be taken immediately, 
 and the remainder in three hours if necessary." 
 
 This mixture proving inefficient, enematamust be resorted to. 
 Great advantage often results from injecting from four to eight 
 ounces of warm olive oil into the bowel, and allowing it to be 
 retained for about six hours. By the end of this time it will have 
 softened the hard motion filling the rectum, so that the substance 
 can then be easily brought away by a common aperient enema. 
 Sometimes, however, tlie mass is so very hard and the gut is so 
 completely obstructed by it, that it has to be mechanically re- 
 moved with a scoop or with the handle of a spoon. In all such 
 cases, as a rule, it is a good plan subsequently to order five or 
 ten grains of the inspissated ox-gall to be taken daily for a con- 
 siderable time, to prevent any recurrence of the constipation. 
 Moreover, if there is evidently a want of tone in the colon, a 
 mixture should be given thrice daily of fifteen or twenty minims 
 of the dilute nitric acid in the compound infusion of gentian, or 
 in the decoction of yellow cinchona. 
 
 10. Icterus Gravidarum. — We sometimes see pregnant wo- 
 men, at an advanced period of gestation, suffering from jaundice, 
 for which we can assign no other cause than the weight of the 
 gravid uterus or of the loaded intestine in constipation pressing 
 on the bile ducts, and so impeding the flow of this secretion. It 
 generally passes away without giving rise to any troublesome 
 syniptoms, except when too actively treated. The effects of this 
 form of jaundice being trifling, only mild remedies are required. 
 Attention to the stomach and bowels will perhaps be called for, 
 while a few doses of alterative or aperient medicine will com- 
 monly do no harm. Possibly, relief will be afforded by the pa- 
 tient lying on her left side. Very often, however, the symptoms 
 continue until after delivery. 
 
 In addition to the foregoing, a pregnant woman may accident- 
 ally become the subject of jaundice from some direct impedi-
 
 396 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 ment — as the obstruction of gall-stones — to the flow of bile into 
 the duodenum. Under these circumstances, if powerful reme- 
 dies be ordered abortion will very possibly be induced. Dr. 
 David Davis mentions two examples which corroborate this re- 
 mark : 
 
 One was married, and gave intimation of her being pregnant; the other 
 was not married, an(] concealed her situation. The first was received into 
 the hospital as a subject of tertian ague, for which one of the physicians 
 prescribed bark. But the bark disagreed, and produced vomiting and abor- 
 tion. Ill two days afterwards the whole of the jaundice had disappeared. 
 She had advanced in her pregnancy about five months. The other being an 
 unmarried woman, omitted to mention the fact of her pregnancy. She was 
 treated actively for jaundice by another physician, who gave her emetics. 
 Part of her ovum came away, and was followe(| by a sanguineous discharge. 
 She then confessed that she was pregnant. The emetics were laid aside and 
 innocent placebos were substituted. All her jaundice left her, and in a few 
 days subsequently she was delivered of the remainder of her ovum.^ 
 
 The mere fact that there is some old-standing hepatic affection 
 is no bar to gestation running a natural course, or to its termi- 
 nating at the proper time in a natural labor. Even when there 
 is great hypertro})hy of the liver, this condition ma}^ not inter- 
 fere with the gradual enlargement of the uterus ; although con- 
 siderable distress will be produced by the abdominal distension 
 as the time of parturition draws nigh. This appears to have 
 been the case in an example of pregnancy complicated with great 
 enlargement of the liver, which has been reported by M. Ville- 
 neuve. The chief points in the history are these : 
 
 A lady, thirty-five years of age, was first attacked with inflammatory en- 
 gorgement of the liver and jaundice when twelve years old. The inflammation 
 and icterus disappeared under the use of remedies, but the gland remained 
 of a large size. At the age of thirty, the general health was bad, while the 
 enlargement of the abdomen was such that she presented the appearance of 
 a woman at the full period of gestation. An opportunity was shortly after- 
 wjirds presented to her of contracting an advantageous marriage; and M. 
 Villeneuve with some other physicians was consulted as to the possibility in 
 the first instance, and then as to the probability, of her being delivered safely 
 of a living child, provided she accepted the ofi'er. Unfavorable replies were 
 given to these interrogatories; but nevertheless the lady married, and be- 
 came pregnant. During the latter weeks of gestation she suifered much 
 from the great tension of the abdominal walls, as well as from dyspnoea ; but 
 when labor set in she had an easy time, the child was healthy and well de- 
 veloped, and a quick recovery ensued.'^ 
 
 1 Tlie Principles and Prartine of OhstPtrif Medicine. Vol. ii, p. 872. London, 1 8-36. 
 ^ Journal de Medecine, Cliirnrgie, Pharinacie, &c. Par Corvisart, Leroux, et Boycr. 
 Tome xxix, p. 354. Paris, 1814.
 
 ACUTE ATROPHY OF THE LIVER. 307 
 
 A much more serious class of cases remains for consideration. 
 Acute atrophy of the liver — described by different authors under 
 the names of softening of the liver, diffused hepatitis, or fatal 
 jaundice — is one of the most remarkable diseases to which any 
 gland in the body is liable. ^Vomen are at all times more sub- 
 ject to acute atrophy of the liver than men ; but pregnant females 
 appear especially predisposed to it. Moreover, this rare affection 
 has happened more frequently between the third and seventh 
 months of gestation than at any other periods. 
 
 The manner in which the disease sets in is not uniformly the 
 same. In about half the recorded cases tiiere have been pre- 
 monitory warnings, lasting from a few days to two or three weeks. 
 During this time com[)laint is chiefly made of slight gastric 
 disturbance, sick headache, rheumatic pains, loss of appetite, 
 irregularity of the bowels, and mental with bodily depression. 
 
 The symptoms which directly arise from acute atrophy of the 
 liver are jaundice, sometimes with the formation of petechite and 
 large ecchymoses; and vomiting, at first of the contents of the 
 stomach with mucus, and then of a matter like coffee-grounds. 
 The effects upon the nervous system are manifested at the onset 
 by irritability and great despondency ; but soon there is wander- 
 ing which merges into noisy delirium and convulsions, followed 
 by stupor and deep coma. At the commencement, the pulse is 
 slow; as the cerebral disturbance is manifested, however, it rises 
 in frequency to about 120, becoming slow again as stupor sets 
 in, and getting frequent and small as the fatal termination ap- 
 proaches. The tongue and teeth are coated with black sordes. 
 The abdomen is more or less tender, pains being complained of 
 about the epigastric and right hypochondriac regions. The ex- 
 tent of hepatic dulness rapidly diminishes, while that of the spleen 
 increases, — conditions whicli will scarcely be appreciable if ges- 
 tation be far advanced. There is always obstinate consti[)ation ; 
 hard clay-colored stools coming away under the influence of pur- 
 gatives, with subsequently evacuations which are black from the 
 presence of blood. The urine is natural in quantity, though 
 from an inability to pass it the catheter may be required. On 
 analysis, this secretion is found loaded with bile-pigment, and 
 perhaps is albuminous. A microscopic examination of concen- 
 trated urine will generally detect the presence of tyrosine and 
 leucine ; the former appearing as long needle-shaped crystals and
 
 398 SYMPATHETIC DISOEDEKS OF PREGNANCY. 
 
 small star-like bodies, the latter as finely-marked lamin?e and glob- 
 ular masses with fissured surfaces and concentricallj-thickened 
 walls. More frequently than not, the uterus expels its contents ; 
 profuse uterine hemorrhage sometimes following the deliver}' of 
 the foetus. Then, lastly, the jaundice increases; bed-sores form 
 over the sacrum, if life be prolonged beyond a week or ten days; 
 and there are hemorrhages from the nose, gums, stomach, uterus, 
 bowels, bronchi, &c. 
 
 This disease usually ends fatally within a week from the appear- 
 ance of the acute symptoms ; while sometimes death occurs at 
 the end of eighteen or twenty- four hours. It has been doubted 
 whether recovery ever takes place ; but, however this may be, I 
 know of no reported case in which there has been a favorable 
 termination during pregnancy. The favorite remedies have been 
 the mineral acids, drastic purgatives, quinine, and the free use of 
 ice ; but patients treated with all the skill the physician could ex- 
 ercise, have fared neither better nor worse than those who have 
 been left alone. 
 
 By way of illustrating the preceding remarks, the following 
 case — abbreviated from the report of Prolessor Frerichs — is de- 
 serving of attention : 
 
 P. Nit.schke, aged 24, a carpenter's wife, wns admitted in a semi-conscious 
 state into tlie All-Saints' Hospital, on 21st January, 1858. She was robust 
 and well-nourished, and of a florid complexion. Her friends said she had 
 previous!}' enjoyed uninterrupted good health. She was in the seventh 
 month of pregnancy. It appeared that on the 17th January she complained 
 of loss of appetite, constipation, headache, general malaise, and low spirits. 
 On the '20th she applied to Dr. Hasse, who observed a slight yellow tinge of 
 the face. He directed her to be admitted into one of the wards : this was 
 done on the following day. After seeing Dr. Hasse she had repeated vomit- 
 ing, and became delirious. On admission she was much excited : pulse 80, 
 respirations 20, temperature natural. Conjunctivje of a pale yellow tinge, as 
 was the skin of face and neck. Both hypochondria and the epigastrium were 
 tender on pressure. 
 
 On percussing tiie hepatic region, the dulness in the axillary line amounted 
 only to ll inch. No dulness corresponding to the spleen could be made out. 
 The thoracic organs were natural. Hydrochloric acid was ordered. During 
 the night of the 21st January, there was great restlessness, and she kept 
 uttering loud unmeaning cries. Pulse had risen to 112 : respirations stertor- 
 ous. 2 <J. At 11 A.M , on the 22d, she was delivered of a dead seven months' 
 foetus, which presented no trace of jaundice. There was profuse uterine 
 hcmorrhuge. The excitement abated, and she lay in a quiet unconscious 
 condition. The jaundice was rather more inten,>e than on the previous day. 
 The bowels had been confined for three days. The urine when drawn oft was 
 found life from albumen. The hydrochloric acid was continued; culocynth
 
 DYSPNCEA. 399 
 
 and jalap were also administered. During the night of the 22d the patient 
 lay in a state of deep con)a. Uterine hemorrhage continued. Ether and 
 u)usk were added to the mineral acid mixture On the niorning of the 28d 
 the jaundice appeared increased. Pulse 108; respirations stertorous, 24 ; 
 no elevation of temperature. Von)iting occurred at intervals : bowels con- 
 tinued confined. The urine contained bile-pigment, but not the biliary acids : 
 acicular crystals of tyrosine were detected, with laminae of leucine, in the 
 afternoon, the pulse ruse rapidly to 134 ; the skin became covered with clammy 
 sweat ; and death took place about 7 o'clock. 
 
 At the autopsy, 18 hours after death, tlie skin about the head and chest 
 was seen to be more jaundiced than that of the lower extremities. There 
 was nothing notewori'hy about the brain, lungs, or heart. The stomach was 
 free from ulceration : it contained a matter like coffee-grounds. The large 
 intestine contained scybala faintly tinged with bile. The liver lay collapsed 
 against the posterior wall of the abdominal cavity : it was dry and soft, while 
 its capsule was puckered and opaque. The dimensions of the gland were di- 
 minished in every direction, particularly in thickness. The gall-bladder con- 
 tained a small quantity of gray mucus. The tissue of the liver felt flabby 
 and dry : the ramifications of the portal vein surrounding the lobules were 
 distended, whilst the centre of the lobules presented a citron-yellow color; 
 here and there were ecchymoses. The secreting cells were disintegrated, 
 numerous drops of oil and brownish-yellow molecules being found in their 
 place ; only a few isolated cells loaded with oil being detected in the rounded 
 border of the right lobe. The weight of the liver was 1.807 lbs. avoir., and 
 that of the entire body 123 898 lbs., making the ratio of the former to the 
 latter as 1 to 68. 5. In healthy females of the same age and weight, the 
 weight of the liver is about 4.409 lbs., and the ratio is as 1 to 28. Thus the 
 organ had lost in six days 2.601 lbs. in weight. It was also considerably 
 diminished in size. The blood in the heart and in the venje cavas contained 
 a small amount of leucine, while larger quantities were found in the cerebral 
 substance, the liver and the spleen. The presence of a considerable amuunt 
 of tyrosine in the liver was made out, while in the spleen none could be de- 
 tected with positive certainty,^ 
 
 Section 2. — Disorders of the Organs of Respiration and 
 
 Circulation. 
 
 1. Dyspn(ea. — Pregnant women sometimes suffer from diffi- 
 culty of breathing during the latter weeks of gestation; and oc- 
 casionally from hysterical dyspnoea in the early months. With 
 regard to the first variety, as it depends on the enlarged uterus 
 pushing up the diaphragm and thus diminishing the capacity of 
 the thorax, but little can be done for its relief beyond propping 
 the patient up in bed, regulating the diet in order to prevent 
 
 1 A Clinical Treatise on Diseases of the Liver. By Dr. F. T. Frerichs, Professor cf 
 Clinical ^letlicine in the University of Berlin. Vol. i, p. 202. Translated by Dr. Mur- 
 chi^on for the New Sydenliain Society. London, 186U.
 
 400 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 flatulent distension of the intestines, keeping the howels properly 
 open, and directing that no tight clothing be worn. The second 
 form of djspncea will be best cured by antispasmodics and diffu- 
 sible stimulants, such as spirit of ether, compound tincture of 
 chloroform, tincture of Indian hemp, camphor, sumbul, assa- 
 foetida, valerian, &c. 
 
 2. Cough. — During the early months of gestation, a nervous 
 or spasmodic cough frequently aftects delicate or suscejitible 
 females. The attacks come on in violent paioxysms, especially 
 at night ; occasioning much distress, preventing sleep, and ren- 
 dering the sufferer anxious and fretful. There is no mucous or 
 purulent expectoration. This cough generally depends on the 
 sympathetic influence exerted by the uterus on the pulmonary 
 organs ; or it may result, at a later period, from the impediment 
 which the progressive growth of the uterus b}" its pressure on the 
 diaphragm and aorta otiers to respiration and circulation. It is 
 at once distinguished from the cough due to organic disease by 
 the absence of expectoration, fever, quickened pulse, and of all 
 stethoscopic signs. "When allowed to go on unchecked, the re- 
 peated shocks will possibly loosen the connection of the placenta 
 with the uterus, and so produce abortion. And even supposing 
 this not to happen, yet the loss of rest, the uneasiness and sense 
 of weariness, with the headache produced hj the fits of coughing, 
 give rise to such general disturbance of the system, that very se- 
 rious mischief may in the end result. M. Aliquel asserts that the 
 epidemic cough of 1675 so powerfully affected pregnant females, 
 that most of those who were attacked by it died.* In the treat- 
 ment of these cases I have found no remedies so useful as anti- 
 spasmodics combined with morphia or opium. Such a mixture 
 as the following often gives great relief: 
 
 Take of, — Spirit of Ether, 3 fluid drachms; Compound Tincture of Chlo- 
 rofunn, 1 fluid drachm; Diluted H}drocjanic Acid, 1.5 minims; Solution of 
 Hydrochlorate of Morphia, 1 fluid drachm ; Compound Tincture of Carda- 
 moms, 6 fluid drachms; Water, to 8 fluid ounces. Mix and label, — "One- 
 sixth part everjf six or eight hours." 
 
 The ofiicinal morphia, or morphia and ipecacuanha, lozenges, 
 can also be recommended. Or an agreeable tincture may be 
 
 1 Tiaite des Convulsions chez les Femmes Enceintes, en Travail, et en Couche, p. 67. 
 Paris, 1H24:.
 
 PALPITATION OF THE HEART. 401 
 
 made with a few drops of the solution of hydrochlorate of mor- 
 phia, and equal parts of sjrup of squill and syrup of tolu. 
 Where the paroxysms are infrequent, they can soniethiies be 
 checked by a draught made thus : 
 
 Take of, — Ammoniated Tincture of Valerian, 30 minims; Tincture of 
 Sumbul, 20 rainiras^; Tincture of Helladonna, 10 minims ; Compound Tinc- 
 ture of Camphor, 30 minims ; Camphor Water, to 12 fluid drachms. Mix 
 for a draught. To be taken immediately a fit of coughing is threatened. 
 
 In the use of these narcotic remedies care must be taken not 
 to allow them to produce prolonged constipation. The doses of 
 the sedatives must also be so regulated as not to induce nausea 
 subsequently. Where the stomach is at all irritable, a cup of 
 strong coftee early in the morning will frequently prevent sick- 
 ness. 
 
 According to some authorities antiphlogistic measures, such as 
 venesection, blisters, croton oil liniments, and tartar emetic, are 
 sometimes required ; but I have always been very loth to try 
 them in the cases which have come under my notice. 
 
 3. HEMOPTYSIS. — Spitting of blood from the rupture of some 
 small artery distributed to the lungs is very rare during preg- 
 nancy, unless the hemorrhage be due to the presence of formid- 
 able organic disease. 
 
 In all cases, a very careful examination of the lungs and heart 
 and large vessels should be made. Mistakes in diagnosis are 
 ^ot very uncommon, a slight deposit of tubercle being often 
 overlooked. I have heard of a lady being assured that the blood 
 which she expectorated was merely a secretion from the mucous 
 membrane of the bronchial tubes ; when in fact she had a small 
 cavity at the apex of one of her lungs. Should the practice of 
 auscultation prove the existence of any organic disease, such 
 special remedies as the nature of the affection may demand must 
 be had recourse to. Where no cause for the bleeding can be de- 
 tected, the recurrence of the latter will in all probability be pre- 
 vented by a few doses of gallic acid, or of the ammonia iron 
 alum. 
 
 4. Palpitation of the Heart. — The increased activity of the 
 circulation during pregnancy, together with the altered compo- 
 sition of the blood, renders most women liable at one period or 
 
 26
 
 402 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 another of gestation to attacks of palpitation of the heart. These 
 attacks are of variable severity. They are quite independent of 
 any organic disease of the heart ; nervous and feeble females suf- 
 fering more than the strong and healthy. When the palpitation 
 occurs in the earlier months, it is said to be due to sympathy 
 with the uterine organs ; when in the latter, either to the pressure 
 of the womb on the abdominal vessels causing a reflux of the 
 blood to the superior parts of the body, or to displacement of the 
 heart and pericardium owing to the pushing upwards of the 
 stomach, diaphragm, &c. Where the palpitations are violent, all 
 the large arteries of the body seem likewise to pulsate exces- 
 sively : the respirations also become hurried, there is noise in the 
 ears, indigestion, headache, and giddiness. 
 
 The physician who has once well observed a case of cardiac 
 hypertrophy, can hardly mistake nervous palpitations for this 
 affection. In the cases we are considering there is none of the 
 lividity of the cheeks and lips so commonly seen in hypertrophy; 
 and the patient, instead of being listless or sluggish, is generally 
 full of life and spirits. Where the pressure of the gravid uterus 
 is the cause of the palpitations, taking food increases them. 
 Moreover, exercise diminishes them very often ; while in hj^per- 
 trophy it increases them. So also the increased impulse of the 
 h^'pertrophied heart contrasts strongly with the sharp, short 
 beat of nervous pulsation. 
 
 The treatment of these cases requires some little caution. 
 Generally speaking, antispasmodics with opiates and rest will 
 sooner give relief during a paroxysm of palpitation than any 
 other remedies ; while a permanent cure may afterwards be 
 effected by the careful use of ferruginous tonics, by allowing a 
 nutritious but unstimulating diet, and by daily gentle exercise 
 in the open air. In those cases where there is plethora and a 
 tendency to internal congestions, a spare diet with mild purga- 
 tives will be needed; depletion in any more active form being 
 usually very injurious. There are possibly a few exceptional cases 
 where the application of leeches is required ; but I do not think 
 such will be met with amongst the inhabitants of large towns. 
 
 5. Fainting. — Some women constantly faint at the period of 
 quickening ; but they are usually in delicateiiealth, and perhaps 
 have been weakened by the continuance of morning sickness.
 
 FAINTING. 403 
 
 Hysterical females, and such as are in the habit of tiiinting from 
 slight mental or corporeal excitement, are also particularly likely 
 to sutler during pregnancy. 
 
 The sensations which precede an attack of syncope are usually 
 distressing; though Chamberet and ihe celebrated Montaigne 
 have stated from their own experience that they are highly 
 pleasurable. During the swoon the surface of the body is cold 
 and pale ; the pulse at the wrist becomes weak, so as often 
 scarcely to be detected ; the power of voluntary motion is 
 abolished ; consciousness is impaired, if not lost ; and the re- 
 spiratory actions are nearly suppressed. On practising ausculta- 
 tion, the heart will be heard beating much more feebly than is 
 natural. In some instances there is relaxation of the sphincters, 
 and a discharge of the excretions. Repeated fits of syncope have 
 produced abortion. The duration of the seizure varies from a 
 few seconds to ten or fifteen minutes, or even longer. As the 
 patient gradually recovers, nausea and vomiting, or palpitations 
 of the heart, or attacks of hysteria, often set in. Prolonged 
 syncope has occasionally ended in dissolution. John Burns 
 says : " There is a species of syncope that I have oftener than 
 once found to prove fatal in the early stage of pregnancy, which 
 is dependent, I apprehend, on organic affections of the heart, 
 that viscus being enlarged, or otherwise diseased, though per- 
 haps so slightly as not previously to give rise to any trouble- 
 some, far less any pathognomonic symptoms. Although I have 
 met with this fatal termination most frequently in the early 
 stage, I have also seen it take place so late as the sixth month 
 of pregnancy."^ 
 
 That fits of syncope should not very uncommonly occur at 
 advanced stages of gestation might be expected ; for we know 
 that then especially the corpuscles of the blood are diminished 
 in amount, the albumen is decreased, the proportion of iron is 
 below the average, while the water is increased. These are 
 precisely the characteristic features of chlorosis and ansemia. 
 Moreover, why in pregnancy the proportion of fibrine in the 
 blood should be almost ahvays above the physiological average 
 can only be explained on the hypothesis, very generally enter- 
 tained by ('hemists at the present time, that this constituent is 
 
 1 Tlie Principles of ilidvvifery. Fourtli Edition, p. 174. London, 1817.
 
 404 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 formed at the expense of the alhumen, the marked diminution 
 of the latter being consequently the cause of the increase of the 
 former. Now, the correctness of the arguments which may be 
 drawn from the results of chemical analysis is borne out by the 
 symptoms which are so often complained of by pregnant women ; 
 for they are identical with those experienced in chlorosis. In 
 both there is the same bodily and mental depression, and a cor- 
 responding liability to palpitations ; the cerebral symptoms are 
 similar; there are the like sudden flushings of the face, and 
 attacks of chilliness alternating with increased heat; and there is 
 the same dyspepsia, loss of appetite, and tendency to neuralgia. 
 Andral has long ago shown tliat either too great or too small an 
 amount of corpuscles deranges certain- functions of the brain in 
 the same manner; and hence so many of the symptoms of anaemia 
 have often been mistaken for indications of plethora. 
 
 During an attack of syncope no treatment can be better than 
 that usually practised ; such as the admission of fresh cool air, 
 sprinkling the head and face with cold water, tlie recumbent 
 posture, the removal of all tight articles of clothing, the cautious 
 application of ammonia to the nose, and perhaps the use of sina- 
 pisms to the epigastrium. Subsequently, tonics and a chiefly 
 animal diet may prevent the recurrence of an attack. Even when 
 there is disease of the heart, great good can often be done by the 
 careful exhibition of mild preparations of steel. 
 
 6. Enlargement of the Thykoid Gland.— A few cases have 
 fallen under my notice in which delicate women, liable to attacks 
 of palpitation of the heart, have suffered from an enlargement 
 of the thyroid gland during pregnancy. In these instances the 
 patients have been living in their customary manner and in lo- 
 calities where they have long resided ; so that none of the usual 
 conditions which lead to the production of goitre have been dis- 
 coverable. The only change has been that they have become 
 pregnant. Sometimes, the gland has been slightly enlarged prior 
 to pregnancy ; and then the occurrence of the latter has appeared 
 to serve as a stimulus, making the hypertrophy progress at a 
 rapid rate. 
 
 The thyroid body is one of those ductless glands >nth the use 
 of which we can hardly be said to be acquainted. I": has been 
 demonstrated by Mr. John Simon, that this body, or an organ
 
 ENLARGEMENT OF THE THYROID. 405 
 
 representing its place and office, may be found in all the verte- 
 brata. And it is this gentleman's opinion, that " although the 
 gland shifts its position most variously, yet it always maintains 
 an intimate relation to the vascular supply of the brain ; being so 
 nourislied that it can alternate a greater or less nutrition, accord- 
 ing to the activity or repose of that nervous centre."' The weight 
 of the gland, in the human subject, varies from one to two ounces. 
 It is generally larger in females than males, and it often appears 
 to swell slightly during menstruation. In the cases of goitre, in 
 women, which have fallen under m}^ notice, the right lobe has 
 been more frequently enlarged than the left. 
 
 During the year 1860, Professor Natal is Guillot read a paper 
 before the Socidte Medicale des Hopitaux, in which he stated 
 that every year he was in the habit of seeing women with enlarge- 
 ment of the thyroid body coming on during pregnancy. The 
 affection, he says, is not usually dangerous, but he relates two 
 instances in which death occurred. The principal points in these 
 interesting cases are as follows : 
 
 In the fir>it instance, a lady, 30 years of age, of good constitution, found 
 her neck slowly increasing during her first pregnancy. In her second preg- 
 nancy, in 1855, the tumor increased again and became ti'oublesonie. After 
 suckling had ceased and the menses had returned regularly, the swelling con- 
 tinued to get larger; giving rise to much pain, facial neuralgia, palpitations, 
 vertigo, and suffocative asthmatic paroxysms. In 1858, there was consider- 
 able weakness: on compressing the enlarged thyroid respiration became em- 
 barrassed. A few days after this examination, the patient was nearly asphyx- 
 iated during an attack of dyspnoea ; laryngotomy was performed with imme- 
 diate relief Death occurred, however, two days afterwards. 
 
 The second example was that of a woman, about 29 years of age, who, after 
 her first pregnancy, four years previou.sly, complained of an enlargement of 
 the neck. She paid but little attention to it, however, until after her second 
 labor, nineteen months back. When this young woman entered the hospital 
 Necker, no other disease beyond the enlargement of the thyroid could be de- 
 tected. This gland had then become very voluminous, extending from the 
 thyroid cartilage to the sternum. The respiration and voice were embarrassed; 
 she was liable to suffocative paroxysms. She stated that these phenomena 
 had come on gradually from the time of her first pregnancy, increasing es- 
 pecially during the second. After remaining in hospital for a week, the 
 paroxysms of dyspnoea became more and more severe, until at last one seizure 
 ended fatally. An examination subsequently revealed no other lesion than 
 the enlargement of the thyroid, this body being nearly the size of the human 
 brain. The mass was divided' i«to three lobes, but the central lobe was over- 
 lapped and hidden by the larger lateral portions. Posteriorly, the trachea 
 
 1 Philosophica] Transactions of tlie Rnv-^^, Snp.jptv. Vol. cxxxiv, p. 302. London, 
 1844.
 
 406 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 was seen considerably flattened. At the sides of the neck, the two carotid 
 arteries and the pneumogastrie nerves were evidently compressed ajrainst the 
 transverse processes of the vertebrae by the weight of the lateral lobes. The 
 tissue of the gland was healthy in appearance ; but its fibrous framework 
 was greatly hypertrophied, forming large and thick and numerous partitions, 
 while the vesicles or cellules were considerably increased in size. Hence 
 the lesion consisted of an hypertrophy of the fibrous and granular elements 
 forming the thyroid ; which hypertrophy Professor Guillot regards as only 
 one of the manifestations of the excessive production of fibrine during preg- 
 nancy. To this is in great part due the progressive development of the uterus 
 and mammary glands ^ 
 
 Professor C. Hecker, while discussing the reactions between 
 disease and the reproductive processes, relates the history of a 
 patient who had a considerable swelling of the thyroid, impeding 
 respiration. In her fifth pregnancy the enlargement rapidly in-* 
 creased; while oedema of the legs and abdomen, with albumi- 
 nuria, set in. When the time for delivery had nearly arrived, 
 she suddenly complained of dizziness of sight; this being fol- 
 lowed by dyspnoea and death. Seven minutes afterwards the 
 Csesarean section was performed, and a stillborn child removed; 
 which could not be resuscitated, though its heart beat slightly.^ 
 
 The cases of goitre, occurring during pregnancy, which have 
 occurred in my own practice have seldom been attended with 
 alarming symptoms. In the following instance, however, a fatal 
 result ensued : 
 
 On the 20th November, 1863, I delivered a lady, 27 years of age, of her 
 second child. The labor was easy and natural : the gestation had only ad- 
 vanced to the seventh and a half month. The infant died at the end of 
 fourteen hours. In a few days my attention was directed to a swelling in 
 the neck, of which these particulars were giv^en : The patient was always 
 strong until her marriage, and there was nothing wrong with her neck, nor 
 had there ever been any strumous enlargements of the cervical glands. 
 While pregnant with her first child, she found that the neck became en- 
 larged, but little notice was taken of it as there was no pain or inconvenience. 
 The child when born seemed feeble, but she suckled him for six weeks, when 
 he died. During the suckling the swelling increased. Three weeks subse- 
 quently to the enforced weaning she a^ain became pregnant. She had ad- 
 vice for the enlargement, and was told it was an ordinary goitre which could 
 not be cured. During this second pregnancy the thyroid gland increased 
 still more, and at times she experienced slight attacks of difficult breathing, 
 but this was generally on making more than ordinary exertion. When I 
 exan)ined the gland, each lobe was found much hypertrophied, being four 
 inches in length and three in breadth. After the mammary glands had 
 
 1 Archives Generales de M^decine, p. 513. Paris, Novemlire, ISfiO. 
 
 2 A Bi(!nnial Retrospect of Medicine, Surgery, &c., for 1865-66, p. .39 1. New Syden- 
 ham Society: London, 1867.
 
 MORBID CONDITIONS OF THE SPLEEN. 407 
 
 become quiescent at the end of November, 1863, she was ordered steel and cod- 
 liver oil, with a very nourishing diet. Under the influence of this treat- 
 ment the general health appeared somewhat to improve; but the enlarge- 
 ment of the thyroid did not diminish. 
 
 In the February of 1864 she went to Ramsgate, and for a time I lost sight 
 of her. On the 5th September, a few weeks after her return to the neigh- 
 borhood of London, I was again requested to see her She was then between 
 two and three months gone with child. Her condition was distressing; 
 while she more particularly complained of great exhaustion, frequent attacks 
 of spasmodic dyspnoea, complete loss of appetite, nausea, palpitation, and diar- 
 rhoea, alternating with constipation. The urine was scanty, high-colored, 
 and albuminous. There was marked exophthalmia, both eyes being equally 
 prominent. The thyroid body measured six inches in length, and nearly as 
 much in breadth. The lower extremities were oedeniatous; and there was 
 considerable enlargement of the spleen, with some ascitic fluid in the perito- 
 neum. Two or three drops of blood, taken from a prick in the finger, showed 
 a large excess of colorless corpuscles when submitted to a microscopic exami- 
 nation. It was clear that nothing could be expected from treatment, beyond 
 an amelioration of suff'ering. Her weakness steadily increased, and death 
 occurred from exhaustion in the early part of December. Permission to 
 make a post-mortem examination could not be obtained. 
 
 7. Morbid Conditions of the Spleen. — Seeing that the color- 
 less corpuscles of the blood are increased during pregnancy, and 
 remembering that in the disease known as leucocythemia the 
 spleen is often considerably enlarged, it is rather surprising that 
 splenic hypertrophy is not much more frequently met with during 
 gestation than it really is. Every now and then, however, a case 
 comes under observation where this gland undergoes enlarge- 
 ment to a great degree; the increase in size being accompanied 
 by a certain amount of softening. Sometimes, the enlargement 
 disappears alter delivery; possibly to return again and again in 
 subsequent pregnancies. But in a few unfortunate cases the 
 capsule of the gland has ruptured, either in consequence of a fall 
 or blo\v, or under the influence of some unusual or sudden mus- 
 cular effort; the laceration being followed by a fatal effusion of 
 blood into the cavity of the peritoneum. It is not unlikely that 
 cases of this severe description are more common in India than 
 in temperate countries : here they are certainly very rarely seen. 
 
 A pregnant woman, with a spleen appreciably enlarged, has a 
 peculiar look which at once attracts the physician's attention. 
 It is not exactly the appearance presented by a patient with ma- 
 lignant disease, and yet probably the first question which sug- 
 gests itself to the observer is, — Has this person cancer? The 
 complexion is sallow and unhealthy, there is a dingy discolora-
 
 408 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 tion of the conjunctivae, while the gums and inner surface of the 
 lips are ansemic. The features are also somewhat pinched, the 
 nose especially being sharp. The hair is thin, and comes away 
 daily on being brushed. The appetite is generally indifferent, 
 and the function of digestion is imperfectly performed. Mental 
 depression is present. There is a liability to liemorrhage from 
 the nose, gums, throat, and stomach ; while if the patient suffer 
 from hemorrhoids they are particularly apt to bleed with every 
 attempt at passing a stool. When the blood is greatly altered 
 from its natural condition, anpemic murmurs will be audible in 
 the heart and large vessels. But abnormal prsecordial dulness, 
 with a loud cardiac bruit, may likewise arise from the enlarged 
 spleen and uterus displacing the heart u^pwards, and preventing 
 the free descent of the diaphragm and full expansion of the left 
 lung. 
 
 The practical hints which I can give as to the management of 
 these cases are few. It is hardly necessary to say that all lower- 
 ing measures are to be avoided. But it is as well to remember 
 that in every variety of splenic disease there is a tendency to 
 hemorrhage ; and consequently great mischief may ensue from 
 the application of only a few leeches, or from the extraction of a 
 tooth. lu the event of abortion, moreover, extra precautions 
 will be needed to prevent flooding. With regard to drugs, none 
 but those belonging to the class of tonics are generally required. 
 Occasionally, a dose of ether and opium at night may relieve 
 painful restlessness. A pill containing some pepsine and rhubarb 
 at dinner, will possibly assist digestion. But bark, or quinine, 
 always proves serviceable; the dilute nitro-hydrochloric acid is 
 grateful to the stomach, and also acts as a haemostatic ; cod-liver 
 oil is invaluable where the stomach will tolerate it; while the 
 cautious employment of some preparation of steel will often be 
 attended with the best results, especially if plenty of nourishing 
 food can be taken simultaneously. 
 
 8. Varices. Hemorrhoids. — A varicose condition of the 
 veins of the lower extremities is a very common occurrence in 
 multiparse towards the latter part of gestation. Altliough rarely 
 attended with danger, yet if the coats of the vessels become 
 inflamed a very distressing and even formidal)le disease may be 
 induced. These varices seldom appear in first pregnancies; but
 
 VARICES AND HEMORRHOIDS. 409 
 
 generally perhaps commence during the second gestation, get 
 worse in the third, and so on until they cause very great annoy- 
 ance and even anxiety for fear of rupture. On examination, the 
 knotted dilated veins are often found of an incredible size; while 
 sometimes the whole network of superficial veins seems to be 
 involved, especially those below the knee. A transverse position 
 of the foetus in utero may, by causing great pressure at the pelvic 
 brim and so obstructing the returning current of blood, give rise 
 to aggravated varices even in primiparous women. The cause 
 being mechanical — i. e., the pressure of the enlarged uterus — a 
 cure during pregnancy cannot be hoped for; while, as a rule, 
 any operation would be improper. Relief may, however, be given 
 by properly bandaging the affected limb, or by the use of a well- 
 made elastic stocking. The latter will especially be serviceable, 
 provided its employment be commenced at an early period of the 
 affection. Rest in tlie recumbent posture may also be enjoined 
 in severe cases ; and in all instances the patients should be cau- 
 tioned against increasing the affection by the use of stays and 
 garters, a simple suggestion which is generally neglected. More- 
 over, where there appears to be the least fear of a rupture of the 
 coats of the vessel, it is advisable to explain to the woman and 
 her friends how, in the event of its occurrence, pressure is to be 
 applied below the wound; so that by this means the bleeding 
 may be controlled until skilled assistance can be obtained. 
 
 A varicose condition of the vaginal veins is not unfrequently 
 met with. If any one of these enlarged vessels should happen 
 to give way, either spontaneously or from injury, a large quan- 
 tity of blood gets eflused into the connective and adipose tissues 
 of the vulva ; so that a considerable swelling rapidly forms, which 
 is spoken of as a sanguineous tumor or thrombus. This tume- 
 faction takes place much more frequently in the latter than in the 
 earlier months of gestation ; and still more commonly occurs 
 during delivery, perhaps just as the head is about to pass. The 
 accident is commonly announced by the sudden occurrence of 
 great pain, rapid distension of the affected labium, and possibly 
 syncope. The prognosis is unfavorable. M. Deneux states that 
 of sixty-two instances brought to his knowledge, the mothers 
 died in twenty-two, either before the end of gestation, or else 
 during or after delivery ; while all the infants of these tAventy- 
 two women likewise perished. Death is either caused by the
 
 410 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 hemorrhage being profuse ; or more rarely by the suppuration 
 and gangrene which are not unlikely to follow the primary 
 symptoms. 
 
 When the thrombus appears prior to the time of labor, and 
 when the tumor is not larger, for example, than an egg, and is 
 not increasing in size, it may reasonably be hoped that a coagulum 
 has formed and that the hemorrhage is thereby arrested. Hence 
 it will be better to trust to an expectant plan of treatment, in the 
 hope that absorption may ocjcyr ; although where the practitioner 
 has faith in such things, he can unobjeetionably apply cold evap- 
 orating lotions. But if the effusion be great, and the blood be 
 still pouring out of the ruptured vessel, the tumor ought to be 
 at once incised. In one case which canre under my notice I was 
 led to adopt this practice, because the blood was evidently mak- 
 ing its way upwards, and the patient's condition warned me that 
 any delay would be attended with extreme danger. After making 
 a free incision externally through the integuments, and turning 
 out a large clot, I pushed in a sponge thoroughly moistened with 
 a solution of the perchloride of iron. All bleeding was arrested, 
 and the patient did well ; being afterwards safely delivered of a 
 live child. 
 
 Hemorrhoids or piles, like varices, arise during pregnancy 
 from the pressure of the womb on the hypogastric vessels; or 
 they originate from prolonged constipation resulting in fecal 
 tumor; or, in short, they are caused by any condition which im- 
 pedes the natural return of the blood from the numerous vessels 
 of the rectum. The symptoms produced both by external and in- 
 ternal hemorrhoids are too well known to need description here. 
 SufHce it therefore to say that when small they usually cause 
 slight uneasiness or j^ain, some itching with irritation, and oc- 
 casionally a little bleeding after an evacuation of the bowels ; the 
 loss of blood more frequently proving beneficial than otherwise. 
 "When, however, the piles are large and inflamed they produce 
 the most excruciating suflering and high sympathetic fever. 
 
 The indications for treatment are in all cases to keep the bowels 
 moderately open ; for which purpose, under the circumstances we 
 are considering, castor oil will be found a more efficient laxative 
 than any other medicine. If this aperient be very objectionable 
 to the patient, a confection made of equal parts of sulphur, acid 
 tartrate of potash, and juice of taraxacum may be substituted;
 
 CEPHALALGIA. 411 
 
 or the officinal confection of sulphur can be tried. Small ene- 
 mata of tepid water are also occasionally useful. Where there is 
 any hepatic derangement, or where engorgement of the portal 
 system is suspected, the chloride of ammonium, in ten-grain 
 doses thrice daily, can be recommended. To simple piles as- 
 tringent lotions should be applied, or the ointment of galls and 
 opium can be used ; while the fundament ought to be thoroughly 
 sponged with cold water after every stool. If, however, the 
 tumor be inflamed, it may be necessary to put one or two leeches 
 to it ; to sedulously foment the parts with a very hot and strong 
 solution of poppy capsules and chamomile flowers ; to enjoin per- 
 fect rest in the recumbent posture ; and to relieve the urgent dis- 
 tress by the internal administration of opium, after the rectum 
 has been thoroughly emptied by an enema of castor oil. Sup- 
 posing that an internal pile has been forced down and become 
 strangulated, it should be well bathed with hot water and care- 
 fully returned ; while if there be any difficulty in accomplishing 
 the latter, the swelling ought to be punctured or scarified. Oc- 
 casionally an external pile is found inflamed and distended by a 
 congulum. In this case a small incision, so as to let out the 
 little clot in its delicate cyst, will afford immediate relief At- 
 tempts at the radical cure of hemorrhoids during pregnancy 
 should not be made. For it is most likely that after delivery a 
 spontaneous cure will take place ; while if this should not happen, 
 the operation with the ligature will certainly be more successful 
 when the pressure of the gravid uterus on the abdominal vessels 
 is removed, than it can possibly be as long as the circulation is 
 impeded by this body. 
 
 Section 3. — Disordeks of the Nervous System. 
 
 1. Cephalalgia. — Pregnant women of all temperaments and 
 constitutions are liable to attacks of severe pain in the head, at- 
 tended with intolerance of noise and incapacity for exertion. 
 These symptoms, if not dangerous, are at all events so distressing, 
 that the aid of medicine is often sought for their relief. 
 
 The two chief varieties of cephalalgia are those dependent on 
 debility, and those simply caused by sympathy with the changes 
 going on in the uterine system. But of course it must not be 
 forgotten, that as in the non-pregnant female so in the pregnant,
 
 412 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 the headache may be due to general plethora and congestion ; or, 
 to inflammatory action in the brain or its membranes ; or, to 
 some organic change in the intercranial mass ; or, to disease of 
 the bones of the skull ; or, to the presence of an active poison in 
 the system, as that of gout, rheumatism, ague, &c. ; or, lastly, to 
 some disorder of the stomach, liver, or bowels. 
 
 The headache dependent on debility is either constant, or it 
 comes on in irregular paroxysms. It is more frequently of a 
 dull aching character, than acute and throbbing ; while it is ac- 
 companied by intolerance of sound and perhaps of light. There 
 may be drowsiness and giddiness. The skin is cool, and the 
 pulse small and feeble. The eyes are dull ; while the face is [)ale, 
 and does not become flushed as in the eongestive varieties. In 
 nervous wom.en the pain is sometimes confined to one side of 
 the head — hemicrania ; in which case it is usually most severe in 
 the morning, often ceasing entirely as the evening approaches. 
 The treatment of these cases is sufliciently simple. The due 
 regulation of the digestive organs, a mild nourishing diet, gentle 
 exercise in the open air, cheerful society, and the exhibition of 
 mild tonics — occasionally of quinine and iron in small doses — 
 always sufiices to efl[ect a cure. When the vital powers are much 
 exhausted, the frequent administration of wdne or any of the 
 diffusible stimulants will do great good. 
 
 The sympathetic headache — clavus hystericus — is generally 
 limited to a small space, or even to a single spot on the cranium ; 
 the pain being described as resembling that of a wedge pressing 
 into the brain. When prescribing for this form, care must be 
 taken that the bowels are properly open. If purgatives are re- 
 quired, enemata of castor oil and turpentine and assafoetida and 
 gruel will be found very efiicacious. Then tonics, diff"usible 
 stimulants, or anodynes may be ordered. The extract of aconite 
 in doses of about half a grain every four or six hours, sometimes 
 gives more relief than other remedies. Cold evaporating lotions 
 or eau de Cologne applied to the painful part, at least aflbrd tem- 
 porary relief. 
 
 2. Sleeplessness. — The problem, — Wliat is sleep ? still re- 
 mains to be solved by some future (Edipus; physiologists and 
 poets having as yet equally failed to define the exact nature and 
 cause of that condition in which more than one-third of human
 
 SLEEPLESSNESS. 413 
 
 existence is consumed. "Half our days we pass in the shadow 
 of the earth, and the brother of death extracteth a third part of 
 our lives," says Sir Thomas Browne ; and yet we really know 
 but little of the complex and ever varying states of that which 
 brings such indispensable comfort and renovation to both mind 
 and body. Ilonest Sancho Panza, with his strings of misapplied 
 proverbs, never spoke more to the purpose than when he said, — 
 " But well I know, that while I sleep, I am troubled neither with 
 fear, nor hope, nor toil, nor glory ; and praise be to Him who 
 invented sleep, which is the mantle that shrouds all human 
 thoughts; the food that dispels hunger; the drink that quenches 
 thirst; the fire that warms the cold; the cool breeze that mod- 
 erates heat ; in a word, the general coin that purchases every 
 commodity ; the weight and balance that makes the shepherd 
 even with his sovereign, and the simple with the sage."' In 
 contrast with this vulgar description, it may be worth while to 
 quote a scientific definition by Dr. J. J. G. Wilkinson. Mr. 
 Braid says that it is interef<ting, as well as elegantly/ and lucidly/ ex- 
 pressed ; but it seems to me to have the one trifling fault of being 
 perfectly unintelligible. The doctor sa3^s, — " The atom of sleep 
 is difiusion ; the mind and body are dissolved in unconscious- 
 ness ; they go off into nothing, through the fine powder of in- 
 finite variety, and die of no attention ; common sleep is imper- 
 sonal."=^ 
 
 Whatever the nature of sleep may be, however, we are only 
 now concerned with the causes which prevent, and the means 
 which may be adopted to favor or produce it. Sleeplessness is 
 often particularly distressing to pregnant women, and when ob- 
 stinate or continued for any length of time leads to serious con- 
 stitutional disturbance. This circumstance is not surprising 
 when the misery of a long and weary restless night is remem- 
 bered. In puerperal cases, insomnia is not unfrequently the pre- 
 cursor of delirium or mania. The women who suffer from an 
 inability to sleep during pregnancy are frequently of a nervous 
 temperament, and such as are easily excited. It is well known 
 that mental occupation when moderate causes sleep, l;)ut when 
 excessive prevents it. Deficient exercise, with a constant resi- 
 
 1 Don Quixote. Part ii, Book v, Chapter 16. 
 
 '■* On Magic, Witchcraft, Aniinal Magnetism, Hypnotism, and Electro-Biology. By 
 James Braid, M.R.C. 8. E , &c. Third Edition, p. 54. London, 185-i.
 
 414 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 dence in a close and overheated atmosphere, produces fever and 
 loss of sleep. So also dyspepsia, in all its forms, is a fertile 
 source of restlessness. Hence, to secure repose which may be 
 refreshing and renovating to both mind and body, a proper 
 amount of exercise ought to be taken during the day; the diet 
 must be digestible, and especially such as will not favor the pro- 
 duction of flatulence or acidity; and no tea or coiiee should be 
 allowed in the after-part of the day. In many cases I have seen 
 benefit from the dinner being taken about half-past one or two 
 o'clock in the afternoon, as was the old-i'ashioned custom; while 
 a light supper has been enjoyed about an hour before bedtime. 
 The joatient should retire to rest at an_ early and regular period ; 
 the apartment ought to be quiet, and proper means taken to have 
 it well ventilated; and if the weather be at all chilly, a fire may 
 often be kept up during the night with great advantage. Al- 
 though a very low temperature predisposes to somnolence, yet I 
 am sure that the moderate degree of cold which we have for six 
 or eight months in this country has the reverse effect with many 
 delicate individuals. The bed had better generally consist of a 
 mattress, without too many heavy blankets ; the pillows must 
 not be high; and no curtains or hangings should be permitted. 
 If attention to these simple rules fails to produce the desired 
 effect, one or other of the following different plans may be prac- 
 tised perhaps somewhat empirically. For example, it has fre- 
 quently happened to me to see a good result, particularly when 
 there has been any debility, from a tumblerful of port wine negus, 
 or of mulled claret, or of white wine whey being taken the last 
 thing at night. In other instances, where the skin has been hot 
 and dry, a glass of cold water has appeared to be useful. So, 
 again, the employment of a bath for about three or five minutes, 
 at a temperature varying from 90° to 96° F., just before going 
 to bed often affords relief; as does also a rapid sponging of the 
 body with tepid water. The reading of exciting works of fiction 
 late in the evening is to be prohibited ; and everything that is 
 possible should be done to remove anxiety, or to allay any feel- 
 ing of apprehension which may exist as to the result of the ap- 
 proaching labor. Where any physical cause for the wakefulness 
 can be discovered, it must of necessity be removed. Thus, sup- 
 posing the bowels to be constipated, or the excretions to be un- 
 healthy, laxatives and alteratives will be required; though it is
 
 SLEEPLESS NP]SS. 415 
 
 as well to remember, that owing to the close dependence of sleep 
 on the condition of the alimentary canal the exhibition of purga- 
 tives at bedtime should be avoided, under the special circum- 
 stances we are now considering. These measures failing to pro- 
 cure the somnus qui facial breves tenebras, sedatives are to be 
 carefully resorted to ; and as conium, hop, henbane, and lettuce 
 neither aflect the head nor confine the bowels, they should first 
 be tried. But not unfrequently stronger drugs will be needed: 
 and then a quarter of a grain of morphia with a few minims of 
 the compound tincture of chloroform, or half a grain of the ex- 
 tract of opium with three or four grains of hyoscyamus, or twenty 
 drops of the liquid extract of opium with half a fluid drachm of 
 the spirit of ether will be found useful forms. 
 
 With regard to the plans recommended by authors who have 
 specially written on sleep, I may say — having often experienced 
 the truth of Madame de Sevign^'s remark, that there are twelve 
 hours in the day and fifty in the night — that I have tried them 
 all without the least benefit. Indeed, to speak the truth, it has 
 seemed that "Nature's soft nurse " has been more certainly pro- 
 pitiated by reading the writings of some of these gentlemen, than 
 by internally re^ieating some half-dozen times any popular rhyme, 
 or by slowly counting up to one thousand, or by directing the 
 eyes and thoughts to any one fixed spot, or by taking deep in- 
 spirations and allowing the imagination to stray until the breath 
 could be seen passing in a continuous stream from the nostrils. 
 However, as the best of these schemes may perhaps succeed with 
 some nervous women, and as they have the recommendation of 
 being harmless, their authors may be allowed to speak for them- 
 selves. First then, Mr. Braid says: "A method of producing 
 sleep at will, however, without the use of opiates, may be most ad- 
 vantageously resorted to, on certain occasions, by most people ; 
 and I shall therefore briefly describe the method devised by me 
 for that purpose. In my work on Hypnotism, published in 1843, 
 I explained how 'tired Nature's sweet restorer, balmy sleep,' 
 might be procured, in many instances, through a most simple 
 device by the patient himself. All that is required for this is 
 simply to place himself in a comfortable posture in bed, and then 
 to close the eyelids, and turn up the eyeballs gently, as if looking 
 at a distant object, such as an imaginary star, situated somewhat 
 above and behind the forehead, giving the whole concentrated
 
 416 SYMPATHETIC DISORD KRS OF PREGNANCY, 
 
 attention of the mind to the idea of maintaining a steady view 
 of the star, and breathing softly, as if in profound attention, the 
 mind at the same time yielding to the idea that sleep will ensue, 
 and to the tendency to somnolence which will creep upon liim 
 whilst engaged in this act of fixed attention. Or it maybe done 
 with still more success, in certain individuals, by their placing 
 some small, bright object in a similar aspect, with a distant light 
 falling thereon, the party looking at the object with open eyes, 
 fixed attention, and suppressed respiration. Other modes of pro- 
 ducins: a state of mental concentration, directed to some unex- 
 citing and empty thing, and thus shutting out the influence of 
 other sensible impressions, may also prove successful for inducing 
 calm sleep, by raonotonizing the mind — just as we see effected 
 in the case of children, who are sent to sleep by rocking, patting, 
 or gentle rubbing, or monotonous unexciting lullabies — but none 
 are so speedy and certain in their eflects, with patients generally, 
 as the modes which I have briefly explained."^ 
 
 Another mode of winning sleep is described by Dr. Binns, who 
 thinks it will succeed when all other plans have failed: The 
 sufferer is to turn on his right side, "place his head comfortably 
 on the pillow, so that it exactly occupies the angle a line drawn 
 from the head to the shoulder would form, and then slightly 
 closing his lips, take rather a full ins[)iration, breathing as much 
 as he possibly can through the nostrils. This, however, is not 
 absolutely necessary, as some persons breathe always through 
 their mouths during sleep, and rest as sound as those who do 
 not. Having taken a full inspiration, the lungs are then to be 
 left to their own action — that is, the respiration is neither to be 
 accelerated nor retarded too much ; but a very full inspiration 
 must be taken. The attention must now be fixed upon the ac- 
 tion in which the patient is engaged. He must depict to himserf 
 that he sees tlie breath passing from liis nostrils in a continuous 
 stream, and the very instant that he brings his mind to conceive 
 this apart from all other ideas, consciousness and memory depart; 
 imtigination slumbers; fancy becomes dormant; thought ceases ; 
 the sentient faculties lose their susceptibility; the vital or gan- 
 glionic system assumes the sovereignty; and as we before re- 
 marked, he no longer wakes but sleeps. For the instant the 
 
 1 On Magic, Witchcraft, Animal Magnetism, Hy[)notisni, and Electro-Biology. Third 
 Edition, p. 91. London, 18n2.
 
 HYPOCHONDRIASIS. 417 
 
 miiul is brought to the contemphition of a single sensation, that 
 instant the sensoriuni abdicates the throne, and the hypnotic 
 faculty steeps it in oblivion."^ 
 
 When the rest is disturbed by frightful dreams but little benefit 
 can be derived from the repose, while occasionally positive mis- 
 chief is done. One Lady is known to have had such fearful 
 dreams that she was obliged to employ a nurse to sit by her bed- 
 side at night to watch her countenance ; so that if it became 
 alarmed or disturbed, she might at once be awoke. Mauquest 
 de la Motte relates an instance where a patient in the ninth 
 month of her first pregnancy dreamed that she saw a frightful 
 spectre, which insisted upon lying down beside her. She awoke 
 in great horror, and was immediately seized with labor pains. 
 At the end of thirty-six hours she was so exhausted, that it was 
 found hecessary to terminate the labor; the child being stillborn, 
 and the mother dying two hours afterwards. 
 
 3. Hypochondriasis. — Amongst the other anomalous symp- 
 toms which may follow on gestation, it is necessary to notice 
 that feeling of despondency which occasionally takes possession 
 of a woman's mind; leading either to an undefined apprehension 
 of present danger, or to the almost ever-present idea that her 
 labor will certainly end fatally. These attacks of mental depres- 
 sion are by no means natural ; for every physician knows not 
 onl}' with what confidence a woman usually looks for-ward to the 
 time of parturition, but with what reliance and fortitude she 
 bears a large amount of suftering. Hence I confess, that w'hen 
 I see a patient frequently in tears, evidently unhappy, losing all 
 interest in life, and anticipating uought but danger from her 
 labor, some anxiety is felt for the result; for more than once it 
 has been proved that these forebodings were not altogether 
 groundless. In such cases it is above all things important, that 
 no weakening plan of treatment be put in force ; no suspicion of 
 congestion or inflammation of the brain is to mislead the practi- 
 tioner into prescribing drastic purgatives, mercury, iodide of 
 potassium, or antimony. But any derangement of the bodily 
 health must be cautiously looked to; and it^ — as is not unfre- 
 quently the case — there is slight fever, bad appetite, loaded 
 
 ■ The Anatomy of Sleep. Second Edition, p. 435. London, 1845. 
 
 27
 
 418 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 tongue, foul breath, nausea, and irregularit}' of the bowels, then 
 mild laxatives will be needed, and subsequently such medicines 
 as are calculated to impart tone to the digestive organs. 
 
 The drugs which I have especially found useful in mitigating 
 attacks of hypochondriasis are rhubarb and soda, solution ot 
 strychnia and citrate of iron, spirit of chloroform with quinine 
 and some bitter infusion, and phosphate of ammonia or soda 
 with nux vomica. A dose of pig's pepsine, with the two chief 
 meals of the daj^, not only assists the assimilation of food, but 
 also allows such a tonic as the following to be given with advan- 
 tage, where without some aid to digestion it could not perhaps 
 be borne: 
 
 Take of, — Aromatic Spirit of Ammonia, 3 fluid drachms; Spirit of Chloro- 
 form, 1 to 2 fluid drachms; Citrate of Iron and Qainia, 80 grains; Solution 
 of Strychnia, 30 minims; Tincture of Ginger, 2 fluid drachms; Wafer, to 8 
 fluid ounces. Mix and label, — " One-sixth part twice or three times a day." 
 
 Another form which is sometimes useful when a tonic with a 
 mild alterative is indicated, may run thus : 
 
 Take of, — Chloride of Ammonium, 40 grains; Liquid Extract of Yellow 
 Cinchona, 90 minims; Wine of Rhubarb, 6 fluid drachms; Peppermint 
 Water, to 8 fluid ounces. Mix and label — " One-sixth part twice a day." 
 
 The moral management of these cases is, however, almost as 
 important as the purel}' medical. If fears are entertained by 
 the patient merely as to the amount of pain which has to be 
 gone through, we can happily undertake to give complete im- 
 munity from suffering by the exhibition of the vapor of pure 
 ether or of chloroform ; or of w^hat is very much better than 
 either singly, a mixture of the two in equal proportions. The 
 dread of bodily anguish has sometimes so upset the balance of 
 the mind as to produce really alarming symptoms, amounting 
 perhaps to a form of monomania. Reasoning or persuasion here 
 does no good. A positive assurance of our power to annul all 
 discomfort, without risk, must be given; and it is often an act 
 of kindness to oifer the assurance in writing, so that it inay be 
 read again and again when the attacks of despondency, come on 
 in the physician's absence. Should the apprehension of danger 
 to life be the cause of the attack, the practitioner will likewise 
 do well to promise to be by his patient's side from the beginning 
 until the completion of the labor. A humane and sympathizing
 
 NERVOUS AFFECTIONS OF THE EAKS AND EYES. 419 
 
 demeanor almost always instils hope and confidence into the 
 woman's mind; and lie who has seen the good effect of thus 
 imparting courage will not regret any little extra trouble which 
 may be necessary. Moreover, hypochondriacs should not be 
 allowed to witness any scenes of real or imaginary distress; and 
 amiable, though perhaps not discreet friends, may be warned 
 against relating the exaggerated histories of any bad accouche- 
 ments with which they happen to be acquainted.^ 
 
 When these manifestations of despondency and dread con- 
 tinue to be exhibited after the process of parturition is safely 
 completed, it is to be feared that they may be due to some 
 serious cerebral derangement; which, if it exist, is not at all 
 unlikely to end in an attack of puerperal mania, or even of con- 
 firmed melancholia. 
 
 4. JSTervous Affections of the Ears and Eyes. — It has 
 happened in some very few instances, that the sensitiveness of 
 the auditory nerves has been rendered painfully acute by preg- 
 nancy. More frequently, the opposite condition has been 
 noticed ; and the power of hearing has been gradually or sud- 
 denly abolished during the earlier months of gestation. The 
 deafness has occasionally persisted for a few weeks : in other 
 cases, the sense of hearing has only been gradually recovered 
 after parturition. An examination of the ears and throat has 
 disclosed nothing unhealthy. In the reports which have been 
 published of these examples of nervous deafness, the state of the 
 urine is not mentioned. For the future, this secretion ought 
 always to be examined for albumen and for sugar. 
 
 For many years obstetric physicians have been familiar with 
 the fact, that pregnant women affected with albuminuria are 
 liable to suffer from dift'erent lesions of the nerves connected 
 with vision. Thus cases are recorded where severe pains have 
 been felt, either continuously or at regular intervals, in the 
 orbit ; or where strabismus has first shown itself; or where the 
 eyes have been rendered preternaturally weak ; or where there 
 has been double vision ; or even where tlie retina has become 
 temporarily insensible to every stimulus, producing complete 
 amaurosis. 
 
 ' The reader will find some fiirtlier observations on the conduct of women during 
 ])rpi;nancy in the author's Practical Treatise on tlie Diseases of Infancy and Cliildliood, 
 pp. 9 to 15. London, 1858.
 
 420 SYMPATHETIC DISORDERS OF PREGNAXCY. 
 
 These cases of amaurosis are especially remarkable. The in- 
 stance of the Jewess, reported by Beer, has already been noticed 
 (p. 143). Dr. Lever has published the history of a woman preg- 
 nant with her lifth child, and who, soon after quickening, sud- 
 denly felt a peculiar sensation in the eyeballs. On opening the 
 lids, she could merely see the outline of objects, their centre 
 being totally dark. The pupils were large and sluggish; while 
 the eyeballs seemed to have lost their mobility, and to have be- 
 come inordinately fixed. After labor at the full term, everytliing 
 was done to impart strength to her system, and with success. 
 At the end of three months she could see perfectly.^ The notes 
 of three examples have been recorded by Dr. Robert Lee ; in 
 one of which labor was artificially brought on. Dr. Churchill 
 also met with a case at the eighth month of pregnancy, in which 
 the symptoms became so urgent that premature labor had to 
 be induced. Dr. Spengler was consulted by a healthy woman 
 who became suddenly blind in her fourth pregnancy, but who 
 recovered completely after delivery at the full time ; the urine 
 was free from albumen. And lastly, Dr. Eastlake has given the 
 particulars of a remarkable case, in which amaurosis occurred 
 eight times in succession after natural labors, and continued 
 for from three to five weeks on each occasion." 
 
 Generally speaking, medical treatment fails to give any decided 
 relief to these disorders. They will continue in spite of all reme- 
 dies until after parturition ; and then they pass off spontaneously. 
 Such tonics as quinine and steel, with nourishing food and cod- 
 liver oil, must effect partial good, however, even though they will 
 not accomplish all we can desire. The chief point is to be able 
 to assure the patient that she may almost certainly reckon upon 
 delivery leading to a cure. Whether the gestation is to be al- 
 lowed to go on until the natural time for its termination must 
 depend upon circumstances. I think, however, it may be laid 
 down as an axiom that premature labor ought to be induced if 
 an ophthalmoscopic investigation reveals the presence of any 
 destructive disease in the choroid or retina ; or if, from the state 
 of the nervous system, the supervention of convulsions be feared; 
 or again, if the amount of albumen in the urine is persistently 
 large, and is seriously deranging the general health. During 
 
 ' Guy's Hospital Reports. Second Series, vol. v, p. 17. London, 1847. 
 
 ^ Transactions of the Obstetrical Society of London. Vol. v, p. 79. London, 1SG4.
 
 PAIN IN THE BREASTS. 421 
 
 the process of parturition every possible precaution should he 
 taken to prevent anything approaching to flooding. And again, 
 if the child be born alive, the mother must not be allowed to 
 suckle it. 
 
 5. Mastodynia, or Pain in the Breasts. — Nervous and irri- 
 table women not unfrequentlj' suffer from severe neuralgic pains 
 in the breast soon after conception. As pregnancy advances the 
 breasts become gradually enlarged and rather hard ; while the 
 tension and pain are sometimes intolerable. This suffering gives 
 rise to sleeplessness, loss of appetite, general agitation, and anxiety 
 lest cancer be commencing. Occasionally, the engorgement ends 
 in inflammation and suppuration. Not unfrequently, tlie pain 
 radiates from the breast and affects the side of the neck and head, 
 or the shoulder, or the muscles down the dorsal region of the 
 back. Sometimes, it is described as being dull and heavy; while 
 in other instances it is so sharp and acute that the patient fears 
 to move. It may disappear for a few weeks and then return ; or 
 it perhaps assumes an intermittent character, coming on at a 
 certain hour every night or every other night. There is gener- 
 ally no tumor, nor any appreciable alteration in the structure of 
 the gland. 
 
 These pains are often difficult to relieve. Emollient poultices, 
 anodyne lotions, the application of the extract of belladonna, 
 and friction with the iodide of lead ointment to which some ex- 
 tract of opium has been added, are the chief remedies. Antacid 
 laxatives and rest will be necessarj'. The valerianate of iron, or 
 of zinc, can be recommended ; as can also the tincture of actea 
 racemosa with small doses of aconite. Cod-liver oil has relieved 
 some cases which have resisted all other remedies. If the suffer- 
 ing occurs with any degree of periodicit}', quinine will often 
 prove beneficial. When the nights are restless, conium, or hen- 
 bane, or Indian hemp, or opium, ought to be given. Should an 
 abscess form, it must be opened. When the mammse are large 
 and heavy they had better be supported with a bandage ; for the 
 mere dragging of a voluminous breast may produce neuralgia. 
 Mental relief will always be given by calming the patient's fears 
 as to the nature of the disease ; since it is worth 3^ of recollection, 
 that directly a nervous woman has pain in her breast she usually 
 concludes it must be due to cancer.
 
 422 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 6. Pain in the Right Side. — Few ailments are more harass- 
 ing while they last than this one of acute pain, coming on more 
 or less suddenly, in the right side. Hence it is fortunate that the 
 affection is not common. In order that the student may not 
 mistake the nature of this pain when he is called upon to treat 
 it, I would ask him to carefullj- consider the details of tlie fol- 
 lowing case, which may be taken as a typical example of this 
 disorder. We will imagine that he has been just summoned to 
 the sick room, that the time is the evening, and that he has before 
 him a patient advanced to the eighth month of pregnancy. He 
 is told that until the last week the general health has been good ; 
 but that there has been some annoyance from the presence of 
 varicose veins, and perhaps from swellings of the legs. He sees 
 the woman on her bed, occupying a semi-recumbent posture, and 
 leaning towards the left side. Every inspiration and cough causes 
 pain, and the least movement makes the sufferer almost shriek. 
 To sit up, or to turn over to the right side, is impossible, such is 
 the agony these positions give rise to. The surface of the body 
 is bathed in sweat, the pulse is quick, the tongue furred, the 
 countenance distressed and anxious; while an earnest cry for 
 relief is made. The bowels have only been slightly open, and 
 the evacuations have been almost black and very offensive. The 
 urine is free from all albumen or sugar, but is probably loaded 
 with urates. All the pain is seated on the right side, about the 
 edges of the false ribs ; in fact, over the right hypochondriac 
 region. It is of a stabbing or stinging nature; and though it 
 has been slightly felt during the last day or two, it is only on 
 this particular evening that it has become quite unbearable. " Is 
 it inflammation of the liver?" she gasps out. Clearly not. For 
 pressure does not aggravate the suffering; there is neither jaun- 
 dice, vomiting, nor hiccough ; no s^^mpathetic pain in either 
 shoulder is experienced; and instead of there being any inability 
 to lie on the left side, this is the only position — except standing 
 upright — that can be borne. " There must be inflammation of 
 the lung then, or pleurisy ?" No, there can be neither. Observe 
 the respiratory murmur, it is quite healthy; there is certainly 
 cough, but no expectoration ; and the pulse, though quick, is not 
 hard like that of pneumonia or pleurisy. " What is it then, 
 which causes this dreadful torture ?" The explanation is difficult; 
 but it is probable that the pain is owing to the pressure of the
 
 PAIN IN THE RIGHT SIDE. 423 
 
 ascending uterus interfering in some inconipreliensible way with 
 the liver. I say " difficult," "probable," and "incomprehensi- 
 ble," advisedly; because I have seen the abdomen occupied by 
 tumors quite as large as the uterus at the full term, but have 
 never found them give rise to similar acute sj'mptoms. How- 
 ever, whatever the nature of the afiection may be, making the 
 suiFerer lie on her left side, covering the region with equal parts 
 of the extracts of belladonna and poppies, together with very hot 
 fomentation flannels, and the administration of the following 
 draught, will soon afford relief: 
 
 Take of, — Spirit of Ether, 30 minims ; Compound Tincture of Chloroform, 
 20 minims; Syrup of Poppies, 1 fluid drachm ; Tincture of Indian Hemp, 
 15 minims; Liquid Extract of Opium, 15 to 30 minims; Tincture of Capsi- 
 cum, 10 minims; JMucilage of Tragacanth, 6 fluid drachms. Mix for a 
 draught, to be taken immediately. 
 
 The practitioner may now leave his patient, feeling tolerably 
 certain that she will enjoy a good night's rest. On the following 
 day it will be quite time enough to get the alimentary canal 
 cleared out by a full dose of mercury and chalk with rhubarb, or 
 by a draught containing sulphate of soda and taraxacum, or by 
 the administration of six or eight drachms of castor oil. The 
 morphia will very probably have to be repeated for the next few 
 nights ; a nutritious diet will necessarily be ordered, perhaps with 
 stimulants ; and the patient must be warned to seek immediate 
 advice if the bowels again become constipated, or if the motions 
 assume an unhealthy character. Moreover, as long as a vestige 
 of pain remains, she should be kept in bed; being directed to lie 
 on her left side, so as to keep the uterine tumor as much away 
 from the liver as possible. While there is any uneasiness, sit- 
 ting up will assuredly increase it; since this posture brings the 
 ffland forward and downward on to the uterus. 
 
 The foregoing cases of acute pain in the right side must not 
 be confounded with those instances of chronic pain just below 
 one or other breast, which almost equally affect the pregnant 
 and non-pregnant female. If the seat of suffering, in one of 
 these chronic cases, be examined, it will probably be found that 
 the pain is confined to the tendinous insertions of the rectus ab- 
 dominis muscle into the cartilages of the fifth and sixth and sev- 
 enth ribs. In a like manner, Dr. Inman has shown that myalgic
 
 424 SYMPATHETIC DISORDERS OF PREGNANCY. 
 
 pain is not unfreqiiently experienced in the insertions of the same 
 muscle into the crest of the puhic bone and the ligaments cover- 
 ing the symphysis pubis. It can easily be understood that these 
 pains may arise from many causes in delicate women ; though 
 they seldom prove more wearying than where there has been 
 long-continued stretching of the rectus by the gravid womb, or 
 by a large uterine or ovarian tumor. The necessary treatment 
 is obvious. Tonics, nourishing food, the avoidance of fatigue, 
 and frictions with sedative liniments will afford relief; but so 
 long as the cause continues in action, so long the patient must 
 expect to feel the annoying effects.
 
 DISEASES OF THE URINARY ORGANS. 425 
 
 CHAPTER XI. 
 
 THE DISEASES OF THE URINARY AND GENERATIVE ORGANS. 
 
 Section 1. Diseases of the urinary organs. — 1. Incontinence of urine. — 2. Re- 
 tention OF URINE. — 3. Uremic eclampsia.' 
 
 Section 2. Diseases of the generative organs. — 1. Pruritus of the vulva. — 
 2. (Edema of the labia. — .3. Vaginal leucorrhcea. — 4. Discharge of watery 
 fluid from the uterus. — 5. Dropsy of the amnion. — 6. Rheumatism of the 
 UTERUS. — 7. Inflammation of the uterus. — 8. Uterine hemorrhage. 
 
 Section 1. — Diseases of the Urinary Organs. 
 
 1. Incontinence of Urine. — Baring the early months, the 
 pregnant woman is usually tormented with a frequently-recurring 
 desire to pass water; and unless she be able to gratify this desire 
 at once, the urine is very likely to come away involuntarily. In 
 these cases, the incontinence is probably due to the congestion 
 and irritation from which all the pelvic viscera suffer, owing to 
 the important series of changes which is progressively taking 
 place in the uterine cavity ; or it may arise from the pressure 
 which the gradually enlarging womb, before rising out of the 
 pelvic cavity, must necessarily exert on the posterior wall of the 
 bladder. Still more common, however, is incontinence ^t a much 
 later period ; when a temporary paralysis of the vesical coats may 
 be induced by the pressure of the enlarged uterus. The urine 
 then very frequently escapes involuntarily, especially on cough- 
 ing ; and great distress ensues from the vulva and upper part of 
 the thighs becoming excoriated by this secretion. Moreover,- no 
 little annoyance, both to the patient and her friends, is produced 
 by the strong urinous odor which attaches to the clothes. 
 
 In the treatment of the first class of cases, only simple remedies 
 will be required. A cure may not unfrequently be effected by 
 the application of fomentations, and the exhibition of a dose or 
 two of the extract of henbane ; or sometimes by the administra- 
 tion of the extract of belladonna in half-grain doses twice a day. 
 Mild laxatives must also be ordered if the bowels are not free.
 
 426 DISEASES OF THE URINARY ORGANS, 
 
 The diet ought to be plain and nourishing ; all kinds of malt 
 liquors being forbidden, while milk and cocoa are to be taken 
 instead of tea and coflee. In the second instance we can only 
 palliate the symptoms until the time of delivery arrives. Fre- 
 quent sponging of the vulva with cold or tepid water should be 
 enjoined. The sufferer had better empty the bladder very fre- 
 quently, to prevent any accumulation and involuntary discharge 
 of urine. The upper part of the thighs, &c., should be protected 
 from the excoriating effects of the secretion, by painting them 
 with a soothing artificial cuticle made of two parts of castor oil 
 to one of collodion, or with the officinal flexible collodion. The 
 practitioner must not forget that a very frequent desire to pass 
 urine is one of the urgent symptoms of calculus. Hence if the 
 secretion contain blood or mucus, or if immediately after mictu- 
 rition the desire to urinate still continue, it is important that the 
 bladder be carefully examined with the sound. It need hardly 
 be added, that where a stone is discovered it must be crushed 
 with a lithotrite and removed; unless, indeed, it he of a very 
 small size, and then perhaps the urethra may be sufficiently di- 
 lated to get it away without any fear of bad consequences, the 
 patient being unable to retain her urine for the future. But the 
 operation of lithotrity in women is comparatively so simple, that 
 nineteen times out of twenty it is greatly to be preferred to ex- 
 tensively dilating or slightly incising the urethra, as well as to 
 vaginal lithotomy. 
 
 2. Retention of Urine. — The pressure of tlie uterus upon the 
 neck of the bladder may be so great as to render the emission of 
 urine difficult or even impossible. Dysuria may thus arise at any 
 period of pregnancy. It is, however, most frequent towards the 
 end of gestation, probably owing to the uterus then falling for- 
 wards with greater force, and so compressing the neck of the 
 bladder against the margin of the symphysis pubis. Anteversion 
 and retroversion of the uterus likewise interfere with the normal 
 performance of the functions of the bladder. 
 
 If the retention depend simply on the pressure of the womb, 
 and if the vesical coats have not lost their tone from long-con- 
 tinued distension, the bladder may generally be volautarily emp- 
 tied by the woman lying upon her back with a bed-pan beneath 
 the buttocks. But if this simple plan be found to fail, the cath-
 
 UREMIC ECLAMPSIA. 427 
 
 eter mu.st be used. It lias not very unfreqnently liappened, that 
 from some error in diag'iiosis the bladder has been allowed to be- 
 come so distended as to reach the umbilicus, tciviuo; rise to the 
 greatest suftering*. Of course rupture ultimately takes place un- 
 less proper treatment be adopted : and even if the urine be with- 
 drawn, still there is no little fear of inflammation setting in, from 
 the great irritation to which the coats have been subjected. In 
 all those cases, therefore, where the practitioner finds, without 
 the presence of any apparent cause, such symptoms as pain at 
 the lower part of the abdomen, a frequent desire to pass small 
 quantities of water, thirst, loss of appetite, heat of skin, and a 
 frequent pulse, he ought to direct his attention to the state of the 
 bladder. He had better introduce a catheter unnecessarily, than 
 fail to do so Avhen it is urgently needed. But if he wish to tem- 
 porize, he should at least see the quantity of urine wliich is passed 
 in the twelve or twenty-four hours, so as to be sure that there is 
 not merely a frequent dribbling from an over-distended bladder. 
 
 3. Uremic Eclampsia. — The gradual manner in which valua- 
 ble pathological facts are brought to light is well illustrated by 
 a consideration of the subject of the present section. Some fifty 
 years have elapsed since Hamilton first gave the clue to a"correct 
 recognition of the nature of puerperal convulsions by showing 
 that they were often preceded by the occurrence of anasarca 
 during pregnancy. About 1840, Dr. Lever and Sir James Simp- 
 son proved — as was to be inferred from the researches of Dr. 
 Bright — that this anasarca was connected with the existence of 
 albuminuria; and until the investigations of Dr. Braun, we learnt 
 but little more. Even now much has to be done ; and it is im- 
 portant yet to ascertain, amongst other points, the various cir- 
 cumstances which give rise to the albuminuria and the retention 
 of urea in the blood. That puerperal convulsions are not always 
 due to actual renal disease is quite certain. We have two classes 
 of cases in which these attacks occur — viz., those in which the 
 albumen disappears from the urine two or three days after de- 
 livery, and those in which it is permanent from structural disease 
 of the kidney. Moreover, it must not be overlooked that many 
 patients sufier from either temporary or persistent albuminuria 
 who never have any ur?emic symptoms developed during preg- 
 nancy or parturition.
 
 428 DISEASES OF THE URINARY ORGANS. 
 
 The term uraemia is employed to denote a peculiar kind of 
 poisoning, which is supposed to result from the accumulation of 
 urea in the blood, and perhaps from the transformation of this 
 salt into carbonate of ammonia. The direct effects of this poison- 
 ing are seen in a disturbed action of the two great nervous cen- 
 tres — the brain and spinal cord. These centres may be aifected 
 either separately or together. Hence we have three forms of 
 ursemic poisoning: (1) That in which a state of stupor super- 
 venes rather abruptly, and from which the patient is aroused 
 with difficulty. It is soon followed by complete coma, with ster- 
 torous breathing, as in ordinary poisoning from opium. (2) 
 The variety in which convulsions of an epileptic character sud- 
 denly set in, often affecting the entire muscular system. Con- 
 sciousness remains unimpaired. And (3) that kind in which 
 coma and convulsions are combined. 
 
 The occurrence of albuminuria daring pregnancy is a rare 
 event. It may, however, be found in every period of pregnancy, 
 though it is seldom detected before the fifth month. Most com- 
 monly it is met with about the latter weeks, but sometimes it 
 only sets in during labor. When due to gestation — in other 
 words, when there is no structural disease of the kidney — this 
 condition generally disappears a few hours after labor is over. 
 The relative frequency of this state of urine, according to the in- 
 vestigations of M. Blot, who analyzed the renal secretion of 205 
 women taken indiscriminately in the wards of. the ISIaternite, is 
 one in five : that is to say, of the number examined, forty-one 
 had albuminuria. I believe, however, this proportion is consider- 
 ably higher than holds in our own country. Of the 205 cases, 
 106 were multiparae, and the urine of 11 of these contained al- 
 bumen ; while 99 were primiparne, and the secretion of SO of 
 this class was albuminous. Hence the proportion in nmltiparse 
 is, in round numbers, one to ten ; whilst in primiparje it is one 
 to three. During Dr. CoUins's mastership at the Dublin Lying-in 
 Hospital there were 30 cases of puerperal convulsions, and 29 of 
 these were priniipara3. The quantity of albumen varies very 
 much. Thus in one set of cases, the urine is found to present 
 all the characters which it assumes in acute desquamative ne- 
 phritis ; being scanty, of a dark smoky color, of a high specific 
 gravity, and loaded with albumen. Then in a second class, the 
 secretion is found to be pale, of a low density, with its salts di-
 
 UR.^MIC ECLAMPSIA. 429 
 
 minished, and heaving the characters of the urine in chronic des- 
 quamative nephritis, or in tatty degeneration of the kidney. 
 
 There is a great difficulty in accounting for the albuminuria of 
 pregnant women. Many practitioners regard it as due to active 
 congestion of the kidneys produced by the pressure of the uterus, 
 and the mechanical obstacle which this compression necessarily 
 opposes to the return of the venous blood. The most telling 
 fact in favor of this explanation is the frequency of ursemia in 
 primiparfe, in whom the abdominal walls are firm and resisting. 
 Yet it is certain that this phenomenon is sometimes observed 
 under circumstances, and at periods of pregnancy, when this ex- 
 planation will not suffice ; while it is not witnessed in the case 
 of large ovarian tumors, the pressure of which is quite equal to 
 that of the gravid womb at the full term. The real cause must 
 be sought elsewhere. It has been very plausibly suggested — I be- 
 lieve by Dr. Barnes — that the albumen found in the urine is the 
 result, and an indication, of the degradation of the mother's 
 blood ; which degradation is wrought, chiefly at least, by the 
 obstruction of its healthy elements in the placenta, and the recep- 
 tion of the effete materials of the foetus, discharged into it through 
 the same organ. This view, though not entirely satisfactory, 
 seems to me more reasonable than that of M. Blot, who gives as 
 the probable cause a nervous irritation of the kidneys, sympa- 
 thetic of pregnancy. Equally to be distrusted is the opinion of 
 many that the cause is to be found in the restraint which preg- 
 nancy opposes, after a certain time, to the freedom of respira- 
 tion. The upholders of this theory assert, that modern chemistry 
 shows how the albuminous matters undergo in the blood, under 
 the influence of the oxygen, a combustion which leaves two 
 bodies of azote — urea and uric acid — to be eliminated by the 
 urine; but if from any cause this combustion be interrupted, the 
 albumen instead of coming away in the urine as urea, is passed 
 unchanged. This results only in pregnancy in the same way as 
 it happens in a certain number of pathological states accompa- 
 nied by impeded respiration and circulation; as is seen in organic 
 lesions of the heart, acute pneumonia, cholera, &c. 
 
 When the albuminuria is due to acute desquamative nephritis, 
 or to fatty or amyloid degeneration of the kidney, the occurrence 
 of uterine congestion and placental apoplexy and abortion is, I 
 believe, more to be feared than the setting in of urajmic convul-
 
 430 DISEASES OF THE URINARY ORGANS. 
 
 sions. During the twelve years ending in June, 1860, I had 
 myself attended seven women in labor, all of whom were suffer- 
 ing from true Briglit's disease in a more or less advanced stage. 
 Kot one of these had even any threatening of ursemia at the 
 time of delivery, or had previously experienced symptoms which 
 might be regarded as warnings ; but four had aborted at an early 
 stage of gestation, and one had even miscarried three times in 
 succession. Another of these cases was also seized with convul- 
 sions three weeks after an easy labor, from which she gradually 
 recovered; afterwards remaining free from acute symptoms and 
 in the enjoyment of moderate health for several months, though 
 her urine was loaded with albumen, and to my certain knowledge 
 had been so for the previous five years. 
 
 The ursemic fits do not arise, as was formerly thought to be 
 the case, from the blood being poisoned simply by urea. The 
 views of Frerichs have been confirmed by Dr. Braun ; and it 
 now appears highly probable that the phenomena of uraemic con- 
 vulsions are not produced by urea nor any other ingredient of 
 the urine, but that they commonly originate from the urea re- 
 tained in the blood being transformed into carbonate of ammonia 
 under the influence of some peculiar ferment. Hence can be 
 explained those cases, where women suftering from Briglit's dis- 
 ease pass through pregnancy and labor — their blood being satu- 
 rated with urea — without any uniemic phenomena taking place; 
 simply because the unknown ferment, by means of which the 
 urea can be changed into carbonate of ammonia, is absent. The 
 same interpretation must be put on those experiments on ani- 
 mals, in which the injection of urea into the veins has failed to 
 produce convulsions. Frerichs states tliat he has proved, by 
 chemical analysis, the existence of carbonate of ammonia in the 
 blood in all cases in which the symptoms of uraemia have been 
 developed. He further observes that the two following j^roposi- 
 tions can be demonstrated beyond a doubt: (1) That in every 
 case of uraemia, a change of urea into the carbonate of ammonia 
 takes place. (2) That the symptoms which characterize uraemia 
 can all be produced by the injection of carbonate of ammonia 
 into the blood. 
 
 The attacks of convulsions commonly appear for the first time 
 during the last three months of gestation ; or more [)articularly 
 ust before the process of parturition commences, or while labor
 
 URiBMrC ECLAMPSIA. 431 
 
 is going on. It is from this latter circumstance, that they are 
 often spoken of as "puerperal convulsions." They are frequently 
 preceded by symptoms which should put the practitioner on his 
 guard ; the most prominent being headache, giddiness, various 
 kinds of illusions, noises in the head, marked mental depression, 
 nausea and retching, languor, rigors, and weakness of the ex- 
 tremities. The urine has generally been albuminous for some 
 time previous to the convulsions; althougli a few cases are re- 
 corded where the albumen has only been found shortly after the 
 first fit. The albumen being al)undant in the urine, it may be 
 taken for granted that the urea is proportionate!}' scanty; so that 
 as the blood becomes deficient in albumen its impurity gets 
 greater. In addition to the albuminous state of the urine, the 
 face and hands and arms will generally be found oedematous; or 
 this condition may perhaps chiefly afifect the feet and ankles, or 
 the lalfia majora. When the fits once come on, they usually fol- 
 low each other in rapid succession, being often repeated several 
 times in the day; the patient being not only insensible during 
 the paroxysm, but most frequently also in the interval. The du- 
 ration of each fit, inclusive of the stage of convulsion and that 
 of coma, varies from half an hour to two or three hours, or even 
 longer. As the symptoms remit, consciousness returns very 
 gradually; a confused dull headache being complained of, though 
 there is no recollection of what ha§ happened. It is quite certain 
 that eclamj)sia can appear quite independently of uterine pains. 
 The fact has been observed by many, that the fits may cease 
 and pregnancy go on safely for weeks until the proper period 
 of parturition arrives; or even if pains have set in, they may 
 completely pass oft' for one or two days. Yet it must also be 
 allowed that spontaneous premature labor is not uncommon 
 with eclampsia 
 
 The life of the child is much endangered by the attacks of 
 convulsions. It is quite exceptional for the foetus to be found 
 alive after numerous paroxysms. Dr. Braun says : 
 
 The cause of death of the foetus of eclamptic mothers is, for this reason, 
 chiefly to be sought for in the passage of carbonate of ammonia into the 
 foetal circulation. But the ureemia itself of the mother may, without eclampsia 
 occurring, destroy the foetus, as we have observed in acute Bright's disease 
 of pregnant women without eclampsia. Besides the urajmic poisoning of 
 the blood, other injurious influences may endanger the lite of the foetus, as 
 interruption of the placental circulation by violent pains, in cases where in-
 
 432 DISEASES OF THE URINARY ORGANS. 
 
 superable difficulty is produced by transverse presentations, disproportion in 
 size, pressure on the cord, premature discharge of the waters, and deficient 
 preparation and softening of the neck of the womb. Albuminuria and 
 Bright's disease of the kidneys of children born of eclamptic mothers, have 
 been observed by Simpson. We have not unfrequently observed apoplectic 
 masses in the cavity of the skull and spine in cases of children dying of con- 
 vulsions in the first days of life.^ 
 
 When the mother dies during pregnancy from eclampsia puer- 
 peralis the result of ursemic toxemia — in other words, from con- 
 vulsions caused by the action of morbid blood on the brain and 
 spinal cord and medulla oblongata — and the Cses^rean section 
 is immediately performed, the infant will almost always be 
 found dead. 
 
 Urtiemic eclampsia is to be distinguished from other convulsive 
 diseases by the albuminous state of the urine, by the oedematous 
 infiltrations of the face or extremities which are generally pres- 
 ent, and by the precursory nervous symptoms which have been 
 already alluded to. It is likely to be confounded with cholsemic 
 eclampsia; an acute disorder that arises from the blood being 
 overcharged with the constituents of the bile and the products 
 of their decomposition, and which is connected with acute atro- 
 phy of the liver, icterus typhoides, pyaemia, as well as with some 
 forms of puerperal fever. But in the case of cholsemia the urine 
 does not contain albumen, while it is charged with biliarj^ pig- 
 ment; the presence of the latter being ascertained by the pro- 
 duction of the well-known plaj^ of colors on the addition of 
 nitric acid. So also hysterical convulsions may occur, but thej^ 
 have no injurious etfect on the mother or child : women afllicted 
 with epilepsy often have the fits recur during pregnancy: there 
 are the convulsions which originate in meningitis, encephalitis, 
 apoplexy, or tuberculosis of the membranes of the brain : while 
 there may be the same from the ingestion of poisonous sub- 
 stances, such as strychnine or brucine. But the simple fact that 
 in these cases all ursemic symptoms are wanting is suflicient to 
 prevent their being mistaken for convulsions due to poisoning of 
 the blood with urea, or with this salt when converted into car- 
 bonate of ammonia. 
 
 1 The Uraamic Convulsions of Pregnancy, Parturition, and Cliildbed. By Dr. Carl 
 R. Braun, Professor of Midwifery, Vienna, p. 48. New York, 1858. Translated by 
 Dr. J. Matttiews Duncan, from the Lehrbuch der GeburtshUlfe mit Einschluss deroper- 
 ativen Therapeulik, der ubrigen Fortpflauznngs-functionen der Frauen und der Puer- 
 peral processe. Wien, 1857.
 
 UREMIC ECLAMPSIA. 433 
 
 The prognosis in eclampsia must always be guarded ; since 
 hitherto, according to Braun, thirty per cent, of the cases have 
 j)roved fatal. The greater the difficulty in diminishing the volume 
 of the uterus, the greater is the danger. The fits have been 
 found to cease completely after evacuation of the uterus in 
 thirty-seven per cent., to become weaker in thirty-one per cent., 
 and to continue of the same severity in only thirty-two per cent. 
 The case may be said to assume a favorable aspect where the 
 fits steadily diminish in frequency and violence ; more especially 
 if the pulse continues cpiiet and of its natural strength, if there 
 be abundant diuresis, if all comatose symptoms disappear, and 
 when no secondary disease of the brain or lungs has been pro- 
 duced. It is fortunately true, that when convulsions have oc- 
 curred in one pregnancy it is quite the exception for them to 
 happen in subsequent gestations. 
 
 Supposing the foregoing hypotheses, on which so much stress 
 has been laid, to be well founded — and I know of no good reasons 
 for doubting their correctness — the indications for treatment are 
 clear and simple. When the existence of albuminuria is dis- 
 covered during pregnancy, medicines should be administered 
 which will prevent the decomposition of the urea, or rather will 
 neutralize the carbonate of ammonia if it be formed in the blood. 
 For this purpose Frerichs strongly recommends benzoic acid in 
 five or ten grain doses, with iced drinks which have been acidu- 
 lated with tartaric acid, lemon-juice, &c. To obviate congestion 
 of the head, costiveness should be prevented by assafoetida and 
 vinegar injections, by jalap, calomel, or croton oil ; while ice may 
 be also used locally, or the cold douche can be cautiously tried 
 if any cerebral symptoms actually show themselves. In the 
 cases which have come under my own observation great benefit 
 has been derived from the early employment of tonics, and par- 
 ticularly from the cautious use of steel with the mineral acids. 
 When convulsions have occurred, or when a paroxysm seems 
 impending — during eitherpregnancy, labor, or childbed — chloro- 
 form proves invaluable ; since its inhalation weakens the fit, and 
 diminishes the reflex excitability of the nervous system. More- 
 over, Sir James Simpson has very ingeniously suggested that the 
 beneficial efi'ects of this anesthetic are due to its producing — as 
 it is well known to do — a temporary diabetes mellitus ; for it has 
 been demonstrated that sugar in small quantities added to the 
 
 28
 
 434 DISEASES OF THE URINARY ORGANS. 
 
 urine out of the body prevents for a timetlie ordinary decompo- 
 sition of urea into carbonate of ammonia. 
 
 Dr. Braun states, that in sixteen cases of echampsia, occurring 
 in succession, which he treated with chloroform and acids, com- 
 plete recovery alwaj's took place. This happy result is certainly 
 much more favorable than has hitherto been obtained by any 
 other course of remedies. With regard to my own experience 
 it may be mentioned, that since I became acquainted with the 
 views here advocated I have been called upon to treat several 
 examples of puerperal convulsions in conjunction with other 
 physicians. In one of these cases the patient was skilfully and 
 successfully treated by another practitioner, who simply hurried 
 the labor and delivered. In another instance pregnancy was 
 only advanced to the eighth month, and a cure was eft'ected by 
 keeping the woman under the influence of chloroform for an 
 bour at a time, on three separate occasions, at intervals of twelve 
 hours ; together with the liberal administration of lemon juice. 
 After the last inhalation the convulsions permanently ceased ; 
 and delivery took place at the pro})er time of a live child. With 
 regard to a third case, labor had well set in, and the os uteri was 
 almost fully dilated when the convulsions commenced. The 
 forceps were, therefore, readily ap[)lied, and a living child was 
 brought into the world ; the mother making a good recovery. I 
 do not of course wish it to be understood that none of my cases 
 have died ; but simply, that as far as my experience goes, a fatal 
 termination in uremic eclampsia is a very exceptional event. 
 
 The last, but certainly not the least important remedy, is the 
 prompt removal of the contents of the uterus. This has to be 
 accomplished either by the use of the forceps, or by turning, 
 when the convulsions occur during delivery at the full term ; or 
 by the induction of premature labor, if the dangerous symptoms 
 of uri\>niia take place in tlie latter months of pregnancy. Sup- 
 posing that there are indications of the death of the foetus, there 
 can be no doubt that the sooner the infant is expelled the better. 
 After emptying the uterus, it will be advantageous to continue 
 the administration of the benzoic acid, so as to prevent any return 
 of the paroxysms ; while ice and acid drinks should be freely 
 allowed. If, after the return of consciousness, there be any dis- 
 tressing bodily restlessness or mental irritability, sponging the 
 body with vinegar and water can be employed with advantage.
 
 VULVAL PRURITUS. 435 
 
 In a]] instances Dr. Braun asserts tliat general depletion does 
 mischief; because by bleeding the anamia is increased, the ner- 
 vous fits are not improved, the spasms are often aggravated, and 
 puerperal thrombosis and pytemia in childbed, are much to be 
 feared. My own observations of this disease at the present day 
 quite confirm this opinion ; and I have no hesitation in express- 
 ing a decided belief that bloodletting, as a general rule, without 
 exerting any valuable effect on the symptoms, is often calculated 
 to produce irreparable mischief. "With regard to the application 
 of blisters to the back of the neck, sinapisms to the legs, hot 
 pediluvia, and such like, it is only necessary to say that they 
 cannot possibly do any good. When a comatose condition su- 
 pervenes, the patient is to be kept perfectly quiet ; while abun- 
 dant diaphoresis had better be encouraged by the wet sheet, hot 
 bottles, blankets, &c. No medicine need be given. It must be 
 remembered that the coma is not due to simple congestion of the 
 brain with blood, but chiefly to the effect of poisoned blood on 
 the nervous substance. At the same time it will often happen 
 that there is slight serous infiltration. 
 
 Section 2. — Diseases of the Generative Okgans. 
 
 1. Pruritus of tue Vulva. — Few affections are more annoy- 
 ing in the early periods of pregnancy than an excessive itching 
 of the external genital organs. The insupportable irritation, the 
 continual scratching which is resorted to for the sake of tempo- 
 rary relief, and the consequent excoriations which are produced, 
 all give rise to so much local and constitutional distress, that 
 sensitive women are sometimes rendered thoroughly ill and 
 miserable. In a lew rare cases, the attack has degenerated into 
 nymphomania ; the impure desires being at first excited by the 
 friction resorted to for the alleviation of the itching. 
 
 The causes of pudendal pruritus are numerous. Thus it may 
 be merely a sympathetic disorder, unattended with any cogniz- 
 able alteration of tissue. There may be only a state of hyper- 
 aesthesia of the nerve filaments. Sometimes, the irritation is 
 simply a symptom of inflammation of the follicles of the mucous 
 membrane of the vulva. Dewees states in his work on midwifery 
 that he examined a lady who was attacked early in pregnancy 
 with an intolerable itching in the pudendum and along the
 
 436 DISEASES OF THE GENERATIVE ORGANS. 
 
 vagina, and on separating the labia be found all tbe parts covered 
 with an incrustation of aphthae ; which disease was thoroughly 
 cured in twenty-four hours by the repeated application of a 
 strong solution of borax. So moreover, pruritus not uncom- 
 monly results from the irritation produced by acrid vaginal dis- 
 charges ; and especially by that variety of leucorrhoea which is 
 due to excoriation of the labia uteri. Or again, the presence of 
 ascarides in the rectum may give rise to pruritus. And lastly, 
 in dirty women, it may be owing to the presence of the pediculus 
 pubis, or crab louse ; a parasitic insect which occasionally infests 
 the hair of the pubes. 
 
 The characteristic feature in all cases is the almost constant 
 and intense itching. If the patient have suffered for any length 
 of time, and if recourse has been had to frequent scratching, 
 troublesome ulcerations about the labia are very likely to be 
 found. There is generally great restlessness at night, loss of 
 appetite, constipation, indigestion, mental irritability or depres- 
 sion, and an indisposition for any kind of exertion. The itch- 
 ings are not always confined to the genital parts. I have seen 
 patients who have suffered just as acutely from the irritation 
 about the upper and inner part of the thighs as from that about 
 the perineum. In one instance the itching extended all round 
 the sphincter ani, but only on the right side of the vulva. Dr. 
 Maslieurat-Lagemard has related the remarkable case of a lady, 
 who, in eight successive pregnancies, was afflicted with itchings 
 so violent as to produce premature labor. On four of these oc- 
 casions the irritation began in the sixth month, twice at eight 
 months and a half, and twice in the seventh month. It spread 
 over the entire cutaneous surface; the whole trunk, neck, face, 
 scalp, thighs, legs, and genitals being all afiected. So severe 
 was the suffering, that the violent rubbings wliich were resorted 
 to produced extensive excoriations ; though except for these abra- 
 sions, the skin appeared perfectly healthy. Simple and alkaline 
 baths ; ammoniacal and camphorated frictions to the spine ; prep- 
 arations of opium, bismuth, valerian, hyoscyamus, and bella- 
 donna ; and lastly, general bleeding, were all employed without 
 an}^ advantage. But almost immediately after the uterus had 
 expelled its contents, the symptoms vanished.^ 
 
 Gazette M^dicale de Paris. Tome Troisifeme, p. 204. 1848.
 
 VULVAL PRURITUS. 437 
 
 The treatment of these cases must vary according to the cause 
 of the aftection. When it is merely symptomatic of pregnancy 
 we shall often fail to do more than give partial relief. In such, 
 at the onset, the bowels should be regulated by some simple 
 aperient, as rhubarb and magnesia, or sulphate of soda and tar- 
 axacum; and then a combination of zinc and nux vomica like 
 the following, may exert a favorable influence on the nerves : 
 
 Take of, — Valerianate of Zinc, 80 grains; Extract of Nux Vomica, 5 grains; 
 Extract of Hyoscyamus, 60 grains. Mix into a mas^, divide into twenty- 
 four pills, and silver them. Label — "One pill to be taken three times a 
 day, — at 10 A.M., 4 p.m., and bedtime." 
 
 With regard to the application of sedative lotions it need only 
 be said, that I have often found one or other of the succeeding 
 forms prove temporarily useful : 
 
 Take of, — Bird's-eye Tobacco, 120 grains; Boiling Water, 1 pint. Infuse 
 for an hour and strain. To be freely u,sed as a lotion, when cold. 
 
 Take of, — Ointment of Aconitia, 50 grains; Liniment of Lime, 2 fluid 
 ounces. Mix. To be applied freely, several times a day, with a large camel's 
 hair pencil. 
 
 Take of, — Solution of Hydrochlorate of Morphia, 1 fluid ounce; Diluted 
 Hydrocyanic Acid, 80 minims; Elder-Flower Water, to 8 fluid ounces. Mix, 
 for a lotion. 
 
 Take of, — Glycerine of Borax, 2 fluid ounces; Rose Water, to 8 fluid 
 ounces. Mix. 
 
 T;ike of, — Solution of Potash, 2 fluid drachms; Diluted Hydrocyanic Acid, 
 90 minims ; Almond Mixture, to 8 fluid ounces. Mix. 
 
 Take of. — Solution of Subacetate of Lead, 4 fluid drachms; Tincture of 
 Digitalis, 6 fluid drachms; Elder-Flower Water, to 8 fluid ounces. Mix. 
 
 Ointments are generally more objectionable than lotions, inas- 
 much as they are dirty applications, and are usually injuriously 
 affected by heat. But sometimes it may appear useful to employ 
 a soothing cerate ; and then the officinal belladonna ointment, or 
 the ointment of spermaceti, or that of the subchloride of mercury, 
 or of the acetate of lead, or the compound ointment of subacetate 
 of lead can be tried. 
 
 Patients have also stated that they have been relieved by the 
 use of the ointment of nitrate of mercury, when properly diluted : 
 by the subnitrate of bismuth mixed up with spermaceti : by 
 Fuller's earth : by astringent lotions containing nitrate of silver, 
 nitric acid, alum, sulphate of zinc, or sulphate of copper : by 
 washing the parts with lime-water, or ice-cold water, or with a
 
 438 DISEASES OF THE GENERATIVE ORGANS. 
 
 lotion formed of equal parts of the solution of perchloride of 
 mercury and almond mixture, or with vinegar and water: and by 
 the employment of tepid hip-baths, made alkaline through the 
 addition of carbonate of potash. In some cases, where the in- 
 cessant and intolerable itching has appeared to be entirely due 
 to congestion and granular abrasion of the lips of the uterus, I 
 have effected cures by the use of leeches to the diseased surface; 
 or by the careful application to the abrasion of the acid solution 
 of nitrate of mercury. "With regard to the internal administra- 
 tion of drugs, I can only say that their use has almost invariably 
 disappointed me. One or other of the different preparations of 
 zinc will probably be serviceable where there is disordered nerve- 
 influence. Quinine has occasionally seemed to be of temporary 
 service. Knowing the great value of arsenic in many cutaneous 
 affections, I at one time anticipated a good result from its em- 
 ployment in pruritus ; but my hopes have been very imperfectly 
 realized. Such also has been the case with alteratives ; although 
 small doses of the perchloride of mercury, continued for a long 
 time, are sometimes indicated. The mineral acids, sarsaparilla, 
 alkalies, strong purgatives, and narcotics, have all failed to do 
 any marked good in my hands. It only remains to notice that 
 if ascarides be present in the rectum they must be removed by 
 enemata consisting of salt and water, or of a strong infusion of 
 quassia ; while if any pediculi are found they are quickly to be 
 destroyed by freely dusting all the parts with calomel, and their 
 return prevented by repeating the application as well as by fre- 
 quent ablutions with soap and water. 
 
 2. (Edema of the Labia. — During the last two or three months 
 of gestation the external labia sometimes become oedematous, 
 while occasionally they get enormously distended with serum. 
 This condition must be carefully distinguished from that general 
 dropsical effusion so often found coexisting with albuminuria. 
 
 A simple oedematous state of the labia is supposed to be due 
 to the pelvis being sufficiently large to allow of the gravid uterus 
 sinking more or less deeply into its cavity; the pressure thus ex- 
 erted upon the veins inpeding the return of blood. It is to be 
 relieved by the recumbent posture being kept, with the head and 
 shoulders as much on a level with the trunk as may be bearable; 
 and this failing, by the exhibition of purgatives, by bathing the
 
 VAGINAL LEUCORRHCEA. 439 
 
 parts with warm water, and — if necessary — by making a few 
 punctures with a sharp needle. 
 
 3. Vaginal Leucorrhcea. — There are very few diseases of the 
 uterus or vagina which are not accompanied by a leucorrhoeal 
 discharge, more or less profuse. As a general rule, I believe the 
 most common cause of severe leucorrhcea to be disease of the 
 mucous membrane of the os and cervix uteri. But in the remarks 
 now about to be made I wish to confine my observations to that 
 variety of vaginal leucorrhcea which often affects pregnant women, 
 particularly during the three or four latter months of gestation ; 
 and which resembles that form of discharge which so commonly 
 occurs after each menstrual period, in which the increased secre- 
 tion of mucus is attended with a partial desquamation of the 
 epithelial surface of the vagina. The fact must be remembered 
 that the mucous membrane of this canal is covered with a layer 
 of pavement epithelium, beneath which are countless villi and 
 numerous mucous glands. These are the structures most con- 
 cerned in producing the discharge under consideration ; and it is 
 astonishing to see the quantity of muco-purulent fluid which the 
 villi or papillae will secrete when they are denuded of epithelium. 
 The cause of this desquamation appears to be some constitutional 
 change or peculiarity acting in conjunction with the pregnant 
 uterus to produce irritation or relaxation of the vaginal tissues. 
 
 This affection usually gives rise to much annoyance. When 
 the discharge is copious it weakens the system, and seems par- 
 ticularly to interfere with the due performance of the functions 
 of the digestive organs. It may sometimes perhaps appear that 
 dyspepsia is the cause and not the result of the disorder; but 
 often, as mentioned, the contrary will be found to be the case. 
 This is proved by the fact, that on relieving the vaginal affection 
 by local remedies the stomach regains its tone. Moreover, the 
 discharge is liable to set up great irritation, a burning heat, with 
 tingling and itching about the external genitals; while, unless 
 great cleanliness is practised, the secretion forms slight crusts 
 with the matted hairs, excoriations are produced, and then even 
 walking becomes a painful act. 
 
 The treatment which has been found most useful and grateful 
 consists in the employment of a tepid hip-bath every morning, 
 or even night and morning ; complete abstinence from sexual
 
 440 DISEASES OF THE GENERATIVE ORGANS. 
 
 intercourse ; plenty of rest in bed, on a mattress, with only moder- 
 ate coverings ; a regulated but nutritious diet, without any 
 stimulants; and the proper employment of simple injections. 
 The injection which I most frequently order is made by adding 
 from four to six fluid drachms of the solution of subacetate of 
 lead to twenty ounces of water; the whole of this being directed 
 to be gently used twice a day by means of the vulcanized India- 
 rubber syphon syringe. At the same time mild laxatives con- 
 taining taraxacum, or rhubarb and magnesia, maybe prescribed. 
 Where there is any evidence of the presence of a syphilitic taint 
 in the system, the solution of perchloride of mercury is to be 
 continuously administered for several weeks — indeed until a 
 complete cure is effected. In other cases, a course of tonics will 
 often do good, especially if there exist any constitutional debility. 
 Small doses of the nitro-hydrochloric acid with compound tinc- 
 ture of bark often prove very beneficial ; or if there be no contra- 
 indicating conditions, such a combination of iron and alum as 
 the following will be found useful : 
 
 Take of, — Ammoniated Iron Alum, from 30 to 60 grains ; Distilled Water, 
 8 fluid ounces. Mix and label, — "One-sixth part twice a day, about 11 
 A.M., and 8 P.M." 
 
 The Sand-rock chalybeate water, in the Isle of Wight, which 
 has long been noted for its efficacy in curing many chronic forms 
 of uterine disease, owes its valuable properties to the large pro- 
 portion of sulphate of iron and sulphate of alumina with which 
 it is impregnated. But in this case the two salts are simply dis- 
 solved in the water; there being no chemical combination. 
 Such a mixture is much less efficacious than the true iron alum ; 
 which, indeed, contains no alumina at all, but consists merely 
 of a double sulphate of ammonia and iron. There is, it may be 
 noticed, another preparation consisting of a double sulphate of 
 potash and iron ; but as this is less soluble than the iron alum 
 with ammonia, it is better to employ the latter. 
 
 4. Discharge of Watery Fluid from the Uterus. — Every 
 now and then it happens that pregnant women sufter for several 
 weeks before labor from a profuse colorless and limpid watery 
 discharge ; the fluid which comes away resembling in all respects 
 the healthy liquor amnii. Tlie terms JiydrorrJioea and metrorrhoea
 
 METRORRHCEA. 441 
 
 have been used to designate tliis affection : but as the former 
 merely signifies an escape of water, so it seems better to employ 
 the latter, which at all events indicates that the discharge is of 
 uterine origin. The quantity of water expelled varies from some 
 two or three ounces to one or two pints daily. The flow may 
 continue for a few days and then cease ; or it may recur at inter- 
 vals, as most frequently happens, until the end of pregnancy. 
 Moreover, the fluid comes from the patient either in gushes or 
 it dribbles away, perhaps ceasing when the recumbent posture 
 is assumed; and it is frequently attended with weakness, and 
 troublesome lumbar pains. There is only a very slight, if any, 
 diminution in the size of the abdomen produced by it. And as 
 far as ni}^ experience goes, it does not appear to have any injurious 
 eftect upon foetal life ; inasmuch as the child is usually born alive 
 and healthy at or near the full time. 
 
 The question of the source of this discharge has given rise to 
 a variety of opinions. Many authorities are in favor of its being 
 due to the evacuation of fluid that has collected in the space 
 which it is said sometimes exists between the amnion and 
 chorion, or between the chorion and the decidua. For although 
 these membranes are properly in close apposition towards the 
 end of gestation, yet it is argued that occasionally — as in the 
 earlier months — they are separated by a kind of gelatinous fluid. 
 Independently of the fact, however, that the separation, when 
 present, is much too slight to allow of the collection of such an 
 amount of fluid as is sometimes expelled, there are many other 
 objections to this view. Dr. David Davis observes that this is 
 "in most cases, a dangerous and often a fatal aflection of the 
 pregnant state ;" but I cannot find any author of note who cor- 
 roborates this statement. The same gentleman seems also to 
 believe that this drihbluig of the ivaters can possibly be due to 
 what may be called a dropsy of the chorion; the chorion taking 
 upon itself to secrete fluid just as the amnion does.^ 
 
 Dr. Harvey, of Dublin, in considering these cases, reasons by 
 the method of exclusion, and shows the great improbability or 
 even impossibility of the fluid coming from the cervical glands 
 of the uterus, or from the vagina, or from the space between the 
 decidua and the chorion, or from the interval between the 
 
 ' The Principles and Practice of Obste'ric Medicine. Vol. ii, p. 90.3. London, 1836.
 
 442 DISEASES OF THE GENERATIVE ORGANS. 
 
 chorion and the amnion. Hence he thinks the conclusion is 
 almost inevitable, that the amnion must be the source of this 
 flood ; solutions of continuity probably occurring in this mem- 
 brane from time to time, so as to allow of these discharges. The 
 openings then either heal up or close again ; or else the me- 
 chanical relations of the bag to the surrounding parts admit of 
 the amnion refilling to a certain extent by a fresh secretion of 
 its peculiar fluid. In confirmation of his views he refers to ex- 
 amples recorded by Denman, Burns, and others, where the 
 amnion is said to have given way from fright ; and in which the 
 watcrS'Were discharged without labor coming on. He then re- 
 lates the following interesting instance where the flow was un- 
 doubtedly amniotic : 
 
 Mrs, , mother of several children, was, for more than a year, the 
 
 subject of heavy san<iuineous discharo;es, which were so little influenced by 
 the treatment adopted that the existence of polypus was thought possible. 
 An examination revealed considerable congestion of the os and cervix uteri, 
 with superficial ulceration, which gave way to treatment generally and locally 
 applied. During last summer her health was considerably improved ; but 
 occasionally menorrhagic attacks, which latterly observed more or less closely 
 the monthly periods, showed tliemselves. JMatters were going on thus when 
 she suffered a considerable shock by her eldest boy meeting with a severe 
 accident, in which his arm was fractured. On that day, for the first time 
 (six weeks before delivery), she had a sudden gush of clear watery fluid from 
 the vagina, and since that time to the date of these notes (5th November), she 
 was scarcely free from it : it would diminish or nearly stop for a few days at 
 a time, to come on again in gushes, and in considerable quantity. The quan- 
 tity escaping in one of these was seldom less, and generally more, than half 
 a pint ; and on the late occasion, when the flow was accompanied by a heavy 
 sanguineous discharge also, she thinks the combined amount was fully a quart. 
 It came on in the horizontal position as well as in the erect, and apparently 
 without any cause. The size of the abdomen did not appear much affected 
 by these at any time. The occurrence of the watery discharge suggesting 
 the probability of pregnancy, notwithstanding the menstrual changes which 
 had been going on with some regularity, and that, if pregnancy did exist, the 
 ovum might have suffered hydatid degeneration, I proposed an examination 
 for the purpose of ascertaining the point. I found an abdominal tumor oc- 
 cupying; the hypogastrium to above the umbilicus, and on laying my hands 
 over its surface, it gave a good example of the value of a diagnostic indica- 
 tion lately suggested by Dr. Oldham ; it afforded distinct evidence of its 
 being uterine by gradually and regularly hardening under my hand. The 
 movements of the child were also felt ; and foetal pulsation distinctly heard 
 by the stethoscope, put an end to all doubts. I told the lady that she had 
 passed some six or near seven months of her pregnancy without being aware 
 of it, and that her labor would probably come on prematurely ; all of which she 
 entirely disbelieved, and I could not induce her to make the necessary prep- 
 arati(jns. Two days after, I was called to her — the first stage of labor hav- 
 ing set in with unusual distress and irritation; the pains peculiarly sharp
 
 METRORRHCEA. 443 
 
 and unbearable; the os uteri was bard and unyieldinji', and the breech, pre- 
 senting in the second position, was felt in close contact. I immediately put 
 her on antinionial solution, notwithstanding which the os uteri took over 
 three hours to relax. After a fiist stage of about four and a half hours, and 
 a second of less than half an hour, a n)ale child, of scarcely seven months' 
 growth was born. The presenting hip and buttock were perfectly black, 
 evidently from the direct pressure to which they had been subjected in con- 
 sequence of the loss of the liquor amnii. None whatever escaped with the 
 child, and the sanguineous discharge was also unusually scanty. I do not 
 think I ever witnessed so dry a labor. ^ 
 
 From a careful consideration of the foregoing facts, as well as 
 of several other recorded cases, I cannot avoid coming to the 
 conclusion that they all tend to support the view of the escaping 
 fluid being the liquor amnii. There are three circumstances 
 which, as it seems to me, especially f ivor this theory. The}^ are 
 these : First, an opening has been found in the membranes 
 through which the fluid has escaped. Thus, Mr. Ingleby relates 
 the case of a lady, six months gone in her third pregnancy, who 
 suddenly lost a large quantity of water during the niglit. From 
 this moment until the occurrence of labor, there escaped every 
 two or three days a pint and a quarter of fluid. The patient was 
 at length delivered of a large boy. The after-birth was expelled 
 spontaneously ; " my hand " — says the narrator — " receiving the 
 mass when at the outlet, lest its weight should tear the mem- 
 branes. I then carefully examined the whole, and in addition to 
 the aperture in the centre of the membranes, made by the pas- 
 sage of the head, there was a circular one very distinct just at 
 the edge of the placenta. From this aperture doubtless the fluid 
 had from time to time escjiped ; the patient prior to each evacu- 
 ation being sensible, by a kind of passive contraction of the 
 uterus, that it was about to come away."- Secondly, the dis- 
 charge often ceases directly the patient lies down, as it would 
 naturally do, were the opening situated in the upper and front 
 part of the amniotic sac. And tJiirdly, it is well known that 
 even the whole of the liquor amnii may escape many days be- 
 fore labor without compromising the life of the foetus. Mau- 
 riceau refers to some few instances where even two or three 
 weeks seem to have elapsed between the rupture of the mem- 
 
 ' The Dublin Quarterly Journal of Medical Science. Vol. xxv, p. 233. February, 
 1858. 
 
 2 A Practical Treatise on Uterine Hemorrhage, in connection with Pregnancy and 
 Parturition. Note, p. 29. London, 1832.
 
 444 DISEASES OF THE GENERATIVE ORGANS. 
 
 branes and the setting in of labor pains. In the year 1860, I 
 attended a lady in her first labor where the whole of the liquor 
 amnii was discharged sixty hours before the birth of a vigorous 
 healthy child. 
 
 On the other hand, the opponents of the foregoing views are 
 numerous. The arguments in an elaborate essay on this subject, 
 by M. Chassinat, are founded upon fortj^-two cases which he has 
 collected from various authors, and ten examples not hitherto 
 published. Although this author's reasonings appear to me un- 
 warranted from the premises, yet they are decidedly ingenious 
 and deserving of attentive consideration. The conclusions at 
 which he arrives are as follows : 
 
 (1) The metrorrhoea of pregnant women, appearing at variable periods in 
 the course of pregnancy, is an affection of the reality of which no doubt can 
 be entertained. (2) In the great majority of cases, if not in all, the liquid 
 is secreted between the internal surface of the uterus and the envelopes of 
 the foetus after detachment of the membranes. The differential characters 
 suffice to distinguish it from the waters of the amnios, discharged by reason 
 of the premature rupture of the membranes. (--5) The causes which seem 
 to favor this abnormal secretion are a general polyasmia, or local irritation of 
 the uterus, supervening in several cases upon external violence. (4) The 
 pathognomonic symptom is the issue of a fluid from the vulva, which is 
 usually limpid, and thin and albuminous; and which mayor may not be ac- 
 companied by painful uterine cimtractions. (5) There is no anatomical lesion 
 known which is peculiar to the disease. (6) In the great number of the 
 cases, the metrorrhoea is dangerous to neither mother nor child, pregnancy 
 going on to its normal term, the liquor amnii being as abundant as usual, and 
 delivery proving neither longer nor more laborious. (7) As a general rule 
 no treatment is required. If general plethora prevails, bleeding may be re- 
 sorted to. With rare exceptions, the pregnancy should be left to itself, and 
 the labor allowed to terminate by the sole efforts of natui'e.^ 
 
 Notwithstanding that various authors differ as to the origin of 
 this affection, yet all agree as to the treatment which it demands. 
 This is exceedingly simple. It consists mainly in the avoidance 
 of all moral and physical excitement, and in the adoption of 
 perfect rest in the recumbent posture until after the discharge 
 has quite ceased for several days. If there are any symptoms 
 which seem to indicate a prospect of uterine contractions setting 
 in prematurely, a dose of the extract of belladonna had better 
 be administered. 
 
 5. Dropsy of the Amnion. — Having already alluded to the 
 
 1 Gazette Medicale de Paris. Nos. 29, 30, .19, 11, 13, 47, and 49. Paris, 1858.
 
 DROPSY OF THE AMNION. 445 
 
 occurrence of this singular affection, and having made some 
 observations on its cause and diagnosis (p. 17C), it is now only 
 necessary to offer a few remarks on the symptoms which it gives 
 rise to, and the treatment which they demand. 
 
 The symptoms are chiefly such as may be produced by any 
 circumstance which gives rise to great distension of the abdomen. 
 The patient suffers so much inconvenience from moving about 
 that she is often compelled to keep in bed ; and being unable to 
 lie down, is obliged to be propped up with pillows. She has 
 alarming attacks of palpitation and dyspnoea ; while fits of taint- 
 ing frequently occur. There is great mental depression and 
 prostration of the vital powers. The stomach is very irritable, 
 so that the sufferings are greatly aggravated by repeated attacks 
 of vomiting. Moreover, there is a scanty secretion of urine, 
 though the calls to micturition may be very numerous and urgent. 
 The uterus soon acquires a remarkable volume, being often more 
 distended at the fifth or sixth month than it is at the full term in 
 normal gestations ; while fluctuation, with a distinct appearance 
 of undulation, can often be detected by palpation. Of course, 
 the increased size of the womb will depend upon the quantity' of 
 liquor amnii secreted. But when it is recollected that from twelve 
 to sixteen ounces is the normal amount, it can easil}' be under- 
 stood that even four or six or eight pints will 1 e sufiicient to 
 pi'oduce very considerable inconvenience. How great then must 
 have been the suft'ering in those cases where, as authors relate, 
 thirt}^ forty, and even fifty pints have existed in the amniotic 
 cavity. 
 
 Several instances have been reported showing that, even prior 
 to the sixth month of gestation, the distension has not been so 
 very remarkable, and yet there has been almost complete as- 
 phyxia; this condition being indicated by nearly total cessation 
 of the respiration, inability to feel the pulse, and lividity of the 
 features. It is strange to find such urgent symptoms produced 
 in these cases of dropsy, when perhaps the womb is not larger 
 than it is at the ninth month. But there are I believe three cir- 
 cumstances which explain this anomaly. Firsts the blood is not in 
 a healthy condition ; as is indicated by the oedema which exists, 
 and by the albuminuria which will often be found to be present. 
 And it is certain, that the greater the amount of albumen present 
 in the urine, tlie smaller will be the proportion in the blood.
 
 446 DISEASES OF THE GENERATIVE ORGANS. 
 
 Secondly,! have found that the amount of albumen in the liquor 
 amnii itself is considerably greater than it ought to be. This 
 fluid, in its healthy condition has the properties of a ver}^ weak 
 solution of albumen ; the proportion of the latter being greatest 
 during the earlier months of conception. Thus, about the fourth 
 month it forms rather more than 10 per cent, of the liquid; at 
 the fifth month, a little more than 7 per cent. ; at the seventh 
 month, less than 6 per cent. ; while at the full term there is 
 scarcely 1 per cent. And, thirdly, ownng to the sudden and 
 rapid development of the uterus, the abdominal walls have not 
 had time to gradually relax and yield; so that instead of the 
 uterus being able to project in front, it is forced backwards and 
 upwards against the diaphragm. 
 
 In one case, the distension of the uterus became so great and 
 the diaphragm got pushed up so high, that the respiration was 
 very greatly interfered with. The abdomen seemed of a remark- 
 able size ; but the chief distress was from the dyspnoea, which at 
 times became so urgent that although gestation had only ad- 
 vanced to the seventh month the woman's life appeared to be 
 very seriously endangered. Some diversity of opinion existed 
 amongst the phj-sicians in attendance as to the best means of in- 
 ducing labor: the difficulty being at length solv^ed by a determi- 
 nation not to interfere until the os uteri evinced a tendency to 
 dilatation. It soon appeared clear, however, that unless relief 
 was afforded the patient would die of suffocation ; and therefore 
 the practitioner who had the responsibility of the case very prop- 
 erly ruptured the membranes. By keeping his finger in the os 
 uteri he so regulated the discharge of the liquor amnii that only 
 a portion came aw^ay at a time; but at the end of two liours four- 
 teen pounds had been collected in basins, and an uncertain 
 quantity lost in the bed. All the distressing symptoms — includ- 
 ing the dyspnoea, vomiting, and cough — immediately disap- 
 peared, while the oedema of the extremities began to diminisli ; 
 Ijut as the uterus appeared incapable of contracting, the cervix 
 was dilated and a living infant brought away by the forceps. 
 The child was puny and feeble, and its limbs were very small. 
 In six weeks the patient got quite restored to health ; and in two 
 years she again became pregnant, and went through the process 
 of parturition in a natural and satisfactory manner. 
 
 The consequences of this state to the foetus are usually very
 
 RHEUMATISM OF THE UTERUS. 447 
 
 disastrous. Either it perishes, and the pregnancy spontaneously 
 terminates prematurely ; or the infant when born at the proper 
 time is small and feeble, so that not unfrequently it only sur- 
 vives its birth a few hours. A remarkable circumstance in these 
 cases, pointed out by MM. Bunsen and Kill, is that the foetus 
 is often dropsical ; sometimes being affected with ascites, and 
 sometimes with hj'drocephalus. The latter gentleman has also 
 remarked that the placenta is often remarkably large, in one 
 case especially, which ended at the sixth month, this organ. being 
 one-third larger and double the thickness of an ordinary placenta 
 at the end of the ninth month. As regards the mother, the labor 
 is very likely to be tedious ; while the act of delivery is apt to be 
 followed by serious flooding, owing to the uterus having par- 
 tially lost its tone and contractile powers. 
 
 In the treatment of this malady medicines will be found to 
 have no beneficial effect. Many attempts have' been made to 
 impede the progress of the dropsy by diuretics and drastic pur- 
 gatives; but such remedies have proved worse than useless. All 
 that the practitioner can do, is to support the maternal strength 
 by nourishing food and tonics; to keep the mind and body tran- 
 quil ; and if the distress be great, to induce premature labor by 
 rupturing the membranes. Care must be taken to prevent ex- 
 haustion during a tedious labor; and the occurrence of hemor- 
 rhage ought to be guarded against by the administration of one 
 or more full doses of ergot, as well as by the proper employment 
 of pressure, directly after the birth of the child. 
 
 6. Kheumatism of the UtiiRUS. — This affection either occurs 
 alone, or it may exist in combination with a general attack of 
 acute or chronic rheumatism. It is not common. Being more 
 frequently met with towards the end of gestation than at any 
 other period of pregnancy, it is doubtless often the cause of un- 
 easiness which is mistaken for false labor pains. More frequently 
 of the subacute than of the actually acute form, it arises from all 
 those circumstances wdiich are favorable to the development of 
 rheumatic aflections generally, especially in such women as are 
 constitutionally predisposed. 
 
 The symptoms consist chiefly of pain in a portion or the wdiole 
 of the uterus. The suflering is increased by pressure, and is ren- 
 dered very distressing by the movements of the foetus ; while it
 
 ^ 
 
 448 DISEASES OF THE GENERATIVE ORGANS. 
 
 varies in severity from a simple feeling of heaviness to an annoy- 
 ing dragging sensation. There is a frequent desire to empty the 
 bladder, the [»assage of the water sometimes causing severe smart- 
 ing sensations; and the urine is commonly loaded with urates. 
 The rectum sympathizes with the uterus, giving rise to tenesmus. 
 There is usually also a certain amount of constitutional distur- 
 bance; such as fever, thirst, agitation, restlessness, and — particu- 
 larly towards the end of the attack — profuse acid perspiration. 
 When the rheumatic pains are very severe, uterine contractions 
 are likely to ensue and to be followed by premature delivery. 
 But this happens more rarely thani might be expected, owing 
 probai)ly to this circumstance, — thapu'hereas in natural labor the 
 -contractions commence at the fundus and terminate at the lower 
 segment of the ucerus, in rheumatism they commence at the 
 painful point and are only irregularly propagated towards the 
 cervix. Lastly, an attack of rheumatism at the period of partu- 
 rition generally retards the progress of the labor; it renders the 
 uterine contraction very painful from the commencement; and 
 it is sometimes the cause of flooding after the expulsion of the 
 child and placenta, owing to its influence in preventing perfect 
 uterine contraction. 
 
 The treatment of this affection is not difficult; opium, bicar- 
 bonate of potash, an abundance of refrigerant or saline drinks, 
 and perfect rest generally sufficing to effect a cure. A fomenta- 
 tion flannel, or a belladonna plaster, applied over the abdomen, 
 will sometimes be found useful. A blister to the sacrum gives 
 considerable ease. The diet should be nourishing, but free from 
 stimulants ; and the bowels ought to be kept regular by mild 
 antacid laxatives, to which it may sometimes be useful to add a 
 little colchicum. 
 
 I have heard it suggested, that in a severe case the injection 
 of carbonic acid gas into the vagina might afford relief, and could 
 not possibly do any harm. I should not recommend its use, how- 
 ever; for at the best it would only soothe for a short time, while 
 it might certainly do permanent mischief. The following case, 
 related by Professor Scanzoni, shows that the injection of this 
 agent into the uterus may be fatal; and although there would, 
 of course, be much less risk in only applying it to the vagina, 
 yet an accident might happen. The chief points in the history 
 are these :
 
 INFLAMMATION OF THE UTERUS. 449 
 
 A youno: pregnant woman was about to undergo amputation of what was 
 thought a hjpertrophied cervix uteri; which protruded out of the vulva in 
 the form of a bluish, chinky tumor, of the size of a small apple. The attend- 
 ing physician — the father of the patient — not thinking she was pregnant, 
 insisted upon having carbonic acid injected into the cavity of the uterus, 
 preparatory to the operation, with the view to prevent too profuse a hemor- 
 rhage (!). This injection was made by means of a suitable apparatus; but 
 hardly had some cubic inches of gas penetrated into the cervix, when the 
 patient screamed, and said that she felt the air rushing into her abdun)en, 
 neck, and head. General tetanic convulsions supervened; then a long agony, 
 followed by death at the end of nearly two hours. At the autopsy no other 
 lesion was found to which death was attributable, but a very considerable 
 oedema of the lungs. The uterus contained an uninjured ovum of about 
 four months. The question arises, was the death due to the poisonous quali- 
 ties of the carbonic acid ? or could the gas have penetrated into the orifice of 
 an open vein, and have acted like air introduced into the veins?^ 
 
 In some severe examples of rheumatism of the uterus it has 
 been deemed expedient to bring on premature labor; but the 
 necessity for such an extreme proceeding can very rarely arise. 
 
 7. Inflammation of the Uterus. — Acute inflammation of the 
 unimpregnated womb is admitted by all observers to be a very 
 rare affection, and one vvhicli seldom endangers life even when it 
 does occur. But I believe metritis during pregnancy to be a still 
 more uncommon ailment ; so that had I not met with one un- 
 doubted instance which ended in suppuration, I should perhaps 
 have been inclined to agree with those obstetricians who alto- 
 gether deny its occurrence. It is, without doubt, quite certain 
 that an extensive practice may be carried on for several years 
 without an example of inflammation of the pregnant uterus being 
 met with ; but I regard it as an equally established fact that the 
 disease does occasionally manifest itself. 
 
 The seat of the inflammation, speaking generally, is the mus- 
 cular tissue ; the peritoneum and the lining membrane being 
 seldom involved. The more advanced the pregnancy, the more 
 limited will be the morbid action ; the entire organ wnth all its 
 tissues being only very rarely affected, and then only in the first 
 two or three months. The disease frequently assumes an ery- 
 sipelatous type ; and perhaps arises from some deterioration of 
 the blood, from cold and damp, from mechanical injuries, or it 
 may spread from neighboring organs — as in instances of cystitis, 
 ovaritis, dysentery, &c. The starting-point of the affection, in an 
 
 1 Beitrage zur Geburtskunde und Gynaekologie. Band iii, p. 181. Wurzbiirg, 1858. 
 
 29
 
 450 DISEASES OF THE GENERATIVE ORGANS. 
 
 unhealthy subject, may be an exaggerated degree of congestion 
 of the uterus. This latter condition can doubtless result from 
 general plethora ; but usually it is probably otherwise, since it is 
 most commonly witnessed in nervous women suffering from 
 anaemia or perhaps even from albuminuria. Such a circumstance 
 will not appear surprising, when it is remembered that these 
 females are precisely those who are most often afflicted with 
 hemorrhoidal discharges, or who have abundant catamenial flows 
 when not pregnant. The chief symptoms of uterine congestion 
 are a feeling of tightness in the abdomen and of weight in the 
 pelvis ; together with pains in the Joins and groins. The upper 
 part of the thighs may be also the seat of a dull sense of un- 
 easiness, which is augmented by standing and by efforts at de- 
 fecation. Moreover, micturition is frequent; and slight uterine 
 contractions are often felt. If pregnancy is too little advanced 
 for the woman to have perceived the foetal movements, the ap- 
 pearance of these will be retarded ; or if they have been mani- 
 fested, they diminish in frequency and even cease entirely. At 
 length, perhaps, a slight flow of blood takes place from the vulva. 
 The consequences of this congestion may be very grave ; since, 
 in addition to the chance of its terminating in metritis, it has 
 likewise an influence in developing hemorrhage and premature 
 contractions. The results to the product of conception are also 
 dangerous ; inasmuch as it may not only be the cause of engorge- 
 ment or apoplexy of the placenta, but, according to some ob- 
 servers, may give rise to deformity by producing compression 
 and contraction of the foetal limbs. 
 
 The constitutional symptoms of metritis are much the same as 
 those produced by inflammation of other important viscera ; 
 chiefly consisting of a feeling of general discomfort, heat of skin, 
 quickness of pulse, restlessness, loss of appetite, great thirst, 
 nausea and vomiting, &c. When only a limited portion of the 
 uterine walls is aftected, the prominent local symptom will be 
 excessive sensibility of this part ; the tenderness being exasperated 
 by pressure, as well as by the active movements of the foetus. If 
 the disease attack the lower segment of the uterus, the bladder 
 will be sympathetically aftected ; and the patient will be tor- 
 mented with a frequent desire to micturate. Moreover, com- 
 plaint is usually made of a sense of weight and bearing-down, of 
 great pain in the back and thighs, and of a feeling of heat and
 
 INFLAMMATION OF THE UTERUS. 451 
 
 throbbing above the piibes. lu the case which came under my 
 own observation there were attacks of pain coming on in parox- 
 ysms, and lasting for half an hour, the intervals having a duration 
 of eight and twelve hours. Tlje paroxysmal exacerbations were 
 exceedingl}' severe, and indeed were only at first relieved by 
 chloroform, which was eagerly inhaled. Full doses of opium and 
 ether afterwards mitigated the suflering. and probably obviated 
 the risk — which appeared considerable — of miscarriage. On ex- 
 amining per vaginam there was found increased heat, great ten- 
 derness of the cervix, and enlargement of the vessels, which 
 could be felt rapidly and strongly pulsating. 
 
 The consequences of metritis setting in daring gestation may 
 be very serious. Where the disease is limited, or when it is 
 early and completely cured, both mother and foetus may escape 
 unharmed. The termination of the inflammation in resolution, 
 cannot, however, always be obtained ; and perhaps the next best 
 result to be expected is the effusion of lymph. Yet it must be 
 remembered that if the inflamed part coincide with the seat of 
 implantation of the placenta, the eff^ect of the pouring out of 
 coagulable lymph may be to cause unnatural adhesion of this 
 organ to the uterine walls; in which case the adherent placenta 
 will in all probability require manual interference to eftect its 
 separation after the birth of the infant. A third mode of termi- 
 nation is in suppuration, and the formation of an abscess in the 
 uterine tissue. This abscess may open into the interior of the 
 uterus, or into the cavity of the peritoneum, or into the bladder 
 or rectum. In the case to which allusion has already been made, 
 the cervix was the part chiefly involved and the abscess pointed 
 in the vagina, so that on making a small puncture its contents 
 were safely evacuated. A fourth and important result is a soften- 
 ing of the inflamed tissue. The uterine parietes during preg- 
 nancy are naturally very much less dense and resisting than in 
 the non-gravid state ; and consequently when the softening pro- 
 ceeds to an abnormal extent, the consequences may often prove 
 serious. At a meeting of the Pathological Society of Dublin, 
 26th January 1839, Dr. E. Kennedy exhibited a specimen of " soft- 
 ening of the uterus," taken from the body of a woman who died 
 on the day of her admission into the Lying-in Hospital. The 
 only symptom of any note which she had complained of was pain 
 at the upper and inner part of the thigh, where a slight redness
 
 452 DISEASES OF THE GENERATIVE ORGANS. 
 
 was observable. On dividing the parietes of the abdomen, the 
 uterus was seen of a deep purple or almost black color, while its 
 texture was remarkably soft, and its mucous surface covered with 
 grumous blood. — The occurrence of rupture of the uterus during 
 pregnancy is I believe oniy to be accounted for on the supposition 
 that the tissues have been previously softened by the inflamma- 
 tory process. It seems otherwise incredible that an attack of 
 vomiting, or a fit of passion, should suflftce to rupture the walls 
 of the womb; though these circumstances would be quite sufii- 
 cieut when the parts had previously been weakened by disease. 
 
 It is hardly suprising that metritis should not unfrequently 
 produce miscarriage or premature labor. If the inflammatory 
 action continue after the expulsion of the ovum, that process of 
 involution by which the uterus is restored to the size and condi- 
 tion it presented prior to conception will be retarded. The de- 
 ficient involution which thus results is often the foundation, as 
 it were, for future chronic disease of the uterine substance ; 
 which disease may annoy the patient for years, materially injure 
 her health, and prevent her from again conceiving. 
 
 The treatment of these cases is exceedingly simple. At the 
 very commencement complete rest in bed and a simple diet 
 must be insisted upon. If there be much fever, the solution of 
 citrate of ammonia in halt-ounce doses may be given every four 
 or six hours ; together with plently of diluents in the shape of 
 iced water, barely water, tea, or lemonade. When the local 
 suttering is great, relief may very quickly be afforded by the ap- 
 plication, through the speculum, of three or four leeches to the 
 lips of the uterus ; a proceeding which will be found more efli- 
 cacious and much less dangerous than the use of a dozen leeches 
 to the hypogastrium or groins. liemembering, too, that the 
 morbid action is frequently of an erj^sipelatous character, it will 
 be a wise course not to lower the patient's strength ; and on this 
 ground alone, not to mention other reasons, general bleeding 
 ought to be forbidden. Anodyne fomentations or hot poultices 
 can be laid over the abdomen without any fear of their inducing 
 uterine contractions ; or sixty grains of the extract of belladonna 
 may be spread over the parietes, and the latter covered with a 
 linseed poultice. Supposing the suffering to be very severe, and 
 to be the source of much restlessness, opiates in full doses will be 
 demanded ; while if the pain recurs in paroxysms and is ex-
 
 UTERINE HEMORRHAGE. 453 
 
 cessive, tlie exhibition of chloroform ma}- be found necessary, 
 or opiate enemata can be resorted to. If we suspect the forma- 
 tion of an abscess, or the occurrence of gangrene — wliich has 
 been said to happen — steps must be taken to support the 
 woman's strength by administering .ammonia and bark, or 
 quinine; together with nourishing food and wine or porter. 
 Should the inflammation appear to have any connection with a 
 syphilitic taint, no remedy will be found more useful than the 
 perchloride of mercury ; it being best to give the pharmacopoeial 
 solution of this metal, in drachm doses, every six or eiglit hours. 
 And then, lastly, the practitioner must l)e advised to watch his 
 patient very carefully, and to do so until she seems quite re- 
 stored to health. It will also be prudent for him to calculate 
 the dates at which she would be menstruating, were it not for 
 her being pregnant, so that she may then be particularly cau- 
 tious as to her exercise, diet, use of purgatives, &c. ; since it is 
 highly probable tRat the uterus becomes somewhat congested at 
 these times, and very often only a slight spark is needed to re- 
 kindle the inflammatory action wliich may have just subsided. 
 
 8. Uterine Hemorrhage. — Of the many topics which come 
 w^ithin the range of obstetric medicine, few demand greater at- 
 tention than the one now to be treated of. For not only is a dis- 
 charge of blood from the pregnant uterus a prominent symptom 
 of several difterent lesions, but the consequences which may re- 
 sult from it are often of vital importance both to the mother and 
 her offspring. JSTow the subject being so serious and extensive, 
 it is only natural that much doubt should be felt as to the best 
 method of dealing with it, in order succinctly to impart all the 
 information that is possible regarding this matter. The simplest 
 plan seems to me to do that here which it is always necessary to 
 carry into practice at the bedside ; viz., to trace the eft'ect to its 
 exact cause. We shall thus have an arrangement, which, if not 
 faultless, has at least the great recommendation of being conve- 
 nient ; while it may also serve to remind us that it will be use- 
 less to expect success in the treatment of these cases unless we 
 attack the source of the hemorrhage instead of resting content 
 with merely prescribing for the symptom. 
 
 In the first place, then, the subject of hemorrhage as it arises
 
 454 DISEASES OF THE GENERATIVE ORGANS, 
 
 from disease of the uterus, claims attention. During the early- 
 weeks of gestation, the great hypertrophy and vascularity of the 
 uterine mucous membrane which naturally exists, together with 
 the remarkable development that the whole glandular apparatus 
 of the cen'ix then undergoes, predisposes to a sanguineous as 
 well as to a leucorrhoeal discharge ; so that slight causes are suf- 
 ficient to directly excite a flow of blood. It can be easilj^ under- 
 stood that this congestion is much' increased by the coexistence 
 of disease; and as readily may it be believed that amongst the 
 disorders which particularly have this eft'ect is chronic inffamma- 
 tory ulceration of the cervix. This aiFection will generally be 
 found to have existed prior to the occurrence of pregnancy; for 
 although it may prove the cause of sterility in newly-married 
 women who have never conceived, yet it does not appear so fre- 
 quently to have this effect in females who have previously had 
 children. The prominent sj-mptoms which are produced by in- 
 flammation and ulceration of the cervix are these: A profuse 
 mucous or muco-purulent discharge ; a sensation of pelvic weight 
 and bearing-down; continued pain in the back, particularly over 
 the sacrum, which is increased by fatigue; and sometimes pain 
 in the ovarian regions, which is occasionally very severe. Sexual 
 intercourse also causes suftering, and very generally brings on 
 slight bleeding. On practising the touch, an educated finger 
 readily detects abrasion of the mucous membrane, coml»ined 
 with a pulpiness of tissue ; while on introducing the speculum 
 the labia will be found presenting a vivid red and velvety and 
 granular appearance, and giving exit to a muco-purulent or san- 
 guineous discharge. !N"ot unfrequently the granulations have a 
 fungoid appearance, almost resembling in their luxuriance an 
 extensive malignant ulcer; and the os uteri is then found some- 
 what patulous. The whole cervix is also soft and congested, and 
 after the first few months of gestation is directed backwards 
 towards the sacrum ; but these conditions are quite normal under 
 the circumstances, and are not dependent upon the morbid state 
 of the textures. 
 
 The fact has already been pointed out that the attacks of hem- 
 orrhage to which this disease gives rise not unfrequently occur 
 periodically ; so that they have been mistaken for the catame- 
 nial flow. But it must be allowed that more generally the dis- 
 charge of blood happens much too often to simulate menstrua-
 
 UTERINE HEMORRHAGE. 455 
 
 tion ; coming on after any extra exertion, or even following upon 
 sudden mental emotion. At the same time, the hemorrhage, 
 though easily produced, is neither continuous nor very abundant, 
 and it probably ceases spontaneously on the patient assuming the 
 recumbent postare, — a position by the#by that is often the only 
 one which affords any relief to the lumbar pain. Such being tlie 
 chief symptoms, it is not surprising that the general health 
 should be considerably diminished below the normal standard. 
 The patient soon becomes weak and loses flesh. Any extra ex- 
 ertion distresses her. There is mental depression ; and fre- 
 quently great irritability is manifested on trifling matters. She 
 is also troubled with constipation, nausea, headache, attacks of 
 faintness, vertigo, and palpitation ; and in not a few cases by 
 aggravated sickness. The feeble condition of system thus en- 
 gendered predisposes to abortion ; while if the inflammatory con- 
 gestion of the uterus proceeds to an excessive degree, it may at 
 once provoke this accident by causing disease of the placenta 
 and death of the foetus. 
 
 The object of our treatment must be to heal the ulceration ; a 
 desideratum which can only be obtained by a skilful combina- 
 tion of constitutional with local remedies. But before taking- 
 charge of the case it will always be advisable for the practitioner 
 to explain to the patient and her friends the danger which exists 
 of the disease producing miscarriage ; as otlierwise, should pre- 
 mature expulsion of the foetus happen, it might very unjustly be 
 attributed to his etiTorts to eft'ect a cure. 
 
 The constitutional treatment will vary with the exact condition 
 of the patient; but it will always be necessary to advise perfect 
 rest in bed, the avoidance of sexual intercourse, complete mental 
 tranquillity, and a light nutritious diet. Supposing the circum- 
 stances to permit of it, benefit will generally accrue from allow- 
 ing a moderate quantity of some light wine, particularly such as 
 champagne, sparkling moselle, hock, or claret. In many in- 
 stances a little brandy and water twice or thrice in the day is of 
 advantage; but I have always found harm arise from the use of 
 malt liquors. As regards medicines, my favorite remedy is the 
 perchloride of mercury; of which from the one-sixteenth to the 
 eighth of a grain may be given thrice in the da}^ either in solu- 
 tion or in a pill with two or three grains of conium. If there be 
 much weakness the compound tincture of bark in one or two
 
 456 DISEASES OF THE GENERATIVE ORGANS. 
 
 drachm doses three times a day, or the officinal liquid extract of 
 yellow bark in the proportion often or fifteen minims to an ounce 
 of peppermint water, will be found invaluable. 
 
 The local remedies will be of the same character in most cases ; 
 since we desire the removal of the fungoid granulations, and 
 their replacement by healthy tissue. Hence the cautious use of 
 caustics must be at first relied upon ; the acid nitrate of mercury 
 being required in severe cases, whereas in milder instances the 
 nitrate of silver will usually suffice. Directly the state of the 
 parts is reduced to that of a simple abraded surface, I have found 
 no agent have such a good eft'ect as the undiluted solution of the 
 subacetate of lead, which should be freely applied, through the 
 speculum, every second or third day. At the same time the cure 
 will be hastened by the patient's using properly a vaginal injection 
 night and morning; which may be formed either of alum and 
 decoction of oak bark, or of sulphate of zinc and water, or of the 
 solution of subacetate of lead in the proportion of half an ounce 
 to a pint of rain-water. 
 
 Pregnancy is occasionally complicated with fibrous jjol^pus of 
 the uterus, but I have not seen any marked symptoms produced 
 thereby during the term of gestation. The injurious etlects re- 
 suiting from these tumors are manifested at the time of parturi- 
 tion ; when they are liable to impede the labor, or to give rise to 
 hemorrhage after the expulsion of the child by preventing due 
 contraction of the womb. Even growths which are of small size, 
 and which perhaps have given no indications of their existence 
 prior to fecundation, may prove very troublesome at the time of 
 labor ; inasmuch as there is every reason to believe that they par- 
 ticipate in the general development of the uterus, and gradually 
 attain a considerable bulk. — A lady who was under my care a 
 few years back, suffered from profuse attacks of hemorrhage 
 during the first three months of pregnancy ; for the relief of which 
 large doses of every variety of astringent had been prescribed in 
 vain. On examination, two inucous yolypi not much larger than 
 peas were found developed on the anterior lip of the womb ; on 
 the removal of which little growths by torsion and scraping, all 
 bleeding ceased. Labor subsequently came on at the proper time, 
 and a healthy child was born without any untoward occurrence. 
 
 A few words must suffice on the subject of hemorrhage as it 
 arises from uterine cancer. It is strange that a woman afflicted
 
 UTERINE HEMORKHAGE, 457 
 
 with this dire mahidy should not have her fertilit}^ destroyed; 
 but even the existence of ulcerated carcinoma does not seem to 
 prevent fecundation, though it renders the process of childbirth 
 one of extraordinary danger and fatality. Fungoid or medullary 
 cancer is by far the most frequent variety of malignant disease 
 which attacks the uterus ; scirrhus or hard cancer l)eing particu- 
 larly rare in this situation. There are four prominent symptoms 
 of ulcerated carcinoma, — viz., the cancerous cachexia, pain, an 
 offensive watery discharge, and hemorrhage. The first is so 
 strikingly peculiar and well-marked that from it alone the nature 
 of the constitutional disorder may be diagnosed by the tutored 
 eye ; while the merest tyro cannot confound it with the appear- 
 ance produced by anaemia from hemorrhage, or with that which 
 characterizes tuberculosis. The pain is generally severe in pro- 
 portion as the disease is far advanced ; and very often amounts 
 to the most frightful agony in the latter stages. The watery dis- 
 charge is not only abundant, but commonly very unpleasant and 
 fetid, owing to its admixture with particles of the decaying tissue 
 of the aflected part. In some cases there is a continuous, though 
 not abundant, draining of blood ; in other instances there is merely 
 a periodical sanguineous discharge, simulating an abundant cata- 
 menial flow; while in a third class we find profuse gushes of 
 blood, coming on without any warning at intervals of a few days, 
 and being succeeded by a lightly-colored serous discharge. The 
 duty of making a vaginal examination when a patient labors 
 under the foregoing symptoms is so obvious that it would be al- 
 most impertinent to insist upon it, did not experience show that 
 the practice is still not unfrequently neglected. By such an ex- 
 amination the nature of the disorder is at once ascertained ; for 
 in at least 98 per cent, of the cases of uterine cancer the disease 
 begins in the cervix, and not in the body of the womb. 
 
 In epithelioma, and in that peculiar disease — corroding or 
 rodent ulcer — first described by the late Dr. John Clarke, there 
 is a watery discharge; but it is not usually fetid, since there is 
 not the same decay of tissue as in ulcerated carcinoma. In the 
 former disease also, the large granular outgrowth — commonly 
 known as cauliflower excrescence — readily bleeds ; while the same 
 thing often happens, though to a less extent, when the affection 
 assumes the form of an intractable ulcer.
 
 458 DISEASES OF THE GENERATIVE ORGANS. 
 
 In the second place, liemorrhage as it is a precursor of ahortioyi 
 demanils our notice. "Whatever cause 'destroys the connection 
 between the ovum and the uterus will give rise to a discharge of 
 blood. Until about the fourth month of gestation, the separation 
 may occur at any part of the ovum ; this body being attached by 
 its membranes to every part of the uterine parietes. But sub- 
 sequently, when the placenta is formed, it is of course only at the 
 seat of attachment of this organ that disruption takes place. 
 The abundance of the hemorrhage will directly depend upon the 
 extent of placental detachment, and the age of the pregnancy. 
 Moreover, in the early months, the result will in some degree be 
 regulated by the seat of separation : for if it hapj^en just above 
 the cervix no ill consequences to the mother or foetus may ensue; 
 whereas when it takes place at the fundus, the blood in its course 
 downwards necessarily increases the mischief by still further 
 rupturing the connecting medium. With some women very 
 slight accidents sulEfice to separate the ovum from the uterus, and 
 the former comes away easily after a few gushes of blood. Yet 
 every now and then the union remains firm at one or more parts; 
 the patient having attacks of flooding for days or even weeks, 
 until the entire separation is effected. 
 
 The general symptoms of abortion, the dangers which arise 
 especially from the hemorrhage, and the appropriate line of 
 practice to adopt in all these cases, are points which have been 
 so fully treated of in the chapter devoted to this subject, that 
 further observations here are unnecessary. But before passing 
 onwards there is one peculiar class of cases which must not be 
 overlooked ; the important feature in which is that the blood 
 effused from the utero-placental circulation, instead of escaping 
 by the vagina, is retained in the womb. A few of these inter- 
 esting examples of concealed accideiital lumorrliage durhig gestation 
 have been recorded by various authors ; and from them the two 
 prominent facts may be gleaned, that the early symptoms are 
 obscure, while the danger to life is very great. In a case which 
 occurred in my own practice some few years ago, and which I 
 fully reported at the time,^ it appeared to me that death would 
 certainly have resulted had not the patient been seen at an early 
 stage, and the nature of the accident been promptly recognized. 
 
 1 The Medical Times. London, 18th October, 1851.
 
 UTERINE HEMORRHAGE. 459 
 
 The symptoms produced l)y this condition are just those which 
 are due to loss of blood generally; with this important addition, 
 that the uterus is found tense and distended and perhaps irregular 
 in form, while it also gradually enlarges as the disposition to 
 syncope increases. Of course, too, the results are more appalling 
 ill the late than in the early months ; for not only do the blood- 
 vessels get larger and larger as the time of parturition approaches, 
 but the uterus seems then to be capable of greater exj^ansion. 
 Moreover, the uterine veins, though developed to an extraordinary 
 size, have very feeble walls, and during gestation at least are 
 destitute of valves ; so that rupture easily occurs from any cause 
 which produces engorgement of the venous apparatus. The ne- 
 cessity for a very guarded prognosis will be apparent from the 
 fact, that seven mothers perished out of the ten published in- 
 stances of concealed hemorrhage with which I am acquainted. 
 In the fatal cases the accident occurred at the full term ; whereas 
 of the women who recovered two were seven months and a half 
 gone, while my patient w^as eight months and a half advanced. 
 In almost all the cases the children appear to have been stillborn. 
 The indications for treatment are twofold : namely, to stop the 
 hemorrhage, while we support the vital powers. The formation 
 of coagula in the open mouths of the utero-placental vessels will 
 be best encouraged by the application of cold to the abdomen, 
 by maintaining the strictest quiet, and by the administration — if 
 time allow — of full doses of gallic acid. If, however, there be 
 reason to suspect that the bleeding is continuing, no time should 
 be lost in effecting delivery ; for which purpose the membranes 
 are to be ruptured, the uterus is to be excited by ergot of rye 
 and galvanism, the activity of parturition is to be aided by tlie 
 proper use of the binder, and the os is to be dilated with the 
 fingers. As soon as the condition of the parts will safely allow 
 of interference, the labor should be completed by turnino:, or by 
 the application of the forceps. In all cases the strength must 
 be kept up by stimulants, in quantities proportioned to the pros- 
 tration ; while rather than let the patient die from exhaustion, 
 transfusion of blood ought to be resorted to. 
 
 Thirdly and lastly, we have to take into consideration the in- 
 teresting subject of unavoidable hemorrhage. This term is applied 
 to that variety of flooding which happens from the implantation
 
 460 DISEASES OF THE GENERATIVE ORGANS. 
 
 of the placenta over the os uteri, since the very process by which 
 the child is to be ushered into existence is the procedure wliich 
 gives rise to it. To enter into a full account of the important 
 subject of placenta prsevia on the present occasion, would, I ap- 
 prehend, answer no useful purpose; while a discussion of the 
 -various opinions entertained regarding it would certainly be out 
 of place. My aim is simply to put the practitioner on his guard, 
 and to show him that frightful attacks of hemorrhage may take 
 place during the last three months of pregnancy from this 
 source.^ 
 
 The mode in which the insertion of the placenta over the os 
 uteri acts as a cause of hemorrhage during the last three months 
 of gestation, as well as in the course of labor, requires explana- 
 tion. Most writers state that up to the fifth calendar month 
 pregnancy chiefly affects the body of the uterus; but that after 
 this time the neck also undergoes important modifications. This 
 part, it is said, then experiences a diminution in length, accom- 
 panied by a considerable expansion of its superior portion on a 
 level with the internal oTifice. The placenta being fixed cannot 
 follow this spreading out of the upper part of the cervix, and 
 hence its bond of union with the womb becomes more or less 
 ruptured. But unfortunately for this view it seems certain, as 
 has already been explained, that the neck does not shorten nor 
 spread out at its superior part in the way which has been so long 
 supposed; since on the contrary it preserves its whole length 
 until the last fortnight of pregnancy. Hence we must seek for 
 another solution of this circumstance; and the most plausible 
 one with which I am acquainted is that given by M. Cazeaux. 
 This gentleman says: "During the first six months of gestation 
 the uterus is developed more especially at the expense of the 
 fibres of the superior part of the body or fundus of the organ ; 
 while in the last three months the fibres appertaining to the 
 lower third of the womb are developed in a rapid manner, and 
 the cavity of the organ is enlarged in consequence of the disten- 
 sion and growth of this lower part; a proof of which is, that the 
 body of the uterus, which was pyriform in the earlier months, is 
 perfectly ovoidal in shape towards the close of pregnancy ; and 
 I will further remark, that the development of the placenta is 
 
 1 For an exposition of the whole subject the reader may be referred to Dr. Robert 
 Barnes's lectures on Tlie Piiysiology and Treatment of Placenta Pra-via. London, 1S58.
 
 UTERINE HEMORRHAGE. 461 
 
 far more rapid in the first six than in the last three months. 
 Now, this double circumstance seems to me quite sufficient to 
 account for the production of liemorrhage; for when the placenta 
 is attached to the fundus, its growth is simultaneous with the 
 enlargement of that portion of the uterine walls on which it is 
 implanted, and it is evident that no hemorrhage need occur; but 
 when the after-birth is inserted over the cervix uteri, or on some 
 adjacent point, the contrary must necessarily ensue, because the 
 growth of the placenta is nearly completed, whilst a more con- 
 siderable extension of the lower third of the womb has yet to 
 take place. Of course, the placenta can no longer partici[)ate 
 in this rapid development, by conforming to the increase of the 
 uterus, and by following the extension of the wall on which it 
 is inserted; and hence it spreads out from the centre towards its 
 circumference, the fissures between the cotyledons become larger, 
 and its difterent lobes are thus widely separated ; but the growth 
 of the interior wall of the uterus is so rapid in the latter months, 
 that this mechanical enlargement of the placenta, on which M. 
 Jacquemier has particularly insisted, is no longer sufficient to 
 prevent the tension of the utero-placental vessels, or of the cellu- 
 lar tissue in which they ramify ; and this tension being ultimately 
 carried to an extreme, all of these cellulo-vascalar adhesions give 
 way and become ruptured, and this gives rise to the production 
 of hemorrhage."^ M. Cazeaux then goes on to show that this 
 theory explains the hemorrhages which occur when the placenta 
 is attached to the lower part of the womb, or some point adjacent 
 to the internal orifice; for it is not because the after-birth is im- 
 planted over the cervix that a flooding takes place during the 
 latter months of pregnancy, but because it is in relation with the 
 inferior third of the uterus. 
 
 The treatment of these attacks of flooding prior to the setting 
 in of labor can never be otherwise than a matter of considerable 
 anxiety ; for a false step is very likely to be speedily fatal. At 
 the time of the discharge, all those measures usually recom- 
 mended in cases of uterine hemorrhage from any cause ought 
 to be resorted to ; and care must especially be taken that the 
 patient is kept absolutely quiet in the horizontal position, with 
 but little bed-clothing, and in a well-ventilated apartment. 
 
 ' A Theoretical and Practical Treatise on Midwifery, &c. By P. Cazeaux. Second 
 American, translated from tiie fifth French Edition, by W. R. Bullock, M.D., p. 684. 
 Philadelphia, 1657.
 
 4G2 DISEASES OF THE GENERATIVE ORGANS. 
 
 Cold or even iced acidulous drinks may be given freely with 
 advantage ; while cloths dipped in vinegar and water can be ap- 
 plied to the vulva and over the lower part of the abdomen, un- 
 less the skin is chilled and clammy, and the pulse small and 
 feeble. When the loss has been inconsiderable, when there is 
 no reason to fear the occurrence of premature labor, and when 
 the sj'stem is excited, it will often be useful to give a dose of 
 opium ; two grains of the extract in a pill being a good form, 
 unless the enema opii of the British Pharmacopoeia be preferred. 
 But if the flooding is profuse and continuous, and the os uteri 
 undilated, agents which are calculated to have an immediate and 
 more decided influence must be resorted to. Of these the chief 
 is the tampon or plug, which is best formed of cotton-wool ; 
 although strips of linen, bits of charpie, or common tow, will 
 answer the same purpose. Whichever substance may be chosen, 
 its eflicacy will probably be increased by saturating it with vine- 
 gar; and small portions of it are then to be introduced, one 
 after the other, right up to the orifice of the wonjb, until the 
 vagina is closely packed. In one instance whicli I had recently 
 to treat, the hemorrhage was readily stopped for a time by soak- 
 ing a small piece of wool in a strong solution of the perchloride 
 of iron and passing it riglit up between the lips of the uterus, 
 the plugging being completed with plain wool in the usual way. 
 The practitioner having controlled the bleeding by this means 
 must still carefully watch his patient; partly because it will be 
 requisite to administer stimulants in proj^ortion to the need for 
 them, but particularly for the reason that the plug sometimes 
 excites uterine contractions through the irritation wdiich it 
 directly produces. Thus, cases have occurred where at the end 
 of a few hours the tampon, coagulated blood, and foetus, have all 
 been suddenly expelled together. — Supposing that the flooding 
 continues, and that the mouth of the womb is only slightly di- 
 lated, it will be advisable to resort to the detachment of that 
 portion of the placenta which is implanted within the cervical 
 zone of the uterus, as recommended by Dr. Barnes. This opera- 
 tion is easily performed by the introduction of one or two fingers; 
 and hence is feasible when total detachment is quite impossible. 
 But if the flow has been great and is continuing in spite of this 
 operation, if the loss has induced great prostration, and if the 
 mouth of the uterus is dilated, it will then be better to pass a
 
 UTERINE HEMORRHAGE. 463 
 
 couple of fingers up between the placenta and uterine wall and 
 rupture the membranes at once ; afterwards endeavoring to in- 
 crease the force of the uterine contractions bj the binder, as 
 well as by two or three full doses of ergot. Should the bleeding 
 cease, the accoucheur will merely have to wait for labor pains, 
 and act as in a natural labor ; but if it continue in spite of the 
 evacuation of the liquor amnii, it only remains for him to resort 
 to turning immediately the parts are sufficiently dilated to admit 
 of the introduction of the hand without the employment of un- 
 due force. The greatest caution, however, will here be requisite ; 
 since a rupture of the cervix, even though it be only slight, will 
 probably be fatal, owing to the great size of the vessels of this 
 part when the after-birth has been implanted over it. — In con- 
 clusion, the principle cannot be too strongly inculcated that 
 each of these serious and responsible cases must be treated ac- 
 cording to the exact nature and urgency of the symptoms which 
 are present, and not after any set rule. There is no one partic- 
 ular line of practice which can be safely adopted in all instances. 
 The obstetrician having diagnosed placenta prtevia, cannot turn 
 to his dictionary and be guided by its absolute statements. Not 
 unfrequently but little or no help is required ; and in such, well- 
 meant interference will only prove a very serious incumbrance. 
 On the other hand, there are cases where life can only be pre- 
 served by the most prompt and skilful action. Thus the ability 
 of the physician will often be put to the test no less in distin- 
 guishing between these two classes, than in eflecting the ap- 
 propriate proceeding.
 
 464 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 CHAPTER XII. 
 
 THE DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 1. Prolapsus of the uterus. — 2. Anteversion of the uterus — Anteflexion. — 3. 
 Retroversion op the uterus — Retroflexion. — 4. Hernia of the uterus — Her- 
 nia of the unimpregnated organ — Hernia of the ovary, and of the Fallopian 
 TUBE — Hernia of the gravid uterus. 
 
 1. Prolapsus of the Uterus. — The fact has ah-eady been men- 
 tioned, that as soon as pregnancy takes place the uterus sinks 
 deeper into the cavity of the pelvis than it was before. This it 
 does in consequence of its increased weight; and it need scarcely 
 be said, that the more roomy the pelvis, and the greater the re- 
 laxation of the uterine ligaments and vaginal tissues, the lower 
 will be the position taken. The mere occurrence of pregnancy, 
 therefore, favors for a time the descent of the womb; and hence 
 it can scarcely be deemed surprising that cases of prolapsus occa- 
 sionally require treatment at the hands of the physician. Indeed, 
 the wonder is that examples of this affection are not much more 
 commonly met witji than they really appear to be. 
 
 The descent of the uterus during gestation, as at other times, 
 may be partial or complete, — in other words, there will exist 
 either prolapsus or procidentia. In the first instance the uterus 
 rests upon the floor of the vagina, with its lips perhaps just visi- 
 ble externally; in the second, the organ is protruded outside of 
 the genitals, and hangs down between the upper part of the 
 thighs. Either form of displacement may occur suddenly after 
 fecundation ; or complete procidentia can come on gradually as 
 an aggravated condition of a pre-existing prolapsus. As preg- 
 nancy advances to about the fourth month, and as the uterus 
 rises out of the pelvic cavity, a spontaneous cure usually becomes 
 eftected ; although more than one case is known, extraordinary 
 as it may seem, where the displacement has continued until 
 delivery. 
 
 The symptoms which result from this condition vary some-
 
 PROLAPSUS UTERI. 4G5 
 
 what according to the capacity of the pelvis. Speaking gener- 
 ally, complaint is made of considerable discomfort, of bearing- 
 down pains, of a sense of weight in the lumbar region and in the 
 groins, of more or less difficulty in micturition, and often of very 
 troublesome consti}»ation. Moreover, there is always a risk of 
 the irritation which the rectum and bladder experience being 
 reflected to the uterus, so as to give rise to premature contrac- 
 tions and abortion. 
 
 In cases of simple prolapsus all that need be done in the way 
 of treatment is to recommend the recumbent position to be main- 
 tained for a time ; while care is taken that the functions of the 
 bladder and rectum are properly performed. Indeed, especial 
 caution is necessary lest the power of micturition be interfered 
 with ; for in one recorded instance a fatal result ensued, chiefly 
 owing to the bladder having been allowed to become excessively 
 distended. Some practitioners have advised the use of a pessary 
 to support the womb; but I have never seen an instance where 
 the introduction of such an instrument during pregnancy seemed 
 aught but a greater evil than the condition it was desired to 
 remedy. — With regard to procidentia, it is necessary that the 
 uterus be gently returned within the vagina; while its further 
 descent is prevented by the patient keeping her bed for some few 
 days at least. If it be impossible for this amount of rest to be 
 obtained, a proper bandage should be worn to support thoroughly 
 the perineum and genital organs, after reduction has been eftected. 
 The use of the cold or tepid salt-water hip bath is always bene- 
 ficial ; while if there be any leucorrhoeal discharge, astringent 
 injections may be gently employed night and morning. Some- 
 times the reduction is impossible, owing to the uterus having 
 formed adhesions with the contiguous viscera; a condition which 
 may terminate in inflammation and pelvic abscess, as the pro- 
 gressive growth of the womb stretches the false membranes or 
 ruptures them. In such a case all that can be effected is to sup- 
 port the uterine tumor by a perineal bandage, while the patient 
 is confined to the bed or sofa. 
 
 Amongst the marvellous cases which occur, once in a way, in 
 the practice of medicine, are those where complete procidentia 
 of the uterus takes place toAvards the end of gestation, or even 
 during the progress of parturition. Sometimes this has happened 
 
 30
 
 466 
 
 DISPLACEMENTS OF THE URAVID UTERUS. 
 
 when there has been a head presentation: occasionally, as in the 
 drawing, the foot has been tlie advancing part. 
 
 The treatment of a case of procidentia uteri during labor re- 
 quires to be promptly carried out. The principal point is to 
 effect delivery at once, and then to replace the womb in its nor- 
 mal position. Unless the placenta has become detached imme- 
 diately after the birth of the child, I would particularly advise 
 the displacement to be reduced prior to attempting the with- 
 drawal of the afterbirth. 
 
 Tig. 16. 
 
 COMPLETE PROCIDENTIA OF A GRAVID WOMB AND INVERSION OF THE VAGINA, WITH FOOT 
 PRESENTATION, IN A MULTIPARA 38 YEARS OF AGE. (After Wagner.) 
 
 When a woman has suffered from a falling of the womb under 
 any of the circumstances we have been considering, care should 
 be taken not to allow her to sit up too soon after delivery; since 
 by proper rest during the puerperal period a radical cure may 
 often be effected, whereas by neglecting this precaution the laxity
 
 ANTEVERSION OF THE UTERUS. 467 
 
 of the ligaments and of the vaginal walls will be increased, and 
 a state of chronic procidentia induced. 
 
 2. Anteversion of the Uterus. — This displacement of the 
 pregnant uterus is of very rare occurrence; so much so that many 
 obstetric physicians in large practice have never seen an instance 
 of it, and even deny the possibility of its. occurrence. But al- 
 though no well-marked exam|)le has ever come under my own 
 notice, it yet seems to me impossible to doubt that complete 
 anteversion does sometimes happen. Indeed, it is not very un- 
 common to meet with cases where the normal inclination of the 
 uterns forwards is rather considerably increased, and slight irri- 
 tability of the bladder thereby induced, at an early period of 
 gestation ; though in these, perfect rest for a day or two will 
 serve to relieve the symptoms, and allow of the womb resuming 
 its natural position. But it does not seem difficult to understand 
 that some powerful cause may suffice to increase this incipient 
 displacement; and hence for my own part certainly, I have no 
 hesitation in accepting the statements which are made by authors 
 who have met with undoubted examples of this malposition. 
 
 In anteversion of the uterus the organ lies transversely in the 
 pelvic cavity ; the fundus being directed forwards on to the 
 bladder, while the cervix is tilted upwards and backwards to- 
 wards the sacrum. The causes of this accident are probably 
 such jerks and shocks as are produced by falls, efforts at vomit- 
 ing, repeated straining at stool, and violent exertion in lifting 
 heavy weights. The signs by which this displacement may be 
 diagnosed are chiefly these : The os uteri is thrown upwards, 
 almost be^'ond the reach of the finger, and completely facing 
 the sacrum ; while the fundus can be felt as a globular tumor 
 in front of the vagina, just behind the sj^mphysis pubis. The 
 veins in the upper portion of tlie vagina are found enlarged and 
 much congested. There will usually be more or less trouble in 
 passing the urine, sometimes amounting to complete retention, 
 this being due to the pressure exerted by the fundus uteri upon 
 the meatus urinarius and the neck of the bladder. There may 
 also exist constijDation or troublesome tenesmus ; though the 
 rectum suffers much less than the bladder. Pain is felt in the 
 lumbar and hypogastric regions in consequence of the dragging 
 of the nerves. The patient is also greatly inconvenienced by a
 
 468 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 constant feeling of fulness and heaviness about the pelvis ; while 
 she may even suffer acutely from severe paroxysms of forcing or 
 bearing-down pain. 
 
 The reduction of an anteverted uterus ought always to be 
 attempted with gentleness and care; the efforts, if they fail to 
 restore the uterus, being discontinued after moderate persever- 
 ance, since otherwise they are not unlikely to cause abortion. 
 To effect replacement, it is necessary that the bladder and rectum 
 be thoroughly emptied : the former by the catheter, and the latter 
 by a large stimulating enema. The patient ma}^ generally be 
 placed under the influence of a mixture of chloroform and ether 
 with advantage. She is then to be turned on to her left side ; 
 and two fingers being introduced into the vagina, the practitioner 
 makes gentle but steady pressure in an upward direction, on the 
 fundus of the uterus as it is felt through the anterior part of the 
 walls of this canal. If there be any difliculty, a small sharp hook, 
 something like an ordinary tenaculum with a long handle, had 
 better be passed firmly into the posterior lip of the uterus ; so 
 that by moderate traction downwards and forwards the cervix 
 may be pulled towards the pelvic outlet, at the same time that 
 the fundus is pushed u[)wards. After reduction has been safely 
 accomplished, a full dose of opium can be at once advantage- 
 ously administered; while the patient is to be kept for several 
 days in a recumbent posture. I have no doubt but that in the 
 majority of cases, the uterus if left alone could right itself as ges- 
 tation advances; but as in the mean time the patient would suffer 
 much pain and inconvenience, it will be better to save her from 
 this by the proceeding just recommended, always provided it 
 can be accomplished without compromising the safety of the 
 foetus. 
 
 In antefiexion of the uterus, the organ becomes more or less 
 completely bent upon itself; so that while the fundus is thrown 
 forwards upon the bladder, the cervix retains its normal position 
 in the centre of the vagina. The point of flexion is generally at 
 about the union of the cervix with the body, or perhaps just 
 above this part. Speaking generally, it will be better not to at- 
 tempt reduction. The following is a good illustration of this dis- 
 placement : 
 
 A lady, thirty-three years of age, the wife of a medical man, in the first 
 month of her pregnancy, fell down a flight of steep stairs. At the time the
 
 RETROVERSION OF THE UTERUS. 469 
 
 bowels were exc-eedin<i;ly constipated. There was no hemorrhage ; but a state 
 of syncope histed for nearly an hour. For the ensuing six or seven weeks 
 she was never free from a heavy bearing-down sensation in front; which ren- 
 dered micturition frequent and painful, but in no way interfered with defe- 
 cation. She was also irritable and feverish ; and it was thought by the hus- 
 band that the womb was retroverted. Dr. Ashwell first saw her at the end 
 of the third month ; and on examination found the cervix uteri in its natural 
 position, while the fundus was lying forwards between the anterior wall of the 
 vagina and the bladder, being felt in the form of a round solid tumor. The 
 cervix was more elongated, fuller, and harder than natural ; the os was open ; 
 and pressure at the point of flexion caused pain. Attempts were made to 
 effect reduction by placing the fingers of the left hand behind the pubis, so 
 as to raise the fundus, while the forefinger of the right hand was employed to 
 draw the cervix downwards and forwards. As these eff'orts foiled, the case 
 was left alone. An examination at the sixth month satisfied the husband 
 that the curvature had nearly disappeared ; and although the patient was not 
 quite free from sufferir)g during the remainder of her pregnancy, yet she was 
 delivered without any difficulty, and completely recovered. 
 
 3. Retroversion of the Utkrus. — The uterus in retrover- 
 sion is thrown completely backwards from its normal erect atti- 
 tude ; so that the fundus gets impacted in the hollow of the 
 sacrum, while the cervix and os are carried upwards and forwards 
 behind the symphysis pubis. Thus both the bladder and rectum 
 become unduly compressed; while the vagina is drawn upwards 
 and forwards by the neck of the womb. This displacement may 
 occur at any stage of pregnancy, though it happens much more 
 frequently during the first three or four months than at any other 
 time. It is also exceedingly rare in primiparous women. 
 
 A correct explanation of this important disease would appear, 
 as far asl can learn, to have been first given in France, by Des- 
 granges, in the year 1715, and subsequently by Gregoire in 1746 ; 
 while in this country the attention of the profession seems never 
 to have been directed to the matter until October, 1754, when 
 William Hunter delivered a public lecture upon a fatal example 
 of it. Some sixteen or seventeen years later the nature of this 
 aflection was so little understood that Dr. Hunter again gave a 
 description of it to the Medical Society, on which occasion he 
 concluded his essay in the following words : 
 
 In the last place, gentlemen, give me leave to tell the public why you 
 thought some account of the retroverted uterus so necessary. You were well 
 assured that it happens frequently, and yet that a numuer of practitioners 
 know but little of it ; so little indeed, that, as you well know, in this town, 
 within these two years last past, two pregnant women hist their lives by this 
 accident, without the cause of their complaints being discovered till after
 
 470 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 dentil. In both of these cases, the symptoms alone were almost sufficient to 
 determine the nature of the complaint ; and the circumstances of the tumor 
 with regard to the vagina and rectum such, that it would now appear to be 
 impossible that an experienced practitioner should mistake the case. Yet, in 
 both of the.'^e instances, experienced practitioners failed ; and saw with regret 
 in the dead body, what they might have easily cured in the living, if they 
 had made a very obvious discovery in a proper time.^ 
 
 This displacement of the uterus may either come on gradually, 
 or it may happen suddenly. In the first case, it is perhaps some- 
 times due to the antero-posterior diameter of the pelvic brim 
 being unduly encroached upon by a large sacral promontory, 
 under which projection the gradually enlarging uterus hitches; 
 so that this organ instead of rising out of the pelvis has its fundus 
 slowly thrown backwards into the curve of the sacrum. This 
 condition o-ives rise to little or no disturbance until the uterus 
 attains a size sufficient to compress the bladder and rectum ; but 
 then the usual symptoms immediately become manifested. Re- 
 troversion can also occur slowly from habitual constipation; 
 owing to the accumulated fsecal matters in the sigmoid flexure of 
 the colon and upper part of the rectum producing constant pres- 
 sure upon the fundus. When the displacement is effected sud- 
 denly, it generally takes place from some violent exertion ; such 
 as long-continued straining to expel hardened faeces, a severe 
 attack of vomiting, attempts to lift heavy weights, and falls. 
 Many authorities assert that a distended bladder may either 
 gradually push the fundus backwards, or may do so suddenly 
 under the impulse of a violent straining to void the urine; but 
 the relations of the bladder to the anterior wall of the abdomen 
 would seem to me quite sufficient to prevent this viscus from 
 having the eftect supposed. The retention of urine which ac- 
 companies these cases is the consequence and not the cause of 
 the disease. 
 
 There is one symptom which is particularly striking in this 
 aftection, and which cannot fail to attract attention. The pressure 
 exerted by tlie misplaced uterus upon the neck of the bladder at 
 first partially, but at length completely obstructs the flow of 
 urine ; and hence results retention, with an uncontrollable desire 
 to empty the bladder, and frequent but fruitless straining eftbrts. 
 The sense of pressure upon the rectum also gives rise, though in 
 
 1 Modioal Oliservations and Inquiries. By a Society of Physicians in London. 
 Second Edition, vol. iv, p. 409. London, 177"2.
 
 RETROVERSION OF THE UTERUS. 471 
 
 a less marked degree, to a constant feeling as if the bowels were 
 loaded ; and consequently numerous attempts at defecation are 
 m^de. Should these symptoms pass on unrelieved, the bladder 
 speedily becomes enormously distended. As a consequence, the 
 urine decomposes in this viscus, giving rise to all the dangerous 
 symptoms of ursemia ; and the coats of the organ either inflame 
 and ulcerate, or they rupture mechanically from over-tension. 
 Whichever happens, the result is of course the same, — the escape 
 of the urine into the peritoneal cavity, and speedily fatal inflam- 
 mation of the serous membrane. The woman may, however, 
 perish from the blood-poisoning caused b}' the absorption of the 
 foul ammoniacal urine before the bladder has had time to rup- 
 ture, for it is astonishing to what an extent the coats of this organ 
 will gradually stretch ; or she may die from the same cause after 
 the urine has been all drawn ofl*, in cases where the catheter has 
 not been used until the system has been too profoundly affected 
 by the morbid fluid. Moreover, in many instances a few ounces 
 of urine dribble away in the course of the day ; and this not 
 only delays the time of rupture, but is calculated to mislead the 
 practitioner, who thinks the bladder must be empty because he 
 is told that the urine cannot be retained and is constantly escap- 
 ing. This latter fact was well exemplified in the following case: 
 
 A woman, thirty-five years of ao-e, quickly became the subject of enor- 
 mous distension of the abdomen. On examination this enhirgement was 
 found to have partially the characters of extreme ascites, that is to say, there 
 was dulness over the greater portion of the abdomen, and distinct fluctua- 
 tion. A medical practitioner who had been called in by the friends was de- 
 sirous of performing paracentesis, so urgent were the symptoms; but fortu- 
 nately this operation was deferred, and the patient was removed to the 
 Westminster Hospital, where she was placed under the care of Dr. Bashaui. 
 On minutely inquiring into the history, it appeared that she was three 
 months advanced in pregnancy ; and as a catheter could not be introduced 
 into the bladder, an examination per vaginam was made. This clearly showed 
 that retroversion of the gravid uterus was present ; which had probably ex- 
 isted for some three weeks, as the abdominal swelling had been forming 
 from about that time. Urine, to the extent of a few ounces, daily dribbled 
 from the bladder; and although this may have given some slight relief, yet 
 the great prominence of the distended viscus made the patient feel as if she 
 would burst. After a little care, the house-surgeon succeeded in pushing 
 the fundus of the uterus upwards into its natural position ; immediately upon 
 the accomplishment of which, more than a gallon of urine flowed away spon- 
 taneously, without the aid of a catheter. The woman ultimately did well. 
 
 The diagnosis of retroversion is not a matter of difficulty.
 
 472 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 The mere fact that a pregnant woman is unable to empty her 
 bladder, that she has a constant desire for defecation, and that 
 she complains of pain and pelvic weight, ought at once to lead 
 the practitioner to institute a physical exploration. A glance at 
 the abdomen must suffice to show that it is enlarged ; while the 
 sense of touch will in all probability detect fluctuation, if the 
 retention have existed many days. On examining per vaginam, 
 it will be found that immediately the finger enters tliis canal it 
 encounters an obstacle in the shape of a firm glol)ular body. 
 This is the posterior surface of the uterus ; which organ fills the 
 whole pelvic cavity, like a tumor spread out much more poste- 
 riorly than anteriorly. No os uteri can then be felt; but if the 
 practitioner persist, as he ought to do, in passing his finger in 
 the only direction in which it will go, he will at length reach the 
 mouth of the womb high up behind the pubes. An examination 
 by the rectum confirms the fact that the pelvis is filled by a 
 globular tumor. And the nature of the ease is then confirmed 
 beyond the possibility of doubt, by the introduction of a long 
 flexible catheter into the bladder; by means of which this viscus 
 will be emptied, and the abdominal tumor removed. 
 
 The prognosis in retroversion is always grave ; and especially 
 is it so when the displacement has existed sufficiently long to 
 allow of the blood being vitiated by the decomposing urine. 
 Moreover, the constipation and retention of urine are not only 
 sources of great danger in themselves, but they serve mechani- 
 cally to increase the displacement. This is clear from the fact, 
 that the bladder cannot enlarge upwards without drawing up the 
 uterine neck with it ; whilst, as the pressure of the fundus uteri 
 blocks up the rectum, of course the stercoraceous matters accu- 
 mulate above the point of obstruction, and thus force the fundus 
 lower and lower by their weight. Moreover, before the patient 
 seeks advice, she very generally has exhausted herself with strain- 
 ing and bearing-down, which expulsory efibrts merely serve to 
 increase the mischief. 
 
 In the treatment of this accident, the first step is to carefully 
 empty the bladder ; for not only is the risk of rupture to be im- 
 mediately lessened, but the equally great danger of ur?emic poi- 
 soning is, if possible, to be obviated. This had better always be 
 done with a flexible male catheter; the bladder being usually 
 drawn up too high, and the urethra consequently too much length-
 
 RETROVERSION OF THE UTERUS. 473 
 
 ened, to allow of the ordinary instrument being of any service. 
 Then, if there should appear to be any passage through the rectum 
 it will be advisable to administer copious soap and water enemata, 
 with the tube of the stomach-pump passed above the obstruction ; 
 since the reduction of the uterus will be much facilitated by the 
 previous dislodgment of the fecal matter which may be present. 
 Sometimes the adoption of this line of practice is sufficient, and 
 the uterus spontaneously assumes its normal position. More 
 generally, however, the fundus has to be pushed upwards. But 
 before attempting this operation, I make a point of administering 
 an anaesthetic; for it is not only cruel to inflict unnecessary pain 
 upon a poor woman already worn out with suffering, but the eflect 
 of removing all sensibility is exceedingly beneficial in preventing 
 those violent bearing-down efforts which the patient, when con- 
 scious, can scarcely help making. The woman being insensible, 
 and lying in the ordinary obstetric position, the accoucheur intro- 
 duces his whole hand into the vagina; and then doubling it, he 
 applies the flat surface of the first phalanges to the tumor, and 
 presses the body and fundus of the uterus upwards and forwards 
 in the direction of the sacral concavity. In one difficult case 
 which was under my care, this proceeding was favored or assisted 
 by passing a large elastic and empty pessaiy into the rectum, and 
 then gradually filling it with water. The reduction will some- 
 times be efifected at the first trial, though not uncommonly the 
 attempt has to be repeated several times ; in which event it must 
 not be forgotten to frequently empty the bladder, if many hours 
 are allowed to elapse between the operations. On making a 
 third or fourth trial it maybe better to place the woman in such 
 a position that the superincumbent weight of the intestines are 
 removed from the uterus. M. Godefroy succeeded in three very 
 grave cases, by adopting the following plan : The patient rested 
 her head and hands upon the floor, whilst the anterior part of 
 the thighs and legs reposed upon the bed, where they were held 
 by assistants, while this gentleman acted upon the fundus through 
 the vagina or rectum. It would, however, have served quite as 
 well to have had the woman on her knees and elbows ; a position 
 which is only objectionable because it does not well allow of the 
 production of anaesthesia. Supposing the attempt, however made, 
 to prove successful, a full dose of opium had better be admin- 
 istered, and the patient ordered to keep the recumbent posture
 
 474 DISPLACEMENTS OF THE GRAVID UTERUS." 
 
 for several days ; whilst if the coats of tlie bladder have lost their 
 tone, the catheter ought to be introduced every eight or twelve 
 hours, until full power is recovered. 
 
 But it sometimes unfortunately happens that the reduction is 
 impracticable, and an anxious question then arises as to the course 
 to be pursued. Hunter advised that the uterine wall and the 
 fojtal membranes should be punctured under these circumstances, 
 in order that the bulk of the uterus might be considerably less- 
 ened by evacuating the liquor amnii ; and one successful case 
 where this operation was performed through the rectum has been 
 recorded, l^evertheless it seems to me that such a proceeding 
 can very seldom, if ever, be necessary ; since some little skill and 
 much patience will enable the practitioner to introduce a stylet 
 or uterine sound through the os uteri, and v/itli it to procure the 
 discharge of the liquor amnii. Even if this could not be accom- 
 plished it would generally be possible to induce uterine contrac- 
 tions by the administration of ergot, combined with the proper 
 use of galvanism. Of course death will sometimes occur, in spite 
 of the best treatment, as in the following instance, which is re- 
 lated by Dr. Blundoll : 
 
 A lady, laboring under ovarian dropsy, was recommended to ride out daily 
 in an open carriage. In one of her excursions, the vehicle was upset, and 
 she was thrown out with great violence ; her abdomen striking with great 
 force against a stone which was lying in the way. On her return home, a 
 very copious secretion from the kidneys ensued, with great abdominal pain ; 
 but in the course of a few days she recovered, and found herself entirely 
 cured of the drop.sy. Some time afterwards she married ; and died with an 
 irreducible retroversion of the uterus, at about the fourth month of gestation. 
 Inspection of the body showed that the fall had produced a rupture of the 
 ovarian cyst, and the effusion, of its contents into the peritoneal sac, whence 
 the fluid had been absorbed by the kidneys. The remains of the cyst, fall- 
 ing upon the uterus, had carried it down below the promontory of the sacrum ; 
 and the womb becoming retroverted, had been fixed by adhesions in its ab- 
 normal position. While the lady remained unmarried, she felt but little in- 
 convenience ; but on the uterus enlarging from pregnancy, fatal pressure on 
 the bladder and rectum took place, as the displacement could not be recti- 
 fied on account of the adhesions. 
 
 Dr. Henry Bond, of Philadelphia, has invented an instrument 
 to aid in the replacement of the retroverted uterus, which Dr. 
 Meigs says was successful in a difficult case that had resisted all 
 other means. Having had no experience in the use of this in- 
 strument it may seem rather bold, if not rash, to condemn it ; but 
 it is necessary to recollect that when skilful eflbrts, perseveringly
 
 RETROFLEXION OF THE UTERUS. 475 
 
 employed, fail to procure reduction, we may be al'most certain 
 that abnormal adhesions have been established between the uterus 
 and adjacent parts. To tear roughly through these false mem- 
 branes, will be simply to produce hemorrhage, or acute inflam- 
 mation ; and either of these alternatives appears to me more 
 fraught with danger than rupturing the membranes with the 
 uterine sound, or than puncturing the uterus, or even than tem- 
 porizing and merely trying to relieve the prominent symptoms. 
 
 It might be thought quite impossible that a woman should 
 reach the full period of gestation with a rctroverted womb ; but 
 the reader will find one extraordinary instance of this nature 
 recorded by Dr. S. H. Jackson,' and another by Dr. Samuel 
 Merriman.^ In both of these cases the patients remained for 
 nearly a week in labor, and suffered severely ; but in each, at the 
 end of some days, the womb was spontaneously restored almost 
 to its natural position, and delivery completed. Both of the 
 women recovered favorably ; though the two children were born 
 dead, while one was considerably decomposed. 
 
 Retroflexion of the uterus may occur during pregnancy, though 
 it is much more seldom met with than retroversion. In the un- 
 impregnated state just the reverse holds good. The typical 
 course of a case of retroflexion, occurring during the early part 
 •of gestation, may be thus roughly sketched: 
 
 A woman thirty-five years of age, three months advanced in her fourth 
 pregnancy, complains of severe attacks of sickness, constant bearing-down 
 pains, great pain in the back, and of tenesmus with much suifering during 
 defecation. For some days before seeking relief her feelings have been such 
 that she has imagined abortion was about to occur; but she has generally de- 
 rived relief from rest in bed. The functions of the bladder have not been 
 interfered with. On making a vaginal examination, the uterus is found en- 
 larged, with its fundus forming a globular tumor under the sacral promon- 
 tory ; but the cervix and os occupy their normal position. The explanation 
 of this condition is clearly, that the uterus is bent upon itself, very much re- 
 sembling the neck of a retort. The evacuation of the rectum, and the use of 
 gentle pressure upon the fundus through the walls of the vagina, fail to effect 
 replacement. The patient is therefore ordered to remain in bed, while she 
 is kept free from pain by sedatives. At the end of a fortnight the retro- 
 flexion will be found to be less ; and at the expiration of another month the 
 uterus will in all probability be detected occupying its normal site. 
 
 1 Cautions to Women respecting the State of Pregnancy, &c. Second Edition, p. 59. 
 London, 1801. 
 
 ^ A Dissertation on the Retroversion of the Womb, including some observations on 
 Extra-Uterine Gestation, p. 28. London, 1810.
 
 476 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 Dr. Merriman was of opinion that pregnancy miglit go on for 
 the full period with a complete retroflexion of the womb ; and 
 that this displacement might fonii an important and dangerous 
 complication of labor. This view has recently been fully con- 
 firmed by a case which was under the care of Dr. Oldham,' in 
 which there was found perfect retroflexion of the gravid uterus 
 during labor at term. In this instance the nates of the infant 
 presented ; and delivery was safely accomplished, so far as the 
 mother was concerned, by grasping a foot and withdrawing the 
 child. 
 
 4. Hernia op the Uterus. — Hernia of the uterus or of its 
 appendages is of very rare occurrence"; but it is rather remark- 
 able that of the recorded cases, the majority are examples of 
 hernia of the gravid uterus. Hernia difi'ers from eventration of 
 the uterus in this respect; that whereas in the former case the 
 womb passes through the inguinal or crural opening, in the latter 
 it is forced through some artificial aperture — as between the recti 
 muscles, &c., or through a wound in the abdominal parietes. 
 For the thorough comprehension of this subject it appears ad- 
 visable to speak, in the first place, of hernia of the unimpreg- 
 nated uterus; secondly, of hernia of the ovaries ; and thirdly, of 
 hernia of the gravid uterus. 
 
 a. Hernia of the unimjyregnated uterus. This accident can 
 happen at the inguinal ring, or at the crural arch, or through 
 the obturator foramen ; while it may probably arise from too 
 great relaxation of the ligaments of the uterus, or from displace- 
 ment of the uterus by tumors within the pelvis, or from the con- 
 traction of bands of false membrane, &c. The diagnosis of this 
 condition from ordinary intestinal hernife will hardly be very 
 difficult, if a vaginal examination be instituted; though without 
 this a mistake is not unlikely to be made, since — as one of the 
 following cases shows — the symptoms may at times resemble 
 those due to strangulation of the intestines. An examination of 
 the recorded cases of uterine hernia shows that pregnancy can 
 occur, and full development of the foetus take place, while the 
 uterus remains in its abnormal position. The treatment of such 
 an accident must depend very much on the length of time which 
 has elapsed since its occurrence, and on the nature of the symp- 
 
 ^ Transactions of the Obstetiical Society of Lonilon. Vol. i, p. 317. London. IhGO.
 
 HERNIA OF THE OVARY. 477 
 
 toms. When recent, it would seem not unlikely that cautious 
 attempts at reduction might be attended with success ; although 
 supposing the manipulations to be fruitless, an operation would 
 scarcely be justifiable, unless there happened to be severe suffer- 
 ing and constitutional disturbance. 
 
 Two instructive examples of this displacement have been 
 recorded by M. Lallement : 
 
 In one, the patient was a laundress who had borne several children with- 
 out experiencing anything remarkable. When about the age of fifty, the 
 catainenia having ceased, a tumor suddenly appeared in the right groin after 
 mailing some unusual exertion. Though at first painful, it soon ceased to be 
 so, and she lived for twenty years afterwards. On making an examination of 
 the tumor after death there was found a very thick hernial sac, containing 
 the uterus and the right ovary and Fallopian tube : the left ovary and tube 
 were pressing upon the external part of the inguinal ring; while the vagina, 
 drawn up by the uterus, was compressing the bladder against the pubes. M. 
 Lallement points out that this altered direction of the vagina is the most 
 certain sign of the existence of an inguinal hernia of the uterus. 
 
 The second instance is an example of crural hernia of the uterus, occur- 
 ring also in a laundress, after eight easy labors. At the age of forty, eight 
 days after the birth of her last child and before resuming her ordinary occu- 
 pation, she perceived a small protrusion in the right groin. Failing to reduce 
 this, she took but little notice of it for a year, when an attack of colic and 
 nausea caused her to apply a bandage for a short time. At seventy-four years 
 of age she had .symptoms indicative of a strangulation of the hernia, such as 
 pain, nausea, vomiting, and colic ; these symptoms partly disappearing after 
 a copious discharge of serum from the tumor. From the age of seventy-four 
 to eighty-two she continued subject to attacks of pain and nausea; until, one 
 day, new symptoms of strangulation set in, which made her enter the infirmary 
 of the Salpetriere. At this time the tumor filled the right groin ; it was about 
 five inches long, and four broad ; its shape was that of a three-sided pyra- 
 mid, with the base above, and the apex below ; and the finger when passed 
 above the tumor could distinguish the inguinal ring in its healthy state, and 
 immediately beneath the crural arch. After death the sac of the hernia was 
 found to contain the uterus, ovaries, Fallopian tubes, the upper part of the 
 vagina greatly stretched, two distinct folds of omentum, and two cysts — per- 
 haps hydatids. It was a crural hernia. The rectum and bladder were in 
 their normal positions.^ 
 
 /5, Hernia of the ovary. The ovary has escaped at the inguinal 
 ring, or at the crural arch, or at the sciatic notch like an intes- 
 tinal ischiatic hernia, or through the tissues of the vagina. The 
 protrusion may take place on one side of the body only, or on 
 both ; it may exist from birth, or it will happen as the result of 
 accident or disease ; and the sac can either contain the ovary 
 
 1 Dictionnaire ties Sciences Medicales. Article Matrice. Vol. xxxi, p. 226. Paris, 
 1S19.
 
 478 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 alone, or with this there may be the uterus aud the Fallopian 
 tube, and even a portion of intestine. From the anatomical re- 
 lations of the pelvic viscera it can be readily understood, that 
 hernia of the ovary occurs more frequently at the inguinal ring 
 than at any other part; the passage of the round ligament through 
 the internal abdominal ring, aud along the inguinal canal, to the 
 labia majora, leaving — as it were — a weak point. This accident 
 has been mistaken for an intestinal hernia, for an enlarged in- 
 guinal gland, and for an abscess ; some interesting examples of 
 which errors have been put on record by M. Deneux.^ The case 
 in which Mr. Pott removed both these glands is well known. 
 The particulars, however, are so inferesting that they may be 
 mentioned here : 
 
 A young woman, twenty-three years old, was admitted into St. Bartholo- 
 mew's Hospital on account of a small swelling in each groin. These swell- 
 ings had been for several months so painful as to prevent her from following 
 her occupation as a servant: they were soft and movable, and they lay di- 
 rectly upon the outside of the tendinous opening of the oblique muscle, 
 through which they appeared to have passed. The woman was large breasted, 
 and menstruated regularly; her general health was good. Owing to the in- 
 convenience which the tumors caused, Mr. Pott determined to remove them ; 
 and having done so, they were found to consist of the two ovaria. The 
 patient subsequently enjoyed good health, but became thinner and more 
 muscular: her large breasts disappeared; and she never menstruated again. 
 The last observation of her was uiade many years subsequent to the operation.'^ 
 
 The treatment here resorted to must not be regarded as ex- 
 emplifying that which should be usuall}^ practised. For although 
 the displaced ovary may be extirpated if it give rise to frequent 
 attacks of pain or to considerable inconvenience, yet cases where 
 an operation is called for are exceptional. Speaking generall}^ 
 the less that is done the better; though, when the hernia is recent, 
 attempts ought to be made at reduction, and if these efforts be 
 followed by success, a bandage or truss should afterwards be 
 worn. 
 
 Dr. Oldham has recorded two cases, in both of which the two 
 ovaria are said to have descended through the inguinal canals 
 and to have become permanently lodged in the upper part of 
 the external labia. The patients were aged respectively nineteen 
 and twenty; neither had ever menstruated; and the most careful 
 
 1 Recherches sur la Hernie de I'Ovaire, pp. 37 to 58. Paris, 1813. 
 
 2 The Chirurgical Works of Percival Pott. Vol. ii, p. 210. London, 1779.
 
 HERNIA OF THE GRAVID UTERUS. 479 
 
 and repeated physical examination failed to detect either uterus 
 or vagina. One case presented the interesting plijsiological 
 peculiarit}' of a spontaneous periodical increase of one or other 
 of the ovaria, followed by its gradual reduction ; thus— it is said 
 — supplying direct evidence of an ovarian menstrual act/ This 
 is really the important feature in the history; for otherwise there 
 is but little to show that the patients were not males, having 
 each a cleft urethra and scrotum, a very short penis, and with 
 the testes just drawn out of the inguinal canal. Without doubt- 
 ing the correctness of Dr. Oldham's views on these cases, it is 
 still certain that many instances of the malformation I have 
 mentioned closely simulate female development; while some- 
 times the similarity is so great, that without a minute examina- 
 tion of the bodies themselves, it cannot really be determined 
 whether they are testicles or ovaries. 
 
 A few examples of hernia of the Fallopian tube alone are re- 
 corded. In one instance, the displacement took the form of a 
 crural hernia. As the sac was thought to contain fluid, it was 
 punctured; the patient afterwards dying from peritonitis. At 
 the autopsy, the sac was found to contain nothing but the hyper- 
 trophied oviduct. 
 
 y. Hernia of the gravid uterus. In considering the chief cir- 
 cumstances which follow from this remarkable casualty, it need 
 scarcely be premised that this variety of hernia is of exceeding 
 rarity. The recorded cases are not, however, on this account 
 the less interesting; neither does such a circumstance render it 
 the less imperative for the practitioner to be acquainted with 
 their nature. 
 
 The protrusion of the gravid uterus at the umbilicus has been 
 met with more frequently than any other variety. Dr. Evory 
 Kennedy says that he met with a remarkable example, in a 
 woman who had borne a number of children. When in labor 
 of her second child, hernia took place at the umbilicus, which 
 gradually increased in extent with each child she carried ; until 
 at length the impregnated womb made its way completely out 
 of the abdomen, and became suspended over the pubes, so that 
 at the end of the ninth month it hung down to the knees.^ A 
 more recent example has been published by Dr. G. C. P. Alurray : 
 
 1 Proceedings of the Royal Society of London. Vol. viii, p. 377. London, 1857. 
 
 2 Observations on Obstetric Auscultation, &c., &c.,p. 40. Dublin, 1833.
 
 4S0 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 The patient was a woman aged thirty, the mother of three children, and 
 had been from infancy affected with a small umbilical hernia, which had 
 always been easily reduced. When in the eighth month of gestation she 
 found one morning, in rising suddenly from the recumbent position, that a 
 large tumor had forced itself through the navel. This protrusion proved to 
 be nothing less than two-thirds of the impregnated uterus, the foetus being 
 distinctly recognized by palpation. There was no rupture of the linea alba. 
 Reduction was at once effected by means of gentle and careful manipulation, 
 and the organ was happily kept in aitu until the end of gestation, when a 
 live female child was born.^ 
 
 I believe that no instance of hernia of the gravid uterus at the 
 inguinal ring is known to have occurred in our own country; 
 and probably not more than five or six examples are to be found 
 recorded in medical literature. Sir 'David D. Davis^ refers to 
 four; and one has been seen since the publication of his work. 
 As the particulars of this last case are very instructive and in- 
 teresting, I shall here conclude by quoting it, in place of making 
 further general observations. The details are as follow -j^ 
 
 On the 26th January, 1839, Professor Ladesina was called to visit in con- 
 sultation Elena Ramos, aged forty-two, a married woman residing at Sala- 
 manca. She was strong, and in the enjoyment of good health. The belly 
 was soft and natural. At the inferior part of the hypogastrium there was a 
 large tumor resting upon both thighs, but especially on the right one. Its 
 base, or origin, was situated at the upper and right part of the raons veneris, 
 extending over the superior portion of the pelvis, involving the integuments 
 of the lower part of the belly of the same side, descending and prolonging 
 itself so as to comprehend the labium and put it in an extreme state of ten- 
 sion. The base of the tumor at this time — 2Gth of January — measured about 
 twenty-two inches : its circumference at the middle was twenty-five : and its 
 whole length twenty-three inches. These dimensions became afterwards very 
 different, the circumference of the neck diminishing, and that of the middle 
 greatly expanding, so as to give the tumor an oval shape. It became sub- 
 sequently more spherical, after using fur some time a suspensory bandage 
 slung from the shoulder. The common integuments covering the tumor 
 were almost of their natural color; but were a little oedematous, and marked 
 with a few slightly varicose vessels. Upon examining the tumor with the 
 hand, Professor Ladesma detected within it a fluid, in which was floating a 
 solid body. During the various manipulations, the patient suffered no in- 
 convenience, nor did she experience any peculiar sensation. She believed 
 that she was with child, and thought she felt the foetus moving within the 
 tumor. 
 
 1 Transactions of the Obstetrical Society of London. Vol. i, p. 77. London, iSfiO. 
 
 2 The Principles and Practice of Obstetric Medicine. Vol. ii, p. 912. London, ISSfi. 
 
 3 Fenoineno Raro de Prefiez ; o Historia de una Hernia de la Matriz, &c. By Don 
 Julian Ladesma, Professor of Surgery at h'alamanca, 8vo., p. 23. Madrid, 1840 — Con- 
 densed from Dr. J. R. Cormack's Contributions to Pathology, Therapeutics, and Forensic 
 Medicine, p. 43. London, 1844.
 
 HERNIA OF THE GRAVID UTERUS. 481 
 
 The following was the previous history of the patient. She had borne 
 six children in an easy way ; having always had such good recoveries, that 
 she was able to attend to her household duties a few days after labor. Before 
 marriage she was subject to a reducible inguinal hernia, which became more 
 troublesome after the birth of her first child. For fou* months prior to the 
 appearance of the tumor she had not menstruated ; and at the time the tumor 
 appeared she believed herself to be three months gone with child. It first 
 presented itself under the following circumstances : One day when on foot 
 in the street, and stooping down to a table to purchase some household neces- 
 saries, she felt an uneasy dragging sensation in the lower part of the left side 
 of the abdomen. Feeling sick, she went home. For a short time, blood 
 dropped from the vulva. Upon examining the groin aft'ected with hernia, 
 she found a tumor in the situation of the usual hernial protuberance, but 
 having a different consistence ; at the same time she noticed that her abdo- 
 men had lost somewhat of its former elevation. The pain which she suffered 
 in the swelling caused her to have recourse to all the means of reduction which 
 she had formerly been in the habit of successfully employing; but though 
 she continued her efforts for some time, they were useless. In her manipu- 
 lations she did not discover a foetus ; but in six or seven weeks after the 
 descent of the tumor, she felt movements in its interior, and became reas- 
 sured of her pregnancy. Under these circumstances she consulted two medi- 
 cal men, who decided that the tumor contained a foetus, and that -it was a 
 case of extrauterine conception. Professor Ladesma, on the other hand, 
 gave it as his opinion that it was a hernia of the womb, ivhich had issued 
 from the right imjuincd ring, carrying with it the product of conception, 
 and, constituting a secondary/ hernia. He further declared that reduction was 
 impracticable, and that when the patient came to her full time it would be 
 neccesary to deliver her by a surgical operation. 
 
 A committee of the medical authorities of Salamanca met in the patient's 
 house upon the 2d March ; and after an examination by the vagina, in 
 which the os uteri could not be discovered, it was agreed that Ladesma's 
 opinion was correct. — The patient went on well. The stethoscope was fre- 
 quently applied ; and both the placental and foetal pulses were found to differ 
 very much, one day from another, while occasionally the former became in- 
 audible for a few minutes. The sounds of the heart were very distinctly 
 heard to be double ; while the beats varied from 130 to 150 in a minute, and 
 were much more frequent than in the mother. 
 
 On the morning of the 6th June the patient stated that during the pre- 
 ceding night she had experienced pains in the lumbar region. On the night 
 of the 6th she continued to feel pains in the loins, and slighter ones in the 
 uterus. At half-past four on the morning of the 7th, the pains increased 
 somewhat, and the waters came away by the vagina. The tumor then be- 
 came considerably diminished in volume; which induced Ladesma to attempt 
 reduction, so that if possible the child might be delivered by the natural 
 passages. The endeavors were unsucces.sful. Under these circumstances, 
 it was determined to resort to hysterotomy ; which was accordingly performed 
 at half-past twelve o'clock in the presence of fourteen medical gentlemen. 
 The patient lay in bed upon her back ; the tumor, which was formerly thirty- 
 two inches in circumference, was only twenty-eight since the discharge of the 
 liquor amnii. Being satisfied by auscultation that the placenta was situate 
 about the middle and on the left side of the tumor, the operator chose that 
 place for his incision. The first cut divided the integuments and peritoneum, 
 
 .31
 
 482 DISPLACEMENTS OF THE GRAVID UTERUS. 
 
 leaving bare the womb ; and it having been ascertained that neither the 
 ovary nor the Fallopian tube were in the way of the knife, the incision was 
 cautiously continued into the interior of the uterus. A copious hemorrhage 
 followed. At the inferior extremity of the wound was seen, under the mar- 
 gin of the placenta, ^e child, with its legs doubled up towards its belly, the 
 head touching that portion of the uterus at the inguinal ring, and the breech 
 at the bottom of the womb with the back upwards. Without a moment's 
 loss of time, the extraction of the child was commenced by the feet ; but the 
 removal was not completed without enlarging the wound, for when the trunk 
 came out the uterus contracted so powerfully as to threaten the child with 
 suffocation. The child was a healthy female, weighing 62 lbs., and measur- 
 ing twenty-two inches in length. It was at first asphyxiated, but soon gave 
 signs of life; and was solemnly baptized by the parish priest in the evening. 
 The mother bore the operation with serenity and heroism, though she was 
 much weakened by the hemorrhage : she had convulsions and cold sweats, 
 with a low and irregular pulse, but was reli-eved by strong beef-tea and an 
 antispasmodic mixture. 
 
 The subsequent history of the case is minutely reported, but a few words 
 will suffice for the important details. Xight cataplasms of mallows and hem- 
 lock leaves were applied to the womb, the edges of which were kept in appo- 
 sition by a bandage. The suppuration was at one time profuse ; and the 
 patient suffered from inflammation of the uterus and peritoneum. On the 
 l'2th June the lochial discharge flowed from the vagina. On the 12th July 
 she menstruated; and on the 11th August she walked out with her infant, 
 both being in perfect health. The tumor remained small, not exceeding in 
 size an ordinary scrotum ; and it formed a hysterocele in the inguinal ring 
 to which it was attached by adhesions. 
 
 The foregoing narrative concludes all that I have to say on the 
 subject of hernia of the gravid uterus. The treatment required 
 in this class of cases is obvious. The ordinary principles of ob- 
 stetric surgery will be found applicable here as they are in those 
 cases where, from disease or some congenital malformation, 
 delivery of the foetus by the natural passages is rendered impos- 
 sible.
 
 INDEX. 
 
 Abdomen, enlargement of the, 92 
 
 of a boy, containing a foetus, 189 
 Abdominal tumors, rules for investigating, 
 
 144 
 Abortion, 219 
 
 as a cause of inversion of the uterus, 251 
 causes of, general!}', 229 
 curative treatment of, 265 
 diagnosis of, 253 
 due to pneumonia, 353 
 feigned, 255 
 
 followed by tetanus, 346 
 hemorrhage as a precursor of, 458 
 criminal law on production of, 98 
 prognosis in, 255 
 prophylactic treatment of, 259 
 symptoms of, 248 
 Abscess of the ovary, 164 
 Accidental causes of abortion, 229 
 Accumulation of urine with pregnancy, 171 
 Acephalocysts in the uterine walls, 281 
 Acute atrophy of the liver, 397 
 
 disease, as a cause of abortion, 232 
 Adhesions between the vaginal labia, S3 
 Advantages of auscultation, 19 
 Age at which menstruation ceases, 29 
 
 of embryo, mode of distinguishing the, 
 
 223 
 of greatest prolificness, 43 
 of parents as influencing sex of children, 
 50 
 as regulating duration of preg- 
 nancy, 215 
 Air, accumulation of, in the uterus, 194 
 
 in the vagina, 194 
 Amaurosis during pregnancy, 420 
 Amnion and chorion, 108 
 dropsy of the, 169, 444 
 partial rupture of, 443 
 iLnatomy of the Graafian vesicles, 77 
 Animals, function of reproduction in, 61 
 Anteflexion of the uterus, 468 
 Anteversion of the uterus, 467 
 Apoplexy of the placenta, 245 
 Appetite, capricious, 374 
 Areola, alterations in the, 86 
 Arterial pulsations in vaginal walls, 141 
 Ascites, 166 
 
 and pregnancy, coexistence of, 169 
 Assafoetida in casesof repeated abortion, 261 
 Atrophy of the liver, 397 
 
 of the uterus after labor, 1 1 7 
 Auscultation, advantages of, 19 
 how practised, 123 
 
 Auscultation, in detecting foetal heart-beats, 
 127 
 foetal movements, 123 
 funic pulsations, 124 
 uterine souffle, 125 
 signs derived from, 121 
 
 Ballottement, 118 
 Bifid uterus, 315 
 Bilobed uterus, 315 
 Birth-rate in 1864, in England, 33 
 Bisexual generation, 61 
 Bleeding during pregnancy, 364 
 Blindness during pregnancy, 420 
 Blood, a clot of, how distinguished from an 
 ovum, 267 
 
 alterations in the, during pregnancy, 139 
 
 amount of, in the body, 364 
 
 discharge of. from uterus, 453 
 
 poisoning from retained placenta, 257 
 
 retained in the uterus, 190 
 
 spitting of, 401 
 
 vomiting of, 390 
 Breasts, alterations in the areolae, 86 
 
 changes in the, 85 
 
 pains in the, 421 
 
 secretion of milk by, 88 
 British Lying-in Hospital, deliveries in, 41 
 
 Csesarean section performed in mistake, 150 
 
 in cancer of the uterus, 359 
 Cancer of the kidney, 184 
 
 of the liver, 182 
 
 of the uterus, 356, 456 
 
 as a cause of abortion, 239 
 Capricious appetite, 374 
 Carbonic acid, exhalation of, 139 
 Cardiac hypertrophy, 355 
 Cardialgia, 390 
 
 Cases of supposed protracted gestation, 207 
 Catamenia, cessation of the, 29 
 
 first appearance of the, 24 
 
 nature of the discharge, 76 
 
 suppression of the, 74 
 Cathartics, use of, during pregnancy, 366 
 Causes of abortion, 229 
 Cavity of uterus, condition of, after labor, 
 
 116 
 Celibacy as predisposing to epilepsy, 338 
 Cephalalgia, 411 
 
 Cerebral paralysis and pregnancy, 335 
 Cervix uteri, how altered by conception, 110
 
 484 
 
 INDEX. 
 
 Cessation of menstruntion, 29 
 Changes in the uterus after conception. 103, 
 110 
 after labor, 116 
 Character of the embryo at different ages, 
 
 223 
 Childbirth, diminution of mortality in, 67 
 Children born out of wedlock, proportion of, 
 35 
 five at one labor, 38 
 four at one labor, 38 
 greatest number born at one labor, 35 
 
 borne by one woman, 31 
 six at one labor, 37 
 three at one labor, 46 
 two at one labor, 41 
 Cholera occurring during pregnancy, 361 
 Chorea complicating pregnancy, 33'J 
 Chorion and amnion, development of the, 
 108 
 cj'stic disease of the, 277 
 Chronic lead-poisoning as a cause of abor- 
 tion, 233 
 Circulation, diseases of the organs of, 399 
 
 in the foetus, 124 
 Classification of the signs of pregnancy, 70 
 Clavus hystericus, 412 
 Clot of blood, how distinguished at the os 
 
 uteri, 2(57 
 Coagula, condensed, from the uterus, 282 
 Color of the mammary areola, 87 
 Complicated pregnancy, 22 
 Compound pregnancy. 22 
 Concealed accidental hemorrhage, 458 
 
 pregnancy, 34, 97 
 Conception after a single coitus, 204 
 in cancer of the uterus, 356 
 its influence on the uterus, 103, 110 
 occurrence of, at an early age, 24 
 signs of, 65 
 Condensed coagula of blood from the uterus, 
 
 282 
 Congestion and inflammation of cervix uteri, 
 
 383 
 Constipation, 392 
 
 Constitutional syphilis as a cause of abor- 
 tion, 234 
 Consumption during pregnancy, 350 
 Contractions of the gr.avid uterus, 137 
 Convul.'-ions, puerperal, 427 
 Cough. 400 
 
 Counterfeiting labor, 52 
 Counter-irritation during pregnancy, 31')" 
 Cows and mares, time of gestation in, 245 
 Customs of the women of Tartary, 67 
 Cutaneous disease as a cause of abortion, 
 
 232 
 Cystic disease of the chorion, 277 
 
 disease of the peritoneum, omentum, 
 
 &c., 188 
 walls in extra-uterine pregnancy, 286 
 
 Data for learning age of embryo, 223 
 Dates of delivery in 885 cases, table of, 202 
 
 of first menstruation, 24 
 Day of labor, prediction of, 215 
 Deafness during pregnancy, 419 
 Death of foetus, signs of the, 246 
 
 Deaths in England in 1864, from childbirth, 
 
 68 
 DeciduEe, formation of the, 107 
 Decidua, structure of the, 81 
 
 the menstrual, 282 
 
 vera and reflexa, fusion of the, 82 
 Definition of pregnancy, 22 
 Degeneration of the chorion villi, 277 
 
 of uterine fibres after labor, 117 
 Delivery, concealment of, 34 
 
 feigned, 52 
 
 premature, 221 
 Dental neuralgia, 376 
 Derangement of maternal health, as a cause 
 
 of abortion, 231 
 Despondency, 417 
 
 Development of foetus arrested by bad feed- 
 ing of mother, 373 
 
 of uterus in extra-uterine pregnancy, 
 113 
 
 of aterus in normal pregnancy, 112 
 Diagnosis of abortion, 253 
 
 of a twin-pregnancy, 130 
 Diaphoretics, use of, during pregnancy, 367 
 Diarrhoea, as a morbid state, 391 
 
 as a symptom of pregnancy, 85 
 Diet of pregnant women, 370 
 Digestive organs, disorders of the, 369 
 Dimensions of the uterus at diiferent periods 
 
 of pregnancy, 114 
 Diminished mortality of childbirth, 67 
 Discoloration of the vagina, 138 
 Disease of the foetus, as a cause of abortion, 
 240 
 
 of the liver simulating pregnancy, 180 
 Diseases, epidemic and infectious, 361 
 
 of the digestive organs, 369 
 
 of the generative organs, 435 
 
 of the placenta, 244 
 
 of the nervous system, 411 
 
 of the organs of respiration and circu- 
 lation, 399 
 
 of the spleen, 407 
 
 of the thyroid gland, 404 
 
 of the urinary organs, 425 
 
 which may coexist with pregnancy, 325 
 
 which simulate pregnancy, 144 
 Displacements of the gravid uterus, 464 
 Disposition, how altered by pregnancy, 65 
 Distended bladder and pregnancy, 171 
 Diuretics, 368 
 Double uteri, 314 
 Doubtful pregnancy, examination of cases 
 
 of, 51 
 Dreams, frightful, 416 
 Dribbling of the waters, 443 
 Dropsy, emergence of umbilicus in, 163 
 
 of the amnion, 170, 444 
 
 of the Fallopian tube, 164 
 
 of the kidney, 182 
 
 of the ovary, 168 
 
 of the peritoneum, 166 
 
 of the peritoneum coexisting with preg- 
 nancy, 169 
 Dublin Lying-in Hospital, deliveries in, 41 
 Duplex uteri, 315 
 Duration of pregnancy, 195 
 Dwarfs, usually born after ordinary term of 
 gestation, 218
 
 INDEX. 
 
 485 
 
 Dysmenorrhoeal membranes, 282 
 Dyspnoea during pregnancy, 399 
 
 Early marriages, 27 
 
 ova, examination of, 271 
 
 pregnancy, 24 
 
 puberty in male children, 24 
 Ears, nervous affection of the, 419 
 Edinburgh Maternity Hospital, deliveries 
 
 in, 42 
 Embrj'o, disease of the, as a cause of abor- 
 tion, 240 
 
 of one calendar month, 223 
 
 of three months, 224 
 
 of two months, 224 
 
 until fifteenth day, characters of, 223 
 Embryonic life, nature of, 99 
 Emergence of the umbilicus in dropsy, 163 
 
 of the umbilicus in pregnancy, 95 
 Emetics, 368 
 Emmenagogues, 368 
 Encysted dropsy of the peritoneum, 188 
 Enlargement of the abdomen, 92 
 
 of the breasts, 85 
 
 of the liver, kidneys, spleen, &g., ISO 
 
 of the spleen, 184, 408 
 
 of the thyroid gland, 404 
 
 of the uterus by pregnancy, 112 
 Epidemic diseases, 361 
 Epilepsy during pregnancy, 337 
 Epithelial substances from the vagina, 283 
 Epitome of symptoms of pregnancy, 72 
 Ergot, use of, in detecting pregnancy, 141 
 Erysipelas, symptoms delayed by labor, 363 
 Evidence of a live birth. 222 
 Examination of an early ovum, 271 
 
 of cases of doubtful pregnancy, 61 
 
 of substances expelled from the uterus, 
 271 
 
 of the urine, 134 
 
 of the uterus, through the rectum, 121 
 Exfoliation of vaginal mucous membrane, 
 
 283 
 Exhalation of carbonic acid, 139 
 Expulsion of foetus prematurely, 219 
 Extra-uterine gestation, 284 
 
 pregnancy, development of uterus 
 in, 114 
 Eyes, nervous affections of the, 419 
 
 Fsecal accumulations, 186 
 Fainting, 402 
 Falling of the womb, 464 
 Fallopian tube, dropsy of the, 164 
 False membranes from the uterus and vagi- 
 na, 282, 283 
 Father, influence of the, in production of 
 
 male children, 50 
 Fatty degeneration of the placenta, 245 
 
 of the uterine fibres after labor, 117 
 Feigned abortion, 255 
 
 delivery, 52 
 
 pregnancy, 51, 146 
 Female births, cause of, 216 
 
 to male births, proportion of, 51 
 Females, age of puberty, 75 
 
 Fibroid tumors, coexisting with pregnancy, 
 178 
 of uterus, 173 
 First labors, comparatively great mortality 
 
 of, 46 
 Fissiparous multiplication, 61 
 Five children at one labor, 38 
 Flooding, unavoidable, 459 
 Foetal age, how to be determined, 223 
 auscultation, opinions on, 20 
 circulation, 124 
 
 disease as a cause of abortion, 240 
 heart-beats, detected by auscultation, 
 127 
 difference of in the two sexes, 
 
 48 
 frequency of, 132 
 life, nature of, 99 
 
 movements, detected by auscultation, 
 123 
 Foetus born alive at fourth month, 221, 224 
 causes of premature expulsion of, 229 
 development of, ariested by bad feed- 
 ing of mother, 373 
 in male abdomen, 189 
 movements of the, 98 
 of eight months, 225 
 of five months, 225 
 of four months, 224 
 of nine months, 226 
 of seven months, 225 
 of six months, 225 
 
 position of, ascertained by palpation, 96 
 premature expulsion of, 219 
 signs of the death of, 246 
 Food of pregnant women, 370 
 Four children at one labor, 38 
 Fruitful births, the proportion of, 33 
 Fruitfulness of marriages in different coun- 
 tries, 33 
 Function of reproduction in animals, 61 
 Funic pulsations detected by auscultation 
 125 
 soulHe, 125 
 Funis, length of the, 124 
 structure of the, 124 
 
 Gardner peerage cause, 195 
 Gas, accumulation of, in the uterus, 193 
 General observations on pregnancy, 17 
 Generative faculty, limits of the, 22 
 power, limit of, in men, 30 
 limit of, in women, 29 
 Germ cells, or ovules, 61 
 Gestation, cardiac hypertrophy in, 355 
 complicated with cancer uteri, 356 
 with chorea, 339 
 with disease of generative organs, 
 
 435 
 with disease of urinary organs, 425 
 with disorders of digestive organs, 
 
 369 
 with disorders of nervous system, 
 
 411 ^ 
 
 with disorders of organs of respira- 
 tion and circulation, 399 
 with eruptive fevers, 361 
 extra-uterine, 284 
 how influenced by hysteria, 345
 
 486 
 
 INDEX. 
 
 Gestation, how influenced by phthisis, 352 
 how influenced by pneumonia, 353 
 privileges it secures to the woman, 65 
 term of, 195 
 
 Glandular follicles of the areola, 86 
 
 Graafian vesicles or follicles, 77 
 
 Grandmothers suckling their grandchildren, 
 
 Habit of aborting, 233 
 
 Hsematemesis, 390 
 
 Haematometra, 190 
 
 Haemoptysis, 401 
 
 Haemorrhoids, 408 
 
 Headache as a disease of pregnancy, 411 
 
 as a sign of pregnancy, 141 
 Heart, hypertrophy of the, 355 
 
 palpitation of the, 401 
 
 sounds of foetal, detected by ausculta- 
 tion, 127 
 Heart-beats of foetus, frequency of the, 131 
 Heartburn, 390 
 
 Heavy children, weights of, at birth, 226 
 Hemiplegia and pregnancy, 335 
 Hemorrhage, uterine, 454 
 Hepatic atrophy, 397 
 
 cancer, 182 
 
 hypertrophy, 180, 396 
 Hermaphrodite animals, 61 
 Hernia of the gravid uterus, 479 
 
 of the ovary, 477 
 
 of the unimpregnated uterus, 476 
 
 with ascites, mistaken for pregnancy, 187 
 Horseshoe kidney, 183 
 Hydatidiforiu moles, 277 
 Hydrometra, 192 
 Hydronephrosis, 183 
 Hydrorrhoea uteri, 193, 440 
 Hymen, imperforation of the, 83 
 
 presence of the, not a certain sign of 
 chastity, 59 
 
 rupture of the, without sexual inter- 
 course, 59 
 Hypertrophy of the heart. 355 
 
 of the liver, 180 
 
 of the spleen, 184 
 Hypochondriasis, 417 
 Hysteria, efi'ect of on pregnancy, 345 
 
 propriety of recommending marriage in, 
 344 
 
 Icterus gravidarum, 395 
 
 Illegitimate children, proportion of, 35 
 
 Imaginary foetal movements, 102 
 
 pregnancy, 59, 146 
 Imitation of disease by pregnant uterus, 57 
 Impregnation during unconsciousness, 55 
 Inclusion of one germ within another, 189 
 Inconclusive cases of protracted gestation, 
 
 207 
 Incontinence of urine, 425 
 Infant, earliest period of maturity in, 228 
 
 weight of, at birth, 226 
 Infants, number born at one labor, 35 
 Infectious diseases, 361 
 Inflammation of the lungs during pregnancy, 
 
 353 
 
 Inflammation of the ovary and suppuration, 
 164 
 of the uterus, 449 
 Influenza, 361 
 Insanity during pregnancy, 326 
 
 seldom cured by pregnancy, 331 
 Insemination and fecundation, distinction 
 
 between, 201 
 Intermittent tetanus during pregnancy, 348 
 Interstitial pregnancy, 294 
 Interval between marriage and pregnancy, 
 
 45 
 Intra-uterine foetal disease, 241 
 Inversion of the uterus after abortion, 251 
 Investigation of cases of feigned delivery, 
 
 53 
 Involution of the uterus, 117 
 
 Jaundice of pregnant women, 395 
 
 Kidneys, diseases of the, 182 
 malposition of the, 182 
 union of the, 183 
 
 Kiestein in the urine, 134 
 
 Labia, oedema of the, 438 
 
 Labor, day of, prediction of the, 215 
 
 feigned, 51 
 
 missed, 321 
 
 pains mistaken for colic, 57 
 
 premature, 219 
 
 protracted, mistaken for protracted ges- 
 tation, 213 
 Latest age for parturition, 29 
 Law as to duration of pregnancy, 195 
 Lead-poisoning as a cause of abortion, 233 
 Length of the funis, 124 
 Leucorrhcea, vaginal, 439 
 Limits of the generative power, 22, 29 
 
 of human fertility, 37 
 Lipopaediou, 287 
 
 Liquor amnii, excessive secretion of, 170 
 Live birth, what constitutes one, 221 
 Liver affections, 395 ' 
 
 atrophy of the, 397 
 
 cancer of the, 182 
 
 hypertrophy of the, 180 
 Longings of pregnant women, 328 
 Looseness of the bowels, 391 
 Lungs, inflammation of the, 353 
 
 Male births, cause of, 216 
 
 breasts, secretion of milk by, 89, 90 
 
 to female births, proportion of, 51 
 Males, age of pubertj' in, 75 
 Malformations of the uterus, 314 
 Malposition of the kidneys, 182 
 Mammary sympathies, 85 
 Mania as influenced by parturition, 330 
 Mares and cows, time of gestation in, 245 
 Marriage and pregnancy, interval between, 
 45 
 
 as a cure for epilepsy, 338 
 
 at an early age, 28 
 
 propriety of advising, in hysteria, 344
 
 INDEX. 
 
 487 
 
 Marringes between near relations, 34 
 
 fruitful ness of, in different countries, 33 
 Mastoclynia, 421 
 Maternity, precocious, 24 
 Maturity of infant, earliest period of. 228 
 Melancholia during pregnancy, 328 
 Membranes, dysmenorrhoeal, 282 
 Membranous formations from the vagina, 
 
 283 
 Menstrual blood, retention of, in uterus, 190 
 
 decidua, 282 
 
 fluid, nature of the, 76 
 quantity of the, 76 
 source of the, 76 
 Menstruation, cessation of, 29 
 
 characteristics of, 75 
 
 during pregnancy, 79 
 
 precocious, 22 
 
 suppression of 74 
 
 usual date of first occurrence, 24 
 Mental depression. 417 
 
 disorders during pregnancy, 326 
 Mercury, mode of administration to preg- 
 nant women, 262 
 Metritis, 449 
 Metrorrhoea, 440 
 Milk, secretion of the. 88 
 Minor signs of pregnancy, 133 
 Miscarriage, 219 
 Misplaced gestation, 284 
 Missed labor, 321 
 Moles, 275 
 
 Moral changes effected by pregnancy, 142 
 Morning sickness, 84, 379 
 Mortality in first labors, 46 
 
 of childbirth, its diminution, 67 
 Movable kidneys, 183 
 Movements of the foetus, 98 
 
 detected by auscultation, 123 
 Mucous membrane of vagina, altered hue 
 
 of, 138 
 Multiplication by gemmation, 61 
 Muscular tumors, 156 
 Myalgic pains in the side, 423 
 
 Narcotics, use of, during pregnancy, 367 
 
 Nature of foetal life, 99 
 
 Nausea and vomiting, 84, 379 
 
 Navel, emergence of the, 95 
 
 Nervous affections of ears and e3'es, 419 
 
 disorders as symptomatic of pregnancy, 
 143 
 
 system, diseases of the, 411 
 Neuralgia of dental nerves, 375 
 Non-sexual reproduction, 61 
 Nubility, age of, 74 
 
 Nulliparous uterus, description of the, 103 
 Number of children a woman can bear, 31 
 
 Obstetric auscultation, how practised, 123 
 Occipital headache as a sign of pregnancy, 
 
 141 
 (Edema of the labia, 438 
 Operations during pregnancy, 265 
 Ordinary duration of pregnancy, 196 
 Organic disease as a cause of abortion, 232 
 Osteopsedion, 287 
 
 Os uteri, shape of, as a sign of pregnancy, 141 
 
 Ova of the frog, 78 
 
 Ovarian disease as a cause of abortion, 238 
 
 dropsy, 158 
 
 coexisting with pregnancy, 164 
 
 nerves, relation of, to parturition, 198 
 
 pregnancy, 292 
 
 tumors, emergence of umbilicus in, 163 
 Ovaritis ending in suppuration, 164 
 Ovary, abscess of the, 164 
 
 hernia of the, 477 
 Oviparous animals, 62 
 Ovo-viviparous animals, 62 
 Ovulation and cestruation simultaneously, 
 199 
 
 during pregnancy, 319 
 Ovule, escape of, from Graafian vesicle, 78 
 Ovum, an early, 271 
 
 in ovo, 190 
 
 Pains of labor mistaken for colic, 57 
 Palpitation of the heart, 401 
 Paraplegia and pregnancy, 334 
 Paralysis consequent on uterine disease, 335 
 Paralytic affections coexisting with preg- 
 nancy, 335 
 Parents, age of as influencing sex of chil- 
 dren, 50 
 as regulating duration of pregnan- 
 cy, 215 
 Parturition among the Abyssinian women, 66 
 Corsican women, 67 
 Iberian women, 67 
 Maori women, 66 
 
 at the age of fifty-four, 29 
 
 feigned, 52 
 
 how influenced by phthisis, 352 
 
 in cancer of the uterus, 358 
 
 influence of, in insanitj', 330 
 
 mortality of, with male children, 45 
 
 protracted, mistaken for protracted ges- 
 tation, 213 
 
 without consciousness, 337 
 Pellicles of kiestein, examination of, 135 
 Period of abortion, table of, 221 
 Peristaltic motions of the uterus, 137 
 Peritoneum, dropsy of the, 166 
 
 encysted dropsy of the, 188 
 
 tubercular disease of the, 185 
 Phantom tumors. 156 
 
 Phthisis, eff"ect of, on pregnant women, 350 
 Physical changes in pregnancy, 142 
 Physometra, 193 
 Pica, 374 
 
 Pigment of the mammary areola, 87 
 Piles, 408 
 Placenta, formation of the, 108 
 
 prsevia, 460 
 
 retention of, followed by tetanus, 347 
 
 size of, at birth, 227 
 
 spuria, or succenturiata, 258 
 
 placental apoplexy, 245 
 
 disease, as a cause of abortion, 244 
 
 mammalia, 62 
 
 murmur heard by auscultation, 125 
 Placentitis, 245 
 Pleurodynia, 422 
 Plugging the vagina in hemorrhage, 267
 
 488 
 
 INDEX. 
 
 Plurality of children at one labor, o5 
 Pneumonia, influence of, on gestation, 353 
 Poisoning by lead as a cause of abortion, 233 
 Polypi of the uterus, 176, 456 
 Polypus, delivery of a, 176 
 Poor, fertility of the, 33 
 Population, in 1866, of United Kingdom, 51 
 Position of the foetus, how learnt, 96 
 
 of uterus at different periods of preg- 
 nancy, 92, 114 
 Precocious maternity, 24 
 
 menstruation, 22 
 Prediction of the day of labor, 215 
 Pregnancy at a late age, 29 
 
 cardiac hypertrophy during, 355 
 
 classification of the signs of, 70 
 
 complicated, 22 
 
 with ascites, 169 
 
 with chorea, 339 
 
 with enlargement of the spleen, 184 
 
 with insanity, 326 
 
 with ovarian dropsy, 164 
 
 with phthisis, 350 
 
 compound, 22 
 
 concealed, 34 
 
 definition of, 22 
 
 diseases which may coexist with, 325 
 
 duration of, 195 
 
 extra-uterine, 284 
 
 extra-uterine, development of the uterus 
 in, 114 
 
 feigned, 51 
 
 from a single intercourse, 44 
 
 genera] observations on, 17 
 
 imaginary, 59 
 
 in epileptics, 338 
 
 in women already insane, 330 
 
 menstruation during, 79 
 
 not prevented by paralysis, 335 
 
 occurrence of, at early stage, 24 
 
 ovarian, 292 
 
 simple, 22 
 
 simulated by disease, 144 
 
 spurious, 146 
 
 therapeutics of, 363 
 
 tubal, 293 
 
 tubo-ovarian, 290 
 
 tubo-uterine, 294 
 Pregnant women, the general privileges of, 65 
 
 the longings of, 328 
 Premature expulsion of foetus, 219 
 
 wedlock, 28 
 Preventive measures against abortion, 259 
 Privileges of pregnant women, 65 
 Procidentia uteri, 465 
 Production of abortion, criminal law on, 98 
 
 of sex, 49 
 Productive marriages, proportion of, 33 
 Prognosis in abortion, 255 
 Prolapsus of the uterus, 240, 464 
 Prolificness, age of greatest, 43 
 Proportion of male to female births, 51 
 
 of stillborn children, 45 
 Protracted gestation, inconclusive cases of, 
 207 
 
 parturition mistaken for protracted ges- 
 tation, 213 
 Pruritus as a cause of abortion, 232 
 
 of the vulva, 435 
 
 Pseudocyesis, 146 
 Pseudo-pregnancy, 22, 146 
 Ptyalism, 85, 377 
 Puberty, early accession of, in boys, 24 
 
 in the female, 75 
 
 in the male, 75 
 Puerperal convulsions, 427 
 
 tetanus, 346 
 Pulse in new-born infants, 49 
 
 vaginal, 141 
 Purgatives, use of, during pregnancy, 366 
 Pus distending the uterus, 192 
 Putrid infection from retained placenta, 257 
 Pyometra, 192 
 Pyrosis, 390 
 
 Quadruplet births, 38 
 Quickening. 98 
 Quintuplet births, 38 
 
 Radiating streaks on the breast, 87 
 Reconstruction of uterus after labor, 117 
 Rectum, examination of uterus by the, 121 
 Relations, marriages between, 34 
 Renal affections, 182 
 Repercussion, 118 
 
 Reproduction, function of. in animals. 61, 62 
 Respiration, disorders of the organs of. 399 
 Retention of the menses, 190 
 
 of urine, 171, 426, 470 
 Retroflexion of the uterus, 475 
 Retroversion of the uterus, 469 
 as a cause of abortion, 240 
 Rheumatism of the uterus, 447 
 Right side, pain in the, 422 
 Rules for examining abdominal tumors, 144 
 Rupture of cyst-walls in extra-uterine preg- 
 nancy, 297 
 
 Salivation, 85, 377 
 
 Scarlet fever, symptoms delayed by labor, 
 
 362 
 Secretion of milk, 88 
 
 Sedatives, use of, during pregnancy, 367 
 Sex of foetus, how foretold, 47 
 
 production of, at will, 47 
 Sextuplet births, 37 
 Sexual reproduction, 61 
 Shortening of the cervix uteri. 111 
 Sickness, as a sign of pregnancy, 84 
 
 during pregnancy, 379 
 Signs and symptoms of pregnancy, 70 
 
 derived from appearances of breasts, 85 
 auscultation, 121 
 ballottement, 118 
 changes in uterus, 103 
 examination of abdomen, 92 
 examining per rectum, 121 
 suppression of menses, 74 
 indicative of conception, 65 
 of death of the foetus, 246 
 of pregnancy, classification of the, 70 
 the minor, 133 
 Silvery streaks on the breast, 87 
 Simple pregnancy. 22 
 Simulated pregnancy, 51, 146
 
 INDEX. 
 
 489 
 
 Simultaneous ovulation and oestruation, 199 
 Six children at one labor, 37 
 Skin disease as a cause of abortion, 232 
 Sleep, delivery during, 55 
 
 impregnation during, 56 
 Sleeplessness, 412 
 Small-pos, 361 
 
 Smell of the vaginal mucus, 140 
 Souffle in the funis, 124 
 
 uterus, 125 
 Spermatozoa, or sperm cells, 63 
 Spitting of blood, 401 
 Spleen, morbid states of the, 184, 407 
 Spurious parturition, 52, 150 
 
 pregnancy, 146 
 Stercoral tumors, 186 
 Stillborn children, proportion of, 45 
 Stimulants and tonics, 367 
 Structure of the umbilical cord, 124 
 
 uterus, 104 
 Substances expelled from the uterus, 271 
 Suckling children by young girls, 88 
 Suicidal tendency in insanity during preg- 
 nancy, 329 
 Superfoetation, 312 
 Suppression of the menses, 74 
 Suppuration in the ovary, 164 
 Surgical operations during pregnancy, 265 
 Sympathetic disorders of pregnancy, 369 
 Symptoms of pregnancy, epitome of the, 71 
 Syncope, 402 
 Syphilis affecting the foetus, 242 
 
 constitutional, as a cause of abortion, 234 
 
 Table of ages of 48,929 women at delivery, 
 44 
 
 of date of labor after a single coitus, 204 
 
 of dimensions of uterus at chief periods 
 of pregnancy, 114 
 
 of duration of pregnancy, 202 
 
 of first appearance of the catamenia, 24 
 
 of mortality in first and subsequent 
 labors, 46 
 
 of percentage of weekly deliveries, 203 
 
 of the signs of pregnancy, 74 
 
 showing decrease of uterus after partu- 
 rition, 116 
 
 showing period of abortion, 221 
 Tampon, or plug, the, 268 
 Tardy labor confounded with protracted ges- 
 tation, 213 
 Temperature of the vagina, 140 
 Temporary insanity during pregnancy, 327 
 Term of gestation, 195 
 Tetanus after abortion, 346 
 
 following retention of the placenta, 347 
 Therapeutics of pregnancy, 363 
 Thermometer, use of, in pregnancy, MO 
 Three children at one labor, 40 
 Thyroid gland, enlargement of the, 404 
 Time of gestation in cows and mares, 245 
 Tonics and stimulants, 367 
 Toothache, 375 
 Toxaemia, uraemic, 427 
 Triplet births, 40 
 Trivial signs of pregnancy, 140 
 True generation, 61 
 Tubal pregnancy, 293 
 
 Tubercular disease of peritoneum, 185 
 Tuberculosis during pregnancy, 350 
 Tubo-ovarian pregnancy, 290 
 Tubo-uterine pregnancy, 294 
 Tumor from faecal accumulation, 186 
 
 ovarian, 158 
 Tumors containing hair and teeth, 189 
 
 fibroid, 173 
 
 muscular or phantom, 156 
 
 of uterus with pregnancy, 179 
 
 true hydatid, 281 
 Twin births, 41 
 
 Twin-pregnancy, diagnosis of, 130 
 Twins, weight of, 227 
 Tympanites of the uterus, 194 
 Typhus symptoms delayed by labor, 362 
 
 Ulceration of cervix uteri, 382, 454 
 Umbilical cord, length of the, 124 
 
 nature of the, 124 
 Umbilicus, alterations in the, 95 
 Unavoidable hemorrhage, 460 
 Unconsciousness, impregnation during, 55 
 Unimpregnated uterus, description of the, 
 
 103 
 Unisexual generation, 61 
 United Kingdom in 1866, population of, 51 
 Unproductive marriages, proportion of, 33 
 Urremic eclampsia, 427 
 Urine, accumulation of, with pregnancy, 171 
 
 examination of the, 134 
 
 incontinence of, 425 
 
 retention of; 171, 426, 470 
 Uterine acephalocysts, 281 
 
 cancer, 456 
 
 disease, as a cause of abortion, 238 
 
 displacement, as a cartse of sickness, 383 
 
 fibroids, 173 
 
 hemorrhage, 453 
 
 hydatids, 277 
 
 malformations, 314 
 
 souffle, 125 
 Uterus, alteration of form as a sign of preg- 
 nancy, 137 
 
 anatomy of the, 103 
 
 anteflexion of the, 468 
 
 anteversion of the, 467 
 
 atrophy of the, after parturition, 117 
 
 cavity of the, after parturition, 116 
 
 changes in the, after parturition, 114 
 from extra-uterine pregnancy, 114 
 after conception, 103, 110 
 
 dimensions of the, at difierent periods of 
 pregnancy, 114 
 
 displacement of the, 464 
 
 double-horned, 314 
 
 hardening of, under pressure, 137 
 
 hernia of the, 476 
 
 inflammation of the, 449 
 
 inversion of the, after abortion, 251 
 
 minute structure of the, 104 
 
 nerves of the, 1 10 
 
 polypus of the, 456 
 
 position of the, during pregnancy, 92, 
 114 
 
 prolapsus of the, 464 
 
 pus in cavity of the, 192 
 
 reconstruction of the, after labor, 117 
 
 82
 
 490 
 
 INDEX. 
 
 Uterus, retention of menses in the, 190 
 retroflexion of the, 475 
 retroversion of the, 472 
 rheumatism of the, 447 
 softening and rupture of the, 452 
 structure of the, 104 
 substances which may be expelled from 
 
 the, 271 
 watery discharges from the, 440 
 watery fluid in cavity of the, 192 
 
 Vaccination during pregnancy, 362 
 Vagina, accumulation of air in the, 194 
 
 discoloration of the, 138 
 
 temperature of the, 140 
 Vaginal labia, adhesions between the, 83 
 
 leucorrhoea, 439 
 
 mucous membrane, exfoliation of the, 283 
 
 mucus, smell of the, 140 
 
 pulse, 141 
 Varices, 408 
 
 Variola during pregnancy, 361, 362. 
 Venereal disease, as a cause of abortion, 234 
 Venesection during pregnancy, 364 
 Ventral omental hernia, 187 
 Vesicular moles, 277 
 Vomiting and nausea, 84, 379 
 Virgin uterus, description of the, 103 
 Viviparous animals, 62 
 Vulval pruritus, 435 
 
 Water-brash, 390 
 
 Water, different kinds of, for drinking, 372 
 
 Watery discharges from the uterus, 440 
 
 fluid distending the uterus, 192 
 Wedlock, premature, 28 
 AVeight of infant at birth, 227 
 
 of twins, 227 
 
 of iiterus after parturition, 116 
 Womb diseases, as a cause of abortion, 238 
 Women bearing many children, 31
 
 IMPORTANT WOEES 
 
 ON OBSTETRICS. 
 
 I. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Bv Hugh L. Hodge, M.D.. 
 Late Professor of Midwifery, &c., in the University of Pennsylvania. Illustrated 
 with large lithographic plates, containing one hundred and fifty nine figures from 
 original photographs, and with numerous wood-cuts. In one large and beautifully 
 printed quarto volume of 550 double-columned pages, strongly bound in extra cloth. 
 $14. {Lately pjihlisked.) 
 
 The work of Dr. HodgH is something more than 
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 embody in a single volume the whole science and 
 art of Obstetrics. An elaboi;p.te text is combined 
 with accurate and varied pictorial illustrations, so 
 
 that no fact or principle is left unstated or unex- 
 plained. — American Alodical Times. 
 
 It is very large, profusely and elegantly illus- 
 trated, and is fitted to take its place near the works 
 of great obstetricians. Of the American works on 
 the subject it is decidedly the hast.— Edinburgh 
 Medical Journal. 
 
 II. 
 OBSTETRICS; THE SCIENCE AND THE ART. By Charles D. Meigs, M.D., 
 Lately Professor of Obstetrics, kc, in the Jefferson Medical College, Phila. Fifth 
 Edition, revised ; with one hundred and thirty illustrations. In one handsome 
 octavo volume of 760 pages, extra cloth, $5.50 ; leather, $6.50. {Just issued.) 
 
 The original edition is already so extensively j It is to the student that our author has more 
 and favorably known to the profession that no : particularly addressed himself— but to the practi- 
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 say, the present edition is very much extended, j as a book of reference. No work that we have met 
 
 with so thoroughly details everything that falls to 
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 improved, and perfected. Whilst the great prac- 
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 practitioner, it is so condensed as to constitute a 
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 dent. — SouUiern Med. and Surg. Journal. 
 
 III. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, 
 in reference to the Process of Parturition. By Francis H. Ramsbotham, M.D. A 
 new and enlarged edition, thoroughly revised by the author. With additions by W. 
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 We will only add that the student will learn 
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 will find it, as a book of reference, surpassed by 
 none otiier. — Slethoscope. 
 
 IV. 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. By Fleetwood Churchill, 
 M.D., M.R.I.A., Professor of Midwifery and Diseases of Women and Children in the 
 King & Queen's College of Physicians in Ireland. A new American, from the fourth 
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 amplified beyond the previous editions, but noth- 
 ing has been added which could be well dispensed 
 with. An examination of the table of contents 
 shows how thoroughly the author has gone over 
 the ground, and the care he has taken in the text 
 to present the subjects in all their bearings, will 
 render this new edition even more necessary to the 
 obstetric student than were either of the former 
 editions at the date of their appearance. No trea- 
 
 tise on obstetrics with which we are acquainted 
 can compare favorably with this, in res))eet to the 
 amount of material which has been gathered from 
 every source. — Boston Med. and Surg. Journal. 
 
 There is no better text-book for students, or 
 work of reference and study for the practising phy- 
 sician than this. It .should adorn and enrich every 
 medical library. — Chicago Med. Journal. 
 
 HENRY C. LEA, Philadelphia.
 
 IMPORTANT KEW WORKS 
 
 ON THE DISEASES OF CHILMEN. 
 
 A PKACTICAL TKEATISE 
 
 THE DISEASES OF CHILDREN. 
 By D. Francis Condie, M.D. 
 
 Sixth Edition, thoroughly Revised. In one large and handsome octavo volume of nearly 800 
 closely-printed pages. (Just Ready.) 
 
 This work has long been known as the standard American treatise on infantile diseases. 
 In preparing a new edition for the press, the author has sedulously endeavored, by a con- 
 scientious revision, to render it in every respect worthy a continuance of the very great 
 favor with which it has been received by the profession. A few notices of former editions 
 are appended. 
 
 This is one of the very best treatisi^s on the dis- 
 eases of early life that has issued from the Ameri- 
 can press. It has long since taken its place among 
 the standard Works of the day. It belongs to the 
 class of indispensables, without which no practi- 
 tioner can get along very well, and with which 
 alone some of our number afford to be satisfied. 
 Although merely claiming to be "practical," it has 
 also a high scholastic claim. We do not find fault 
 ■with the reservation, for. when properly under- 
 stood, it is very appropriate. A '• practical" trea- 
 tise is not merely one which conveys intelligence 
 that admits of being applied under circumstances 
 of necessity, but it is also one which with this yields 
 the cream of the best information that other au- 
 thors have derived as the result of their personal 
 
 observations. A practical treatise, therefore, should 
 not be barely a collection of useful directions, but, 
 with fhis. it should be <a digest of the science of its 
 subjects. Both these characters are po.ssessed by 
 Dr. Coudie's present work. Aud furthermore, upon 
 the special department of Therapeutics, his aim 
 appears to have been to reduce the remarks down 
 to those only which have been proved to have the 
 weight of authority in their favor, and can ex- 
 hibit a clear prospect of benefit upon their injunc- 
 tions being carried into execution. — Montreal Med. 
 Chronicle. 
 
 A far more complete exposition of its subject 
 than any other treatise on the diseases of children 
 in the English language. — Am. Jour. Med. Sciences. 
 
 II. 
 
 LECTURES 
 
 ON 
 
 THE DISEASES OF INFANCY AND CHILDHOOD. 
 
 By Charles West, M.D., 
 Physician to the Hospital for Sick Children, &c. 
 
 Fourth American from the Fifth Revised and Enlarged English Edition. In one large and handsome 
 octavo volume of ebii closely-printed pages. Extra C'lolli, $i.50; Leather, %5.bQ. (Just Issued.) 
 
 This work may now fairly claim the position of a standard authority and medical classic. 
 Five editions in England, four in America, four in Germany, and translations in French, 
 Danish, Dutch, and Russian, show how fully it has met the wants of the profession by the 
 soundness of its views and the clearness with which they are presented. Few practition- 
 ers, indeed, have had the opportunities of observation and experience enjoyed by the au- 
 thor. In his preface he remarks, "'The present edition embodies the results of 1200 re- 
 corded cases and of nearly 400 post-mortem examinations, collected from between 30,000 
 and 40,000 children, who, during the past twenty-six years, have come under my care, 
 either in public or in private practice." The universal favor with which the work has 
 been received, shows that the author has made good use of these unusual advantages. 
 
 Of all the English writers on the diseases of chil- 
 dren, there is no one so entirely satisf;ictory to us 
 as Dr. West. For years we have held his opinion 
 as judicial, and have regarded him as one <if the 
 highest living authorities in the difficult depart- 
 ment of medical science in which he is most widely 
 known. His writings are characterized by asound, 
 practical common sense, at the same time that they 
 bear the marks of the most laborious study and 
 investigation. We commend it to all as a most 
 reliiible adviser on many occasions when many 
 treatises on the same subjects will utterly fail to 
 help us. It is supplied with a very copious general 
 index, and a special index to the formula? scattered 
 throughout the work. — Boston Med. and Surgical 
 Journal, .April 2ii, 1866. 
 
 Dr. West's volume is, in our opinion, incompar- 
 
 ably the best authority upon the maladies of chil- 
 dren that the practitioner can consult. Withal. 
 too, — a minor matter, truly, but still not one that 
 should be neglected, — Dr. WVst's composition pos- 
 sesses a peculiar charm, beauty and clearness of 
 expression, thus affording the reader much pleas- 
 ure, even independent ot that which arises from 
 the acquisition of valuable truths. — Cincinnati 
 Jour, of Medicine, March, 1866. 
 
 We have long regarded it as the most scientific 
 and practical book on diseases of children which 
 has yet appeared in this country. — Buffalo Medical 
 Juurn(d. 
 
 Dr. West's book is the best that has ever been 
 written in the English language on the diseases of 
 infancy and childhood. — Columbus Review of Med. 
 and Surgery. 
 
 HENKY C. LEA, Philadelphia.
 
 HEHSrHY C. LEA.'S 
 
 (late lea & blanchard's) 
 OF 
 
 MEDICAL AND SUEGIOAL PUBLICATIONS. 
 
 In asking the attention of the profession to the works contained in the followino- 
 pages, the publisher would state that no pains are spared to secure a continuance of 
 the confidence earned for the publications of the house by their careful selection and 
 accuracy and finish of execution. 
 
 The printed prices are those at which books can generally be supplied by booksellers 
 throughout the United States, who can readily procure for their customers any works 
 not kept in stock. Where access to bookstores is not convenient, books will be sent 
 by mail post-paid on receipt of the price, but no risks are assumed either on the 
 money or the books, and no publications but my own are supplied. Gentlemen will 
 therefore in most cases find it more convenient to deal with the nearest f ookseller. 
 
 An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- 
 warded by mail, postpaid, on receipt of ten cents. 
 
 HENRY C. LEA. 
 
 Nos. 706 and 708 Sansom St., Philadelphia, April, 1868. 
 
 ADDITIONAL INDUCEMENT FOE SUBSCRIBERS TO 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 THEEE MEDICAL JOURNALS, containing over 2000 LAEGE PAGES, 
 Tree of Postage, for SIX DOLLAES Per Annum. 
 
 TERMS FOR 1868-IN" ADVANCE: 
 
 The American Journal of the Medical Sciences, and \ Five Dollars per annum. 
 The Medical News and Library, j in advance. 
 
 The Medical News and Library, separate. One Dollar per annum, in advance. 
 
 Banking's Half-Yearly Abstract of the Medical Sciences, separate, Two Dol- 
 lars and a Half per annum in advance. 
 
 on. 
 The American Journal of the Medical Sciences, published quar- ^ 
 
 quarterly (1150 pages per annum), with 
 The Medical News and Library, monthly (384 pp. per annum), and 
 Banking's Abstract of the Medical Sciences, published half- 
 yearly (600 pages per annum), 
 
 (ALL FREE OF POSTAGE.) 
 
 Six Dollars 
 per annum 
 in advance. 
 
 In thus offering at a price unprecedentedly low, this vast amount of valuable 
 practical matter, the publisher felt that he could only be saved from loss by an 
 extent of circulation hitherto unknown in the annals of medical journalism. It is 
 therefore with much gratification that he is enabled to state that the marked appro- 
 bation of the profession, as evinced in the steady increase of the subscription list, 
 promises to render the enterprise a permanent oue. He is happy to acknowledge the 
 1
 
 2 Henry C. Lea's Publications — (Am. Journ. lied. Sciences). 
 
 valuable aid rendered by subscribers who have kindly made known among their friends 
 the advantages thus offered, and he confidently anticipates a continuance of the same 
 friendly interest, which, by enlarging the circulation of these periodicals, will enable 
 him to maintain them at the unexampled rate at which they are now supplied. Ar- 
 rangements have been made in London by which " Banking's Abstract'' will be issued 
 here almost simultaneously with its appearance in England: and, with the cooperation 
 of the profession, the publisher trusts to succeed in his endeavor to lay on the table 
 of every reading practitioner in the United States a monthly, a quarterly, and a half- 
 yearly periodical at the comparatively trifling cost of Six Dollars jje/" annum. 
 
 These periodicals are universally known for their high professional standing in their 
 several spheres. 
 
 I. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 Edited by ISAAC HAYS, M. D., 
 
 is published Quarterly, on the first of January, April, July, and October. Each 
 number contains nearly three hundred large octavo pages, appropriately illustrated, 
 wherever necessary. It has now been issued regularly for over forty years, during 
 nearly the whole of which time it has been under the control of the present editor. 
 Throughout this long period, it has maintained its position in the highest rank of 
 medical periodicals both at home and abroad, and has received the cordial support of 
 the entire profession in this country. Among its Collaborators will be found a large 
 number of the most distinguished names of the profession in every section of the 
 United States, rendering the department devoted to 
 
 ORiaiNAL COMMUNICATIONS 
 
 full of varied and important matter, of great interest to all practitioners. Thus, during 
 i^GT, contributions have appeared in its pages from more than one hundred gentlemen 
 of the highest standing in the profession throughout the United States.* 
 
 Following this is the "Rrvikw Department," containing extended and impartial 
 reviews of all important new works, together with numerous elaborate "Biblio- 
 graphical Notices" of nearly all the publications of the day. 
 
 This is followed by the " Quarterly Summary op Improvements and Discoveries 
 IN THE Medical Sciences," classified and arranged under different heads, presenting 
 a very complete digest of all that is new and interesting to the physician, abroad as 
 well as at home. 
 
 Thus, during the year 1867, the "Journal" furnished to its subscribers One 
 Hundred and Sixteen Original Communications, Ninety Reviews and Bibliographical 
 Notices, and Two Hundred and Five articles in the Quarterly Summaries, making a 
 total of over Four Hundred articles emanating from the best professional minds in 
 America and Europe. 
 
 To old subscribers, many of whom have been on the list for twenty or thirty years, 
 the publisher feels that no promises for the future are necessary; but gentlemen who 
 may now propose for the first time to subscribe may rest assured that no exertion will 
 be spared to maintain the "Journal" in the high position which it has so long occu- 
 pied as a national exponent of scientific medicine, and as a medium of intercommu- 
 nication between the profession of Europe and America — to render it, in fact, neces- 
 sary to every practitioner who desires to keep on a level with the progress of his 
 science. 
 
 The subscription price of the "American Journal of the Medical Sciences" has 
 never been raised, during its long career. It is still Five Dollars per annum in ad- 
 vance, for which sum the subscriber receives in addition the "Medical News and 
 Library," making in all about 1.500 large octavo pages per annum, free of postage. 
 
 ir. 
 THE MEDICAL NEWS AND LIBRARY 
 
 is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
 annum. Its "News Department" presents the current information of the day, with 
 Clinical Lectures and Hospital Gleanings; while the " Library Department" is de- 
 voted to publishing standard works on the various branches of medical science, paged 
 
 * Communications are invited from gentlemen in all parts of the country All elaborate articles inserted 
 by the Editor are paid for by the Publisher.
 
 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 3 
 
 separately, so that they can be removed and bound on completion. In this manner 
 subscribers have received, without expense, such works as " Watson's Practice," 
 "Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery," 
 &c. &c. The work now appea,ring in its pages is Dr. Hudson's valuable "Lectures 
 ON the Study of Fever," which was commenced in the number for July, 1867. Gen- 
 tlemen desiring their subscriptions to commence with Jan. 1868 can procure, for fifty 
 cents, the portion which has appeared from July to December inclusive. 
 
 As stated above, the subscription price of the "Medical News and Library" is 
 One Dollar per annum in advance ; and it is furnished without charge to all sub- 
 scribers to the "American Journal of the Medical Sciences." 
 
 III. 
 
 RANKING'S ABSTRACT OF THE MEDICAL SCIENCES 
 
 is issued in half-yearly volumes, which will be delivered to subscribers about the first 
 of August, and first of February. Each volume contains about 300 closely printed 
 octavo pages, making six hundred pages per annum. 
 
 "Banking's Abstract" has now been publislied in England regularly for more than 
 twenty years, and has acquired the highest reputation for the ability and industry 
 with which the essence of medical literature is condensed into its pages. It pur- 
 ports to be "A Digest of British and Continental Medicine, and of the progress of 
 Mcdiczne and the Collateral Sciences," and it presents an abstract of all that is impor- 
 tant or interesting in European Medical Literature. Each article is carefully con- 
 densed, so as to present its substance in the smallest possible compass, thus affordino' 
 space for the very large amount of information laid before its readers. The volumes 
 of 1867, for instance, thus contained 
 
 FIFTY-FIVE ARTICLEii'oX GENERAL QUESTIONS IN MEDICINE. 
 
 NINETY-SEVEN ARTICLES ON Sl'ECIAL QUESTIONS IN MEDICINE. 
 
 riYE ARTICLES ON FORENSIC MEDICINE 
 
 THIRTY-TWO ARTICLES ON GENERAL QUESTIONS IN SURGERY. 
 
 ONE HUNDRED AND SEVEN ARTICLES ON SPECIAL QUESTIONS IN SURGERY 
 
 SEVENTY-TWO ARTICLES ON MIDWIFERY AN I) DISEASES OF WOMEN AND CHILDREN 
 
 FORTY-EIGHT ARTICLES ON M.\TERIA MEDICA AND THERAPEUTICS. 
 
 SIXTY-THREE REVIEWS AND BIBLIOGRAPHICAL NOTICES. 
 
 THREE ARTICLES IN APPENDIX. 
 
 Making in all four hundred and eighty-two articles in a single year. Each volume, 
 moreover, is systematically arranged, with an elaborate Table of Contents and a very 
 full Judex, thus facilitating the researches of the reader in pursuit of particular sub- 
 jects, and enabling him to refer without loss of time to the vast amount of infor- 
 mation contained in its pages. 
 
 The subscription price of the "Abstract," mailed free of postage, is Two 
 Dollars and a Half per annum, payable in advance. Single volumes, $1 50 each. 
 
 As stated above, however, it will be supplied in conjunction with the "American 
 Journal of the Medical Sciences" and the "Medical News and Library,'' the 
 whole free of postage, for Six J^ollars per annum in advance. 
 
 For this small sum the subscriber will therefore receive three periodicals, each of 
 the highest reputation in its class, containing in all over two thousand pages of the 
 choicest reading, and presenting a complete view of medical progress throughout the 
 world. 
 
 In this effort to bring so large an amount of practical information within the reach 
 of every member of the profession, the publisher confidently anticipates the friendlv 
 aid of all who are interested in the dissemination of sound medical literature. He 
 trusts, especially, that the subscribers to the "American Medical Journal" will call 
 the attention of their acquaintances to the advantages thus offered, and that he will 
 be sustained in the endeavor to permanently establish medical periodical literature on 
 a footing of cheapness never heretofore attempted. 
 
 *^* Gentlemen desiring to avail themselves of the advantages thus offered will do 
 well to forward their subscriptions at an early day, in order to insure the receipt of 
 complete sets for the year 1868. 
 
 1^ The safest mode of remittance is by postal money order, drawn to the order of 
 the undersigned. Where money order jiost-offices are not accessible, remittances for 
 the "Journal" may be made at the risk of the publisher, by forwarding in registered 
 letters. Address, 
 
 HENRY C. LEA, 
 Nos. 706 and 708 Saxsom St., Philadelphia, Pa.
 
 Henry C, Lea's Publications — (Dictionaries). 
 
 jnUNGLISON {ROBLEY), M.D., 
 
 "^ Professor of Institutes of Medicine in Jefferson Medical College, Philadeljjhia. 
 
 MEDICAL LEXICON; A Dictionary op Medical Science: Con- 
 taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
 Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
 Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
 Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
 the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
 English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented 
 In one very large and handsome royal octavo volume of 1048 double-columned pages, in 
 small type; strongly done up in extra cloth, $6 00 ; leather, raised bands, $6 75. 
 The object of the author from the outset has not been to make the work a mere lexicon or 
 dictionary of terms, but to afford, under each, a condensed view of ita various medical relations, 
 and thus to render the work an epitome of the existing condition of medical science. Starting 
 with this view, the immense demand which has existed for the work has enabled him, in repeated 
 revisions, to augment its completeness and usefulness, until at length it has attained the position 
 of a recognized and standard authority wherever the language is spoken. The mechanical exe- 
 cution of this edition will be found greatly superior to that of previous impressions. By enlarging 
 the size of the volume to a royal octavo, and by the employment of a small but clear type, on 
 extra fine paper, the additions have been incorporated without materially increasing the bulk of 
 the volume, and the matter of two or three ordinary octavos has been compressed into the space 
 of one not unhandy for consultation and reference. 
 It would be a work of supererogation to bestow a | It is undoubtedly the most complete and useful 
 
 word of praise upon this Lexicon. We can only 
 wonder at the labor expended, for whenever we refer 
 to its pages for information we are seldom disap- 
 pointed in finding all we desire, whether it be in ac- 
 centuation, etymology, or definition of terms. — New 
 York MedicalJournal, November, 186.5. 
 
 It would be mere waste of words in ns to express 
 our admiration of a work which is so universally 
 and deservedly appreciated. The most admirable 
 work of its kind in the English language. As a book 
 of reference it is invaluable to the medical practi- 
 tioner, and in every instance that we have turned 
 over its pages for information we liave been charmed 
 by the clearness of language and the accuracy of 
 detail with which each abounds. We can most cor- 
 dially and confidently commend it to our readers. — 
 Glasgow MedicalJournal, January, ISSti. 
 
 A work to which there is no equal in the English 
 language. — Edinburgh Medical Journal. 
 
 It is something more than a dictionary, and some- 
 thing less than an encyclopedia. This edition of the 
 
 medical ■dictionary hitherto published in this country 
 — Chicago Med. Examiner, February, 1S65. 
 
 What we take to be decidedly theljest medical die- I 
 tionary in the English language. The present edition I 
 is brought fully up to the advanced state of science. ! 
 For many a long year "Duuglison" has been at our | 
 elbow, a constant companion and friend, and we i 
 greet him in his replenished and improved form with ; 
 especial satisfaction. — Pacific Med. and Surg. Jour- ' 
 nal, June 27, 1S6.5. | 
 
 This is, perhaps, the book of all others which the j 
 I physician or surgeon should have on his shelves. It 1 
 is more needed at the present day than a few years ] 
 back. — Canada 3Ied. Journal, July, 186.5. 
 
 It deservedly stands at the head, and cannot be 
 surpassed in excellence. — Buffalo Med. and Surg. 
 Journal, April, 186.5. 
 
 We can sincerely commend Dr. Dnnglison's work 
 as most thorough, scientific, and accurate. We have 
 tested it by searching it* pages for new terms, which 
 have abounded so much of late in medical nomen- 
 
 well-known work is a great improvement on its pre- | clature, and our search has been successful in every 
 
 decessors. The book is one of the very few of which 
 it may be said with truth that every medical man 
 should possess it. — London Medical Times, Aug. 26, 
 186.5. 
 
 Few works of the class exhibit a grander monument 
 of patient research and of scientific lore. The extent 
 of the sale of this lexicon is sufficient to testify to its 
 usefulness, and to the great service conferred by Dr. 
 Robley Dunglison on the profession, and indeed on 
 others, by its issue. — London Lancet, May 13, 186.5. 
 
 The old edition, which is now superseded by the 
 new, has been universally looked upon by the medi- 
 cal profession as a work of immense research and 
 great value. The new has increased usefulness ; for 
 medicine, in all its branches, has been making such 
 progress that many new terms and subjects have re- 
 cently been introduced : all of which may be found 
 fully defined in the present edition. We know of no 
 other dictionary in the English language that can 
 bear a comparison with it in point of completeness of 
 subjects and accuracy of statement. — N. Y. Drug- 
 gists'' Circular, 1S65. 
 
 For many years Dunglison's Dictionary has been 
 the standard book of reference with most practition- 
 ers in this country, and we can certainly commend 
 this work to the renewed confidence and regard of 
 our readers. — Cincinnati Lancet, April, 1865. 
 
 instance. We have been particularly struck with the 
 fulness of the synonymy and the accuracy of the de- 
 rivation of words. It is as necessary a work to every 
 enlightened phy.sician as Worcester's English Dic- 
 tionary is to every one who would keep up his know- 
 ledge of the English tongue to the standard of the 
 present day. It is, to our mind, the most complete 
 work of the kind with which we are acquainted. — 
 Boston Med. and Surg. Journal, June 22, 1S65. 
 
 We are free to confess that we know of no medical ( 
 dictionary more complete; no one better, if so well I 
 adapted for the use of the student; no one that may ■ 
 be consulted with more satisfaction by the medical 
 practitioner. — Am. Jour. Med. Sciences, April, 186.5. j 
 
 The value of the present edition has been greatly ! 
 enhanced by the introduction of new subjects and j 
 terms, and a more complete etymology and accentua-; 
 tion, which renders the work not only satisfactory j 
 and desirable, but indispensable to the physician.— 'j 
 Chicago Med. Journal, April, 1865. _; 
 
 No intelligent member of the profession can or will ; 
 be without it. — St. Louis Med. and Surg. Journal, i 
 April, 1865. ] 
 
 It has the rare merit that it certainly has no rival-. 
 in the Euglish language for accuracy and extent , 
 references. — London Medical Gazette. ; 
 
 I 
 
 TTOBLYN [RICHARD D.), M. D. j 
 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AND! 
 
 THE COLLATERAL SCIENCES. A new American edition, revised, with numerous 1 
 additions, by Isaac Hay.s, M.D., Editor of the "American Journal of the Medical^ 
 Sciences." In one large royal 12mo. volume of over 600 double-columned pages; extraj 
 cloth, $1 50 ; leather, $2 00. ■ \ 
 
 It is the best book of definitions we have, and ought always to be npon the student's table.— iSoui/j«r»| 
 Med. and Surg. Journal. j
 
 jyEILL {JOHN), 31. D., 
 
 Henry C. Lea's Publications— (i7/ar?waZs). 
 
 a7id JgMITH {FRANCIS G.), M.D., 
 
 Prof, o/the Inatmues of Medicine in the Univ. of Ptnna 
 
 AN^ ANALYTICAL COMPEXDIIJM OP THE YARimm 
 
 BRANCHES OP MEDICAL SCIENCE; for the Use and Examin.Uon of sfude tV A 
 new edition revised and improved. In one very large and handsomely printed royal ^mo 
 volume of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly bo^nd 
 in leather, with raised bands, $4 75. ' """""ev ""«iia 
 
 , quite 
 
 a miracle of success. The outlines of tlie whole are 
 admivably drawn and illustrated, and the authors 
 are emiaently entitled to the grateful consideration 
 of the .student of every class.— A'. 0. Med. and Surg. 
 Journal. 
 
 This popular favorite with the student is so well 
 known that it requires no more at the hands of a 
 medical editor than the annunciation of a new and 
 
 improved edition. There is no sort of comparison ! ates in medicine of more than ten 
 between this work and any other on a similar plan, [ who have not studied medicine si 
 and for a similar object.— iV'a*/t. Jo^t.rn. of Medicine. I perhaps find out from it that the > 
 
 There are but few students or practitioners of me 
 diciue unao<;{uainted with the former editions of this 
 unassuming though highly instructive work. The 
 whole science of medicine appears to have been sifted, 
 as the gold-bearing sands of El Dorado, and the pre- 
 cious facts treasured up in thi.s little volume. A com- 
 plete portable library so condensed that the student 
 may make it his constant pocket companion. — West- 
 ern Lancet. 
 
 here work for the 
 ecessary for an exa- 
 , , . - - .,' valuable, but it is 
 
 almost a srae qua non. The one before us is, in most 
 of the divisions, the most unexceptionable of all books 
 of the kind that we know of The newest and sound- 
 est doctrines and the latest improvements and dis- 
 coveries are explicitly, though concisely, laid befure 
 the student. Of course it is useless for us to recom- 
 mend it to all last course students, but there is a class 
 to whom we very sincerely commend this cheap book 
 as worthjts^weight^in silver— that class is the gradu- 
 „j,„ e ., . years' standing, 
 
 nee. They will 
 - - science is not ex- 
 
 actly now what it was when they left it oS.—The 
 SletlioscDpe. 
 
 Having made free use of this volume in oar exanl- 
 
 natious of pupils, we can speak from experience in 
 recommending it as an admirable compend for stu- 
 dents, and especially useful to preceptors who exam- 
 ine their pupils. It will .save the teacher much labor 
 by enabling him readily to recall all of the points 
 ™ ,, , , . ,,..., I upon which his pupils .should be examined. A work 
 
 To compress the whole science of medicine in less of this sort should be in the hands of every one who 
 than 1,000 pages is an impossibility, but we think that takes pupils into his office with a view of examining 
 
 the book before us approaches as near fo it as is po; 
 Bible. Altogether, it is the best of its class, and has 
 met with a deserved success. As an elementary text- 
 book for students, it has been useful, and will con- 
 tinue to be employed in the examination of private 
 classes, whilst it will often be referred to by the 
 country practitioner. — Va. Med. Journal. 
 
 them ; and this is unquestionably the best of its class. 
 Let every practitioner who has pupils provide himself 
 with it, and he will find the labor of refreshing his 
 knowledge so much facilitated that he will be able to 
 do justice to his pupils at very little cost of time or 
 trouble to himself.— rmnsy/waia Med. Journal. 
 
 TVDLOW{J.L.), 31. D., 
 
 A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 
 
 Surgery, Practice of Medicine, Obstetric.', Materia Medica, Chemistry, Pha'riuacy, and 
 Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
 and greatly extended and enlarged. With 37i) illustrations. In one handsome royal 
 12mo. volume of 816 large pages, extra cloth, $3 26; leather, $3 75. 
 
 The arrangement of this volume in the form of question and answer renders it especially suit- 
 able for the office examination of students, and for those preparing for graduation. 
 
 of the student in preparing for his final examination, 
 it might be profitably consulted by the practitioner 
 also, who is most apt to become rusty in the very kind 
 of details here given, and who, amid the hurry of his 
 daily routine, is but too prune to neglect the study of 
 more elaborate works. The possession of a volume 
 of this kind might serve as an inducement for him to 
 seize the moment of excited curiosity to inform him- 
 self on any subject, and which is otherwise too often 
 allowed to pass unimproved. — St. Louis Med. and 
 Surg. Journal. 
 
 We know of no better companion for the student 
 during the hours spent in the lecture-roorn, or to re- 
 fresh, at a glance, his memory of the various topics 
 crammed into his head by the various professors to 
 whom he is compelled to listen. — Western Lancet. 
 
 As it embraces the whole range of medical studies 
 it is necessarily voluminous, containing 816 large 
 duodecimo pages. After a somewhat careful exami- 
 nation of its contents, we have formed a much more 
 favorable opinion of it than we are wont to regard 
 Buch works. Although well adapted to meet the wants 
 
 /TANNER {TH031AS HA WKES), 31 D., 
 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
 
 NOSIS. Third American, from the second enlarged and revised English edition. To 
 which is added The Code of Ethics of the American Medical Association. In one band- 
 some volume 12mo. {Preparing for early publication.) 
 
 This work, after undergoing a very thorough revision at the hands of the author, may now be 
 e.Tpected to appear shortly. The title scarcely affords a proper idea of the range of subjects em- 
 braced in the volume, as it contains not only very full details of diagnostic symptoms propeply 
 classified, but also a large amount of information on matters of every day practical importirnce, 
 not usually touched upon in the systematic works, or scattered through many different volumes.
 
 Henry C. Lea's Publications — {Anatomy). 
 
 QRAY (HENRY), F.R.S., 
 
 Lecturer on Anatomy at St. George's Hospital, London. 
 
 ANATOMY, DESCRIPTIYE AND SURGICAL. The Drawings by 
 
 H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissec- 
 tions jointly by the Author and Dr. Carter. Second American, from the second revised 
 and improved London edition. In one magnificent imperial octavo volume, of over 800 
 pages, with .388 large and elaborate engravings on wood. Price in extra cloth, $6 00; 
 leather, raised bands, $7 00. 
 The author has endeavored in this work to cover a more extended range of subjects than is cus- 
 tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
 also the application of those details in the practice of medicine and surgery, thus rendering it both 
 a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
 gravings form a special feature in the work, many of them being the size of nature, nearly all 
 original, and having the names of the various parts printed on the body of the cut, in place of 
 figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
 which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
 refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
 the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with 
 a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
 essential use to all physicians who receive students in their offices, relieving both preceptor and 
 pupil of much labor in laying the groundwork of a thorough medical education. 
 
 Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical 
 
 execution, one of the handsomest that has yet been offered to' the American profession ; while the 
 
 careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed 
 
 in the English edition. 
 
 Thus it is that book after book makes the labor of I and with scarce a reference to the printed text. The 
 
 the student easier than before, and since we have 
 seen Blanchard & Lea's new edition of Gray's Ana- 
 tomy, certainly the finest work of the kind now ex- 
 tant, we would fain hope that tlie bugbear of medical 
 students will lose half its horrors, and ihis necessary 
 foundation of physiological science will be much fa- 
 cilitated and advanced. — 2f. 0. Med. News. 
 
 The various points illustrated are marked directly 
 on the structure; that is, whether it be muscle, pro 
 cess, artery, nerve, valve, etc. etc. — we say each point 
 i.s distinctly mai-ked by lettered engravings, so that 
 the student perceives at once each point described as 
 readily as if pointed out on the subject by the de- 
 monstrator. Mo.st of the illustrations are thus ren- 
 
 surgical application of the various regions is also pre- 
 sented with force and clearness, impressing upon the 
 .student at each step of his research all the important 
 relations of the structure demonstrated. — Cincinnati 
 Lancet. 
 
 This Is, we believe, the handsomest book on Ana- 
 tomy Hs yet published in our language, and bids fair 
 to become in a short time the standard text-book of 
 our colleges and studies. Students and practitioners 
 will alike appreciate this book. We predict for it a 
 bright career, and are fully prepared to endorse the 
 statement of the London Lancet, that "We are not 
 acquainted with any work in any language which 
 can take equal rank with the one before us." Paper, 
 printing, binding, all are excellent, and we feel that 
 dered exceedingly satisfactory, and to the physician | a grateful profes.sion will not allow the publishers to 
 they serve to refresh the memory with great readiness i go unrewarded. — Naahville Med. and Surg. Journal. 
 
 <^MITH [HENRY E.), 31. D., and TJORNER ( WILLIAM E.), M.D., 
 
 Prof, of Surgery in the Univ. of Penna., &c. Late Prof, of Anatomy in the Univ. of Penna., &c- 
 
 AN ANATOMICAL ATLAS, illustrative of the Structure of the 
 
 Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred 
 and fifty beautiful figures. $4 60. 
 
 The plan of this Atlas, which renders it so pecu- I the kind that has yet appeared: and we must add, 
 liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up " 
 tistical execution, have been already pointed out. We is so creditable to the country as to be flattering to 
 must congratulate the student upon the completion our national pride. — American Medical Journal. 
 of this Atlas, as it is the most convenient work of I 
 
 R 
 
 VRNER [WILLIAM E.), 31. D., 
 
 SPECIAL ANATOMY AND HISTOLOGY. Eighth edition, exten- 
 
 sively revised and modified. In two large octavo volumes of over 1000 pages, with more 
 than 300 wood-cuts ; extra cloth, $6 00. 
 
 OHARPEY [ W1LLIA31), 3LD., and Q GAIN [JONES Sj- RICHARD). 
 HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 
 
 Lkidv, M.D., Professor of Anatomy in the University^ of Pennsylvania. Complete in two 
 large octavo volumes, of about 1300 pages, with 511 illustrations; e.xtra cloth, $6 00. 
 The very low price of this standard work, and its completeness in all departments of the subject, 
 should command for it a place in the library of all anatomical students. 
 
 ALLEN [J. M.), 31. D. 
 THE PRACTICAL ANATOMIST; or, The Student's Guide in the 
 
 Dissecting Room. With 266 illustrations. In one very handsome royal 12mo. volume, 
 of over 600 pages; extra cloth, $2 00. 
 One of the most useful works upon the subject ever written. — Medical Examiner.
 
 Henry C. Lea's Publications — {Anatomy). 
 
 TyiLSON {ERASMUS), F.R.S. 
 
 A SYSTEM OF HIJMAX AXATOMY, General and Special. A new 
 
 and revised American, from the last and enlarged English edition. Edited by W. H. Go- 
 BRECHT, M.D., Professor of General and Surgical Anatomy in the Medical College of Ohio. 
 Illustrated with three hundred and ninety-seven engravings on wood. In one large and 
 handsome octavo volume, of over 600 large pages; extra cloth, $4 00; leather, $5 00. 
 The publisher trusts that the well-earned reputation of this long-established favorite will be 
 more than maintained by the present edition. Besides a very thorough revision by the author, it 
 has been most carefully examined by the editor, and the efforts of both have been directed to in- 
 troducing everything which increased experience in its use has suggested as desirable to render it 
 a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
 tomy. The amount of additions which it has thus received may be estimated from the fact that 
 the present edition contains over one-fourth more matter than the last, rendering a smaller type 
 and an enlarged page requisite to keep the volume within a convenient size. The author has not 
 only thus added largely to the work, but he has also made alterations throughout, wherever there 
 appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
 most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
 h.TS exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
 the number of illustrations, of which there are about one hundred and fifty more in this edition 
 than in the last, thus bringing distinctly before the eye of the student everything of interest or 
 importance. 
 
 J>T THE SAME AUTHOR. ~ ' 
 
 THE DISSECTOR'S MAXUAL; or, Practical and Surgical Ana- 
 tomy. Third American, from the last revised and enlarged English edition. Modified and 
 rearranged by William Hunt, M. D., late Demonstrator of Anatomy in the University of 
 Pennsylvania. In one large and handsome royal 12mo. volume, of 582 pages, with 154 
 illustrations; extra cloth, $2 00. 
 
 TTODGES, {RICHARD 3L), M.D., 
 
 -*—*- Late Demonstrator of Anofo'iay in the Medical Department of Harvard University. 
 
 PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 
 
 one neat royal 12mo. volume, half-bound, $2 00. (Just Issued.) 
 The object of this work is to present to the anatomical student a clear and concise description 
 of that which he is expected to observe in an ordinary course of dissections. The author has 
 endeavored to omit unnecessary details, and to present the subject in the form which many years' 
 experience has shown him to be the most convenient and intelligible to the student. In the 
 revision of the present edition, he has sedulously labored to render the volume more worthy of 
 the favor with which it has heretofore been received. 
 
 JTACLISE {JOSEPH). 
 
 SURGICAL ANATOMY. By Joseph Maclise, Snrgeon. In one 
 
 volume, very large imperial quarto ; with fiS large and splendid plates, drawn in the best 
 style and beautifully colored, containing 190 figures, many of them the size of life; together 
 with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. 
 Price $14 00. 
 As no complete work of the kind has heretofore been published in the English language, the 
 present volume will supply a want long felt in this country of an accurate and comprehensive 
 Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- 
 tain the exact relative positions of the various portions of the human frame towards each other 
 and to the surface, as well as their abnormal deviations. The importance of such a work to the 
 student, in the absence of anatomical material, and to practitioners, either for consultation in 
 emergencies or to refresh their recollections of the dissecting room, is evident. Notwithstanding 
 the large size, beauty and finish of the very numerous illustrations, it will be observed that the 
 price is so low as to place it within the reach of all members of the profession. 
 
 We know of no work on surgical anatomy which refre.shed by those clear and distinct dissections, 
 
 can compete with it. — Lancet 
 
 The work of Maclise on surgical anatomy is of the 
 highest value. In some respects it is the best publi- 
 cation of its kind we have seen, and is worthy of a 
 place in the libiavy of any medical man, while the 
 student could t^carcely make a better investment than 
 this. — The Western Journal of Medicine and Surgery. 
 
 No such lithographic illustrations of surgical re- 
 gions have hitherto, we think, been given. While 
 the operator is showu every vessel and uevve where 
 an operation is-contemplated, the exact anatomist is 
 
 which every one must appreciate who has a particle 
 of enthusiasm. The English medical press has quite 
 exhausted the words of praise, in recommending this 
 admirable treatise. Those who have any curiosity 
 to gratify, in reference to the perfectibility of the 
 lithographic art in delineating the complex "mechan- 
 ism of the human body, are invited to examine our 
 specimen copy. If anything will induce surgeons 
 and students to patronize a book of such rare value 
 and everyday importance to them, it will be a survey 
 of the artistical skill exhibited in these fac-similes of 
 nature — Boston Med. and Surg. Journal. 
 
 TDEASLEE {E. /?.), M.D., 
 
 -i Professor of Anatomy and Physiology in Dartmouth Med. College, K. H. 
 
 HUMAN HISTOLOGY, in its relations to Anatom}^, Physiology, and 
 
 Pathology; for the use of medical students. With four hundred and thirty-four illustra- 
 tions. In one handsome octavo volume of over 600 pages, extra cloth. $3 75.
 
 Henry C. Lea's Publications — {Physiology). 
 
 riARPENTER ( WILLIAM B.), M. D., F. R. S., 
 
 Examiner in Phyfiiology and Comparative Anatomy in the University of London. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 
 
 cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
 American from the last and revised London edition. With nearly three hundred illustrations. 
 Edited, with additions, by Francis Gurney Smith, M. B., Professor of the Institutes of 
 Medicine in the University of Pennsylvania, &c. In one very large and beaxitiful octavo 
 volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 ; leather, raised 
 bands, $6 60. 
 
 The highest complimnnt that can be extended to 
 this great work of Dr. Carpenter is to call attention 
 to this, another new edition, which the favorable 
 regard of the profes.<<ion has called fir. Carpenter is 
 the standard authority on physiology, and no physi- 
 cian or medical student will regard his library as 
 complete without a copy of it. — Cincinnati Med. Ob- 
 server. 
 
 With Dr. Smith, we confidently believe "that the 
 present will more than sustain the enviable reputa- 
 tion already attained by former editions, of being 
 one of the fullest and most complete treatises on the 
 subject in the English language." We know of none 
 from the pages of which a satisfactory knowledge of 
 the physiology of the human organii-m can be as well 
 obtained, none better adapted for the use of such as 
 take up the study of physiology in its reference to 
 the institutes and practice of medicine. — Am. Jour. 
 Med. Sciences. 
 
 A complete cyclopjedia of this branch of science.— 
 N. ¥. Med. Times. 
 
 We doubt not it is destined to retain a strong hold 
 on public favor, and remain the favorite text-book in 
 our colleges. — Virginia Medical Journal. 
 
 We have so often spoken in terms of high com- 
 mendation of Dr. Carpenter's elaborate work on hu- 
 man physiology that, in announcing a new edition, 
 it is unnecessary to add anything to what has hereto- 
 fore been said, and especially is this the case since 
 every intelligent physician is as well aware of the 
 character and merits of the work as we ourselves are. 
 — St. Louis Med. and Surg. Journal. 
 
 The above is the title of what is emphatically the 
 great work on physiology ; and we are conscious that 
 it would be a useless effort to attempt to add any- 
 thing to the reputation of this invaluable wcivk, and 
 can only say to all with whom our opinion ha.s any 
 intiuence, that it is our authority. — Atlanta Med. 
 Journal. 
 
 The greatest, the most reliable, and the best book 
 on the subject which we know of in the English lan- 
 guage. — SteXhoscope. 
 
 Y THE SA3IE A UTHOR. 
 
 B 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 
 can, from the Fourth and Revised London Edition. In one large and handsome octavo 
 volume, with over three hundred beatitiful illustrations Pp. 752. Extra cloth, $5 00. 
 As a complete and condensed treatise on it? extended and important subject, this work becomes 
 a necessity to students of natural science, while the very low price at which it is offered places it 
 within the reach of all. 
 
 B 
 
 Y THE SAME AUTHOR. 
 
 THE MICROSCOPE AND ITS REVELATIONS. With an Appen- 
 
 dix containing the Applications of the Microscope to Clinical Medicine, &c. By F. G-. 
 Smith M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. 
 In one large and very handsome octavo volume, of 724 pages, extra cloth, $5 25. 
 
 rpODD [ROBERT B.), 31. D. F.R.S., and 7^0W3IAN (W.), F.R.S. 
 THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF 
 
 MAN. With about three hundred large and beautiful illustrations on wood. Complete in 
 one large octavo volume of 950 pages, extra cloth. Price $4 75. 
 
 The names of Todd and Bowman have long been 
 familiar to the student of physiology. In this work 
 we have the ripe experience of these laborious physi- 
 ologists on every branch of this science. They gave 
 each subject the most thorough and critical examina- 
 tion before making it a matter of record. Thus, while 
 they advanced tardily, apparently, in their publica- 
 tion, the work thus issued was a complete exponent I subject of their care. The possession of such kuow- 
 of the science of physiology at the time of its final ! ledge will do more to make sound and able prarti- 
 appoarance. We can, therefore, recommend this tioners than anything else. — British and Foreign 
 Wurk as one of the most reliable wliich the student or ' Medico-Chirurgical Review. 
 
 practitioner can consult relating to physiology. — xV. 
 Y. Journal of 3Iedicine. 
 
 To it the rising generation of medical men will 
 owe, in great measure, a familiar acquaintance with 
 all the chief truths j-especting the healthy structure 
 and working of the frames which are to form the 
 
 JT-IRKES [WILLIAM SENHOUSE), 3LD., 
 
 A MANUAL OF PHYSIOLOGY. A new American from the third 
 
 aind improved London edition With two hundred illustrations. In one large and hand- 
 some royal 12mo. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2 75. 
 By the use of a fine and clear type, a very large amount of matter has been condensed into a 
 comparatively small volume, and at its exceedingly low price it will be found a most desirable 
 manual for students or for gentlemen desirous to refresh their knowledge of modern physiology. 
 It is at once convenient in size, comprehensive in 
 
 design, and concise in statement, and altogether well 
 adapted for the purpose designed. — St. Louis Med. 
 and Surg. Journal. 
 
 The physiological reader will find it a most excel- 
 
 Ifint guide in the study of physiology in its most ad- 
 vanced and perfect form. The author has shown 
 himself capable of giving details sufflcjently ample 
 in a condensed and conceutraied shape, on a science 
 in which it is necessary at once to be correct and not 
 lengthened. — Edinburgh Med. and Surg. Journal.
 
 Henry C. Lea's Publications — {Phyf^iology). 
 
 Y)ALTON [J. C), M.D., 
 
 -*-^ Professor of Physiology in the College of Physicians and Surgeons, New York, &c. 
 
 A TREATISE ON HUMAN PHYSIOLOGY, Designed for the use 
 
 of students and Practitioners of Medicine. Fourtli edition, revised, with nearly tliree hun- 
 dred illustrations on wood. In one very beautiful octavo volume, of about 700 pages, extra 
 cloth, $5 25 i leather, $6 25. {Now Ready.) 
 
 From tlie Preface to the Xetc Edition. 
 •' The progress made by Physiology and the kindred Sciences during the last few years has re- 
 quired, for the present edition of this work, a thorough and extensive revision. This progress 
 has not consisted in any very striking single discoveries, nor in a decided revolution in any of 
 the departments of Physiology ; but it has been marked by great activity of investigation in a 
 multitude of different directions, the combined results of which have not failed to impress a new 
 character on many of the features of physiological knowledge. ... In the revision and 
 correction of the present edition, the author has endeavored to incorporate all such improve- 
 ments in physiological knowledge with the mass of the text in such a manner as not essentially 
 to alter the structure and plan of the work, so far as they have been found adapted to the wants 
 and convenience of the reader. . . . Several new illustrations are introduced, some of them 
 as additions, others as improvements or corrections of the old. Although all parts of the book 
 have received more or less complete revision, the greatest number of additions and changes were 
 required in the Second Section, on the Physiology of the Nervous System." 
 
 The reputation which this work has acquired, as a compact and convenient summary of the 
 most advanced condition of human physiology, renders it only necessary to state that the author 
 has assiduously labored to render the present edition worthy a continuance of the marked favor 
 accorded to previous impressions, and that every care has been bestowed upon the typographical 
 execution to make it, as heretofore, one of the handsomest productions of the American press. 
 
 The advent of the first edition of Prof Dalton's merits of clearness and condensation, and being fully 
 
 Physiology, about eight years ago, marked a new era 
 in the study of physiology to the American student. 
 Under Dalton's skilful management, phj'siological 
 science threw off the long, loose, ungainly garments 
 of probability and surmise, in which it had been ar- 
 rayed by most artists, and came among us smiling 
 and attractive, in the beautifully tinted and closely 
 fitting dress of a demonstrated science. It was a 
 stroke of genius, as well as a result of erudition and 
 talent, that led Prof Dalton to present to the world 
 a work on physiology at once brief, pointed, and com- 
 prehensive, and which exhibited plainly in letter and 
 drawings the basis upon which the conclusions ar- 
 rived at rested. It is no disparagement of the many 
 excellent works on physiology, published prior to 
 that of Dalton, to say that none of them, either in 
 plan of arrangement or clearness of execution, could 
 be compared with his for the use of students or gene- 
 ral practitioners of medicine. For this purpose his 
 book has no equal In the English language. — Western 
 Journal of Medicine, IS^ov. 1S67. 
 
 A capital text-book in every way. We are, there- 
 fore, glad to see it in its fourth edition. It has already 
 been examined at full length in these columns, so that 
 we need not now further advert to it beyond remark- 
 ing that both revision and enlargement have been 
 most judicious. — London Med. Times and Gazette, 
 Oct. 19, 1867. 
 
 Xo better proof of the value of this admirable 
 work could be produced than the fact that it has al- 
 ready reached a fourth edition in the short space of 
 eight years. Possessing in an eminent degree the 
 
 brought up to the present level of Physiology, it is 
 undoubtedly one of the i^jost reliabie text-books 
 upon this science that could be placed in the hands 
 of the medical student. — Am. Journal Med. Sciencts, 
 Oct. 1S67. 
 
 Prof. Dalton's work has such a well-established 
 reputation that it does not stand in need of any re- 
 commendation. Ever since its first appearance it has 
 become the highest authority in the English language; 
 and that it is able to maintain the enviable positioa 
 which it has taken, the rapid exhaustion of the dif- 
 ferent successive editions is sufficient evidence. The 
 present edition, which is the fourth, has been tho- 
 roughly revised, and enlarged by the incorporation 
 of all the many important advances which have 
 lately been made in this rapidly progressing science. 
 —JSr. r. Med. Record, Oct. 15, 1867. 
 
 As it stands, we esteem it the very best of the phy- 
 siological text-books for the student, and the most 
 concise reference and guide-book for the practitioner. 
 —TV. r. Med. Journal, Oct. 1867. 
 
 The present edition of this now standard work fully 
 sustains the high reputation of its accomplished au- 
 thor. It is not merely a reprint, but has been faith- 
 fully revised, and enriched by such additions as the 
 progress of physiology has rendered desirable. Taken 
 as a whole, it is unquestionably the most reliable and 
 useful treatise on the subject that has been issued 
 from the American press. — Chicago Med. Journal, 
 Sept. 1867. 
 
 T)UNGLISON {ROBLEY), M.D., 
 
 -*-^ Professor of InstitiUes of Medicine in Jefferson Medical College, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 
 
 extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
 large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. 
 
 TEHMANN [C. G.) 
 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
 tion by George E. Day, M. D., F. R. S., kc, edited by R. E. Rogers, M. D., Professor of 
 Chemistry in the Medical Department of the University of Penn,sylvania, with illustrations 
 selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
 plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
 hundred illustrations, extra cloth. $6 00. 
 
 »r THE SAME AUTHOR. 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 
 
 German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory 
 Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- 
 vania. With illustrations on wood. In one very handsome octavo volume of 336 pages 
 extra cloth. $2 25.
 
 10 
 
 Henry C. Lea's Publications — {Chemistry). 
 
 jyRANDE ( WM. T.), D. G.L., and rpAYLOR [ALFRED S.), M.D., F.B.S. 
 CHEMISTRY. Second American edition, thoroughly revised by Dr. 
 
 Taylor. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 00. 
 [Now Ready.) 
 
 From Dr. Taylor's Preface. 
 
 "The revision of the second edition, in consequence of the death of mj' lamented colleague, 
 has devolved entirely upon myself. Every chapter, and indeed every page, has been revised, 
 and numerous additions made in all parts of the volume. These additions have been restricted 
 chiefly to subjects having some practical interest, and they have been made as concise as possible, 
 in order to keep the book within those limits which may retain for it the character of a Student's 
 Manual " — London, June 29, 1867. 
 
 A book that has already so established a reputa- 
 tion, as has Bi-ande and Taylor's Chemistry, can 
 hardly need a notice, save to nieution llie additions 
 and improvements of the edition. Doubtless the 
 work will long remain a favorite text-book in the 
 schools, as well as a conveuient book of reference for 
 all.— iV. Y. Medical Gazme, Oct. 12, 1SC7. 
 
 For this reason we hail with delight the republica- 
 tion, in a form which will meet witli general approval 
 aud comraaud public attention, of this really valua- 
 ble stacdard work on chemistry — more particularly 
 as it has beeu adapted with such care to the wants of 
 the general public. The well known scholarship of 
 its authors, und their extensive researches for many 
 years iu experimental chemistry, have been long ap- 
 preciated in the scientific world, but in this work they 
 have been careful to give the largest possible amount 
 of information with the most sparing use of technical 
 terms aud phraseology, so as to furnish the reader, 
 "whether a student of medicine, or a man of the 
 world, with a plain introduction to the science and 
 practice of chemistry." — Journal of Applied Chem- 
 istry, Oct. 1867. 
 
 [ This second American edition of an excellent trea- 
 tise on chemical science is not a mere republication 
 from the English pre.ss, but is a revision and en- 
 largement of the original, under the supervision of 
 ihe surviving author. Dr. Taylor. The favorable 
 opinion expressed on the publication of the former 
 edition of this work is fully sustained by the present 
 revision, in which Dr. T. has increased the size of 
 the volume, by an addition of sixty -eight pages. — Am. 
 Jimrn. iied. iSuiences, Oct. lSt)7. 
 
 The Handbook in- Chemistry of the Student. — 
 For clearness of language, accuracy of description, 
 extent of-informatiou, and freedom from pedantry 
 aud mysticism, no other text-book comes into com- 
 petition with it. — The Lancet. 
 
 The authors set out with the definite purpose of 
 writing a book which shall be intelligible to any 
 educated man. Thus conceived, and worked out in 
 the most sturdy, common-sense method, this book 
 gives iu the clearest and most summary method 
 possible all the facts aud doctrines of chemistry. — 
 Medical Times. 
 
 no WMAN {JOHN E.) , 31. D. 
 
 PEACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 
 
 by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fourth 
 American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
 pp. 351, with numerous illustrations, extra cloth. $2 25. 
 
 The fourth edition of this invaluable text-book of 
 Medical Chemistry was publislied iu Englaud in Octo- 
 ber of the last year. The Editor lias brought down 
 the Handbook to that date, introducing, as far as was 
 compatible with the necessary conciseness of such a 
 work, all the valuable discoveries in the science 
 
 which have come to light since the previous edition 
 was printed. The work is indispensable to every 
 student of medicine or enlightened practitioner. It 
 is printed iu clear type, and the illustrations are 
 nnmenius aud intelligible. — Boston Med. and Surg. 
 Journal. 
 
 B 
 
 T THE SAME AUTHOR. 
 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 
 
 ANALYSIS. Fourth American, from the fifth and revised London edition. With numer- 
 ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. {Just Issued.) 
 
 One of the most complete manuals tliat has for a 
 long time been given to the medical student. — 
 Athenaum. 
 
 We regard it as realizing almost everything to be 
 desired in an introduction to Practical Chemistry. 
 
 It is by far the best adapted for the Chemical student 
 of any that has yet fallen in our way. — British and 
 Foreign Medico-Ohirurgicnl Review. 
 
 The best introductory work on the subject with 
 which we are acquainted. — Edinburgh Monildy Jour. 
 
 flRAHAM [THOMAS], F.R.S. 
 
 THE ELEMENTS OF INORGANIC CHEMISTRY, including the 
 
 Applications of the Science in the Arts. New and ranch enlarged edition, by IIenrt 
 Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, 
 of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. 
 $5 60. 
 
 Part II., completing the work from p. 431 to end, with Index, Title Matter, ic, may be had 
 separate, cloth backs and paper sides. Price S3 00. 
 
 Prom Prof. E. N. Horsford, Harvard College. [ afford to be without this edition of Prof. Graham's 
 
 It has, in its earlier and less perfect editions, been Elements.— Si7Zi»«rt.n'« Journal, March, IS.iS. 
 
 familiar to me, and the excellence of its plan and From Prof. Wolcoft Glhfis, N. Y. Free Academy. 
 
 the clearness and completeness of its discussions, T,,e ^,-,rk"is an admirable one in all respects, ana 
 
 have long been my admiration. [ ^^ republication here cannot fail to exert a positive 
 
 No reader of Euglish works on this science can i influence upon the progress of science in this country.
 
 Henry C. Lea's Publications — (Chemisfrv/, Pharmacy, <&c.). 11 
 
 TlOWNES {GEORGE), Ph.D. 
 
 A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 
 
 Practical. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, 
 M. D. In one large royal 12mo. volume, of 600 pages, extra cloth, $2 00; leather, $2 50. 
 
 We know of no treatise in the language so wpII 
 calculated to aid the student in becoming familiar 
 with the numerous facts in the intrinsic science on 
 which it treats, or one better calculated as a text- 
 book for those attending Chemical lectures. * * * * 
 The best text-book ou Chemistry that has issued from 
 our press. — American Medical Journal. 
 
 We again most cheerfully recommend it as the 
 best text-book for students in attendance upon Chem- 
 ical lectures that we have yet examined. — III. and 
 Ind. Med. and Surg. Journal. 
 
 A first-rate work upon a first-rate subject. — St. 
 Louis Med. and Surg. Journal. 
 
 No manual of Chemistry which we have met 
 comes so near meeting the wants of tlie beginner. — 
 Western Journal of Medicine and Surgery. 
 
 We know of none within the same limits which 
 has higher claims to our confidence as a college class- 
 book, both for accuracy of detail and scientific ar- 
 raogenieut. — Augusta Medical Journal. 
 
 We know of no text-book on chemistry that we 
 would sooner recommend to the student than this 
 edition of Prof. Fownes' work. — Montreal Medical 
 Chronicle. 
 
 A new and revised edition of one of the best elemen- 
 tary works on chemistry accessible to the American 
 and English student. — N. ¥. Journal of Medical and 
 Collateral Science. 
 
 We unhesitatingly recommend it to medical stu- 
 dents. — N. W. Med. and Surg. Journal. 
 
 This is a most excellent text-book for class instruc- 
 tion in chemistry, whether for schools or colleges. — 
 Silliman's Journal. 
 
 ABEL AND BLOXAM'S HANDBOOK OF CIIEMIS- 
 TilY, Theoretical, Practical, and Technical. In one 
 vol. Svo. of 662 pages, extra cloth, $t .00. 
 
 GAUDNEK'S MEDICAL CHEMISTRY. 1 vol. 12mo., 
 with wood-cuts ; pp. 396, extra cloth, $1 00. 
 
 KNAPP'S TECHNOLOGY ; or Chemistry Applied to 
 the Arts, and to Manufactures. With American 
 additions, by Prof. Waltkr K. Johnson. In two 
 very handsome octavo volumes, with 500 wood 
 engravings, extra cloth, $6 00. 
 
 JpARRISH {ED WARD), 
 
 Professor of Materia Medica in the Philadelphia College of Pharmacy. 
 
 A TREATISE ON PHARMACY. Designed as a Text-Book for the 
 
 Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
 Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 
 pages, with several hundred illustrations, extra cloth. $5 00. 
 The immense amount of practical information condensed in this volume may be estimated from 
 the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- 
 ences ; under Emplastrum, 36 ; Extracts, 159 ; Lozenges, 25 ; Mixtures, 55 ; Pills, 56 ; Syrups, 
 131 ; Tinctures, 138 ; Unguentum, 57, &c. 
 
 We have examined this large volume with a good 
 deal of care, and find that the author has completely 
 exhausted the subject upon which he treats ; a more 
 complete work, we think, it would be impossible to 
 find. To the student of pharmacy the work is indis- 
 pensable ; indeed, so far as we know, it is the only one 
 of its kind in existence, and even to the physician or 
 medical student who can spare five dollars to pur- 
 cha.se it, we feel sure the practical information he 
 will obtain will more than compensate him for the 
 outlay. — Canada Med. Journal, Nov. 166-1. 
 
 The medical student and the practising physician 
 will find the volume of inestimable worth for study 
 and reference. — Sati Francisco Med. Press, July, 
 1864. 
 
 When we say that this book is in some respects 
 the best which has been published on the subject in 
 the English language for a great many years, we do 
 not wish it to be understood as very extravagant 
 praise. In truth, it is not so much the best as the 
 only book. — The London Chemical News. 
 
 An attempt to furnish anything like an analysis of 
 Parrish's very valuable and elaborate Treatise on 
 Practical Pharmacy would require more space than 
 we have at our disposal. This, however, is not so 
 much a matter of regret, inasmucli as it would be 
 difficult to think of any point, however minute and 
 
 not been clearly and carefully discussed in this vol- 
 ume. Want of space prevents our enlarging further 
 on this valuable work, and we must conclude by a 
 simple expression of our hearty appreciation of its 
 merits. — Dublin Quarterly Jour, of Medical Science, 
 August, 1S64. 
 
 We have in this able and elaboi'ate work a fair ex- 
 position of pharmaceutical science as it exists in the 
 United States ; and it shows that our transatlantic 
 friends have given the subject most elaborate con- 
 sideration, and have brought their art to a degree of 
 perfection which, we believe, is scarcely to be sur- 
 passed anywhere. The book is, of course, of more 
 direct value to the medicine maker than to the physi- 
 cian ; yet Mr. Parrish has not failed to introduce 
 matter in which the prescriber is quite as much 
 interested as the compounder of remedies. In con- 
 clusion, we can only express our high opinion of the 
 value of this work as a guide to the pharmaceutist, 
 and in many respects to the physician, not only in 
 America, but in other parts of the world. — British 
 Med. Journal, Nov. 12th, 1864. 
 
 The former editions have been sufilciently long 
 before the medical public to render the merits of the 
 work well known. It is certainly one of the most 
 complete and valuable works on practical pharmacy 
 to which the student, the practitioner, or the apothe- 
 
 apparently trivial, connected with the manipulation cary can have access. — Chicago Medical Examiner, 
 of pharmaceutic substances or appliances which has | March, 1S64. 
 
 JJVNGLISON {ROBLEY), M.D., 
 
 "^^^ Professor of Institutes of Mi-.dicine in Jefferson Medical College, Philadelphia. 
 
 GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted 
 
 for a Medical Text-Book. With Indexes of Remedies and of Diseases and their Remedies. 
 Sixth edition, revised and improved. With one hundred and ninety-three illustrations. In 
 two large and handsomely printed octavo vols, of about 1100 pages, extra cloth. $6 50. 
 T>Y THE SAME AUTHOR. . 
 
 NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARA- 
 TION AND ADMINISTRATION. Seventh edition, with extensive additions. In on© 
 very large octavo volume of 770 pages, extra cloth. $4 00.
 
 12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 
 
 /GRIFFITH {ROBERT E.), 31. D. 
 
 A UNIVERSAL FORMrLARY, Containing the Methods of Pre- 
 paring and Administering Officinal and other Medicines. The ivhole adapted to Physicians 
 and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by 
 Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of 
 Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. 
 Extra cloth, $4 00 ; leather, $5 00. 
 In this volume, the Formulary proper occupies over 400 double-column pages, and contains 
 about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable 
 receipts for the preparation of essences, perfumes, inks, soaps, varnishes, &o. &c. In addition to 
 this, the work contains a vast amount of information indispensable for daily reference by the prac- 
 tising physician and apothecary, embracing Tables of Weights and Measures, Specific Gravity, 
 Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific Gravities of some 
 of the Preparations of the Pharmacopoeias, Relation between different Thermometrical Scales, 
 Explanation of Abbreviations used in Formulas, Vocabulary of Words used in Prescriptions, Ob- 
 servations on the Management of the Sick Room, Doses of Medicines, Rules for the Administration 
 of Medicines, Management of Convalescence and Relapses, Dietetic Preparations not included in 
 the Formulary, List of Incompatibles, Posological Table, Table of Phnrmaceutical Names which 
 differ in the Pharmacopoeias, Officinal Preparations and Directions, and Poisons. 
 
 Three complete and extended Indexes render the work especially adapted for immediate consul- 
 tation. One, of Diseases and their Remedies, presents under the head of each disease the 
 remedial agents which have been usefully exhibited in it, with reference to the formulae containing 
 tliem — while another of Pharmaceutical and Botanical Names, and a very thorough General 
 Index afford the means of obtaining at once any information desired. The Formulary itself is 
 arranged alphabetically, under the heads of the leading constituents of the prescriptions. 
 
 This is one of the most useful books for the prac- 
 tising physician which has been issued from the press 
 of late years, containing a vast variety of formulas 
 for the safe and convenient administration of medi- 
 cines, all arranged upon scientific and rational prin- 
 ciples, with the quantities stated in full, without 
 Blgns or abbreviations. — MeTnphis Med. Recorder. 
 
 We know of none in our language, or any other, so 
 comprehensive in its details. — London Lancet. 
 
 One of the most complete works of the kind in any 
 language. — Edinburgh Med. Journal. 
 
 We are not cognizant of the existence of a parallel 
 work. — London Med. Gazette. 
 
 OTILLE {ALFRED), M.D., 
 
 ^ Professor of Theory and Practice of Medicine in the University of Penna. 
 
 THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 
 
 on the Action and Uses of Medicinal Agents, including their Description and History. 
 
 Third edition, revised and enlarged. In two large and handsome octavo volumes. (Nearly 
 
 Ready.) 
 Owing to the author's engagements, this work has been for some time out of print. It is now, 
 however, passing rapidly through the press, and its publication may be expected at an early 
 moment. That two large editions of a work of such magnitude should be exhausted in a few 
 years, is sufficient evidence that it has supplied a want genernlly felt by the profession, and the 
 unanimous commendation bestowed upon it by the medical press, abroad as well as at home, 
 shows that the author has successfully accomplished his object in presenting to the profession a 
 systematic treatise suited to the wants of the practising physician, and unincumbered with de- 
 tails interesting only to the naturalist or the dealer. 
 
 We have placed first on the list Br. Stille's great , than formerly. We can cordially recommend to those 
 work on Therapeutics. When the first edition of this of our readers who are interested in Therapeutics a 
 work made its appearance nearly five years ago, we ! careful perusal of Dr. Still6's work. — Edinburgh Med. 
 expressed our high sense of its value as containing a . .Journal, lS6o. 
 
 full and philosophical account of the existing state \ An admii-able digest of our pi-esent knowledge of 
 of Therapeutics. From the opinion expressed at that ' Materia Medica and Therapeutics. — Am. Journ. Med. 
 time we have nothing to retract; we have, on the [ Sciences. .Tuly, 1860. 
 
 contrary, to state that the introduction of numerous i Dr. Stille's splendid work on therapeutics and raa- 
 a'Jditions has rendered the work even more complete ! teria medica. — London Med. Tiraes, April 8, 1865. 
 
 pLLIS {DEN.JA31IN), M.D. 
 
 THE MEDICAL FORMULARY: being a Collection of Prescriptions 
 
 derived from the writings and practice of many of the most eminent physicians of America 
 and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To 
 which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether 
 and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Ob- 
 servations. Eleventh edition, carefully revised and much extended by Robert P. Thomas, 
 M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one 
 volume 8vo., of about 350 pages. $3 00. 
 
 frequently noticed in this .Tournal as the successive 
 editions appeared, that it is sufficient, on the present 
 occasion, to state that the editor has introduced into 
 the eleventh edition a large amount of new matter, 
 derived from the current medical and pharmaceutical 
 works, as well as a number of valuable prescriptions 
 furnished from private sources. A very comprehen- 
 sive and extremely useful index has also been sup- 
 plied, wliich facilitates reference to the particular 
 article the prescriber may wish to administer; and 
 the language of the Formulary has been made to cor- 
 respond with the nomenclature of the new national 
 Pharrnacopceia. — Am. Jour. Med. Sciences, Jan. 1864. 
 
 We endorse the favorable opinion which the book 
 has so long established for itself, and take this occa- 
 sion to commend it to our readers as one of the con- 
 venient haudbook.s of the ofiice and library. — Cin- 
 cinnati Lancet, Feb. 1861. 
 
 The work has long been before the profession, and 
 its merits are well kuown. The present edition con- 
 tains many valuable additions, and will be found to 
 1>e an exceedingly convenient and useful volume for 
 reference by the medical practitioner. — Chicago 
 Medivcd Examiner, March, 1864. 
 
 The work is now so well known, and has been so
 
 Henry C. Lea's Publications— (J/a^. Med. and TJierajyeutics). 13 
 
 2> ERE IRA [JONATHAN), M.D., F.R.S. and L.S. 
 
 MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 
 ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with 
 the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and 
 Druggists, Medical and Pharmaceutical Students, &c. By F. J. Farre, M.D., Senior 
 Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; 
 assisted by Robert Bentlev, M.R.C.S., Professor of Materia Medica and Botany to the 
 Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S., Chemical 
 Operator to the Society of Apothecaries. With numerous additions and references to the 
 United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
 University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
 printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. 
 (Just Issued.) 
 
 The task of the American editor has evidently been 
 no sinecure, for not only has he given to us all that 
 is contained in the abridgment useful for our nur- 
 poses, but by a careful and judicious embodiment of 
 over a hundred new remedies has increased the size 
 of the former work fully one-third, besides adding 
 many new illustrations, some of which are original. 
 We unhesitatingly say that by so doing he has pro- 
 portionately Increased the value, not only of the con- 
 densed edition, but has extended the applicability of 
 the great original, and has placed his medical coun- 
 trymen under lasting obligations to him. The Ame- 
 rican physician now has all that is needed in the 
 shape of a complete treatise on materia medica, and 
 the medical student has a text-book which, for prac- 
 tical utility and intrinsic worth, stands unparalleled. 
 Although of considerable size, it is none too large for 
 the purposes for which it has been intended, and every 
 medical man should, in justice to himself, spare a 
 place for it upon his book-shelf, resting assured that 
 the more he consults it the better he will be satisfied 
 of its excellence. — N. Y. Med. Record, Nov. 15, 1S66. 
 
 It will fill a place which no other work can occupy 
 in the library of the physician, student, and apothe- 
 cary. — Boston Med. and Surg. Journal, Nov. S, 1866. 
 
 We have here presented, in a volume of a thousand 
 pages, that which we sincerely believe the best work 
 on materia medica in the English language. No phy- 
 sician, no medicaUjitudent, can purchase this book, 
 and make anything like a proper use of it, without 
 being amply rewarded for his outlay. — The Cincin- 
 nati Journal of Medicine, November, 1806. 
 
 The American editor can very justly say, then, that 
 "his ofiice has been no sinecure." The result, how- 
 ever, of the labors of the different gentlemen engaged 
 on the work has been to give us a compendium that 
 is admirably adapted for the wants and necessities of 
 the student. We willingly concede to the American 
 editor that we have rarely examined a work that, on 
 the whole, is more carefully and laboriously edited 
 than this ; or, we may add, that is more improved in 
 the process of editing. — New York Medical Journal, 
 December, 1S66. 
 
 Of the many works on Materia Medica which have 
 appeared since the issuing of the British Pharmaco- 
 
 poeia, none will be more acceptable to the student 
 and practitioner than the present. Pereira's Materia 
 Medica had long ago asserted for itself the position of 
 being the most complete work on the subject in the 
 English language. But its very completeness stood 
 in the way of its success. Except in the way of refer- 
 ence, or to those who made a special study of Materia 
 Medica, Dr. Pereira's work was too full, and its pe- 
 rusal required an amount of time which few had at 
 their disposal. Dr. Farre has very j udiciously availed 
 himself of the opportunity of the publication of the 
 new Pharmacopoeia, by bringing out an abridged edi- 
 tion of the great work. This edition of Pereira is by 
 no means a mere abridged re-issue, but contains ma- 
 ny improvements, both in the descriptive and thera- 
 peutical departments. We can recommend it as a 
 very excellent and reliable text-book. — Edinburgh 
 Med Journal, February, 1866. 
 
 The reader cannot fail to be impres.sed, at a glance, 
 with the exceeding value of this work as a compend 
 of nearly all useful knowledge on the materia medica. 
 We are greatly indebted to Professor Wood for his 
 adaptation of it to our meridian. Without his emen- 
 dations and additions it would lose much of its value 
 to the American student. With them it is an Ameri- 
 can hooix.. — Pacific 3Iedical and Surgical Journal, 
 December, 1S66. 
 
 Altogether, the work is a most valuable addition to 
 the literature of this subject, and will be of great use 
 to the practitioner of medicine and medical student. 
 The work, as issued by the American publisher, is a 
 handsome volume of 10.30 pages, most amply illus- 
 trated, the wood-cuts being of superior finish, and 
 clearly impressed.— Caw«rf« Med. Journal, Nov. 1S66. 
 
 Only iJM pages, while Pereira's original volumes 
 included 2000, and yet the results of many years' ad- 
 ditional research In pharmacology and therapeutics 
 are embodied in the new edition. Unquestionably 
 Dr. Farre has conferred a great benefit upon medical 
 students and practitioners. And in both respects we 
 think he has acted very judiciously. And the work 
 is now condensed — brought fully into accordance with, 
 the pharmacological opinions in vogue, and can be 
 used with great advantage as a handbook for exami- 
 nations.— T/ie Lancet, December, 1865. 
 
 PARSON [JOSEPH], 31. D., 
 
 \y Profe.s.'ior of Materia Medica and Pharma.cy in the Vniver.Hty of Pennsylvania, &-o. 
 
 SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA 
 
 MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three 
 
 ' . Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth 
 
 $3 00. (Now Beady.) ' 
 
 EOTLE'S MATERIA MEDICA AND THERAPEU- 
 TICS; including the Preparations of the Pliarma- 
 copoeias of London, Edinburgh, Dublin, and of the 
 United States. With many new medicines. Edited 
 by Joseph Carson, M.D. With ninety-eight illus- 
 trations. In one large octavo volume of about 700 
 pages, extra cloth. $3 00. 
 
 CHRISTISON'S DISPENSATORY; or. Commentary 
 on the Pharmacopoeias of Great Britain and the 
 United States; comprising the Natural History, 
 Description, Chemistry, Pharmacy, Actions, Uses, 
 and Doses of the Articles of tJie Materia Medica. 
 Second edition, revised and improved, with a Sup- 
 plement containing the most important New Reme- 
 dies. With copious additions, and two hundred 
 and thirteen large wood-engravings. By R. EiiLE.s- 
 PELD Griffith, M. D. In one very handsome octavo 
 volume of over 1000 pages, extra cloth. $i 00. 
 
 CARPENTER'S PRIZE ESSAY ON THE USE OF 
 Alcoholic Liquors ix Health and Disease. New 
 edition, with a Preface by D. F. Condie, M.D., and 
 explanations of scientific words. In one neat 12mo. 
 volume, pp. 178, extra cloth. 60 cents. 
 
 De JONGH on THE THREE KINDS OF COD-LIVER 
 Oil, with their Chemical and Therapeutic Pro- 
 perties. 1 vol. 12mo., cloth. 75 cents. 
 
 MAYNE'S DISPENSATORY AND THERAPEUTICAL 
 Rememhraxcer, With every Practical Formula 
 contained in the three British Pharmacopoeias. 
 Edited, with the addition of the Formula of the 
 U. S. Pharmacopoiia, by R. E. Griffith, M. D. In 
 one 12mo. volume, 300 pp., extra cloth. 75 cents.
 
 14 
 
 Henry C. Lea's Publications — {Pathology). 
 
 ffROSS [SAMUEL D.), M. D., 
 
 ^^ Professor of Surgery in the Jefferson 3fedicnl College of Philadelphia. 
 
 ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, 
 
 thoroughly revised and greatly improved. In one large and very handsome octavo volume 
 of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a 
 large number are from original drawings ; extra cloth. $4 00. 
 The very beautiful execution of this valuable work, and the exceedingly low price at which it 
 is offered, should command for it a place in the library of every practitioner. 
 
 UieboDk-shelf of every American physician. — Charles- 
 ton Med. Journal. 
 
 It contains much new matter, and brings down our 
 
 To the student of medicine we would say that we 
 know of no work which we can more heartily com- 
 mend than Gross's Pathological Anatomy. — Southern 
 Med. and Surg. Journal. 
 
 The volume commends itself to the medical student ; 
 it will repay a careful perusal, and should be upon 
 
 knowledge of pathology to the latest period.- 
 Lancet. 
 
 -London 
 
 TONES [C. HANDFIELD), F.R.S., and SIEVEKING [ED. K), M.D., 
 
 
 A.9sista7it Physicians and Lecturers in St. Mary's Hospital. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. First American 
 
 edition, revised. With three hundred and ninety-seven handsome wood engravings. In 
 one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. 
 
 Our limited space alone restrains us from noticing 
 more at length the various subjects treated of in 
 this interesting work; presenting, as it does, an excel- 
 lent summary of the existing state of knowledge in 
 relation to pathological anatomy, we cannot too 
 strongly urge upon the student the necessity of a tho- 
 rough acquaintance with its contents. — Medical Ex- 
 aminer. 
 
 We have long had need of a hand-book of patholo- 
 gical anatomy which should thoroughly reflect the 
 present state of that science. In the treatise before 
 us this desideratum is supplied. Within the limits of 
 a moderate octavo, we have the outlines of tliis great 
 department of medical science accurately defined, 
 
 and the most recent investigations presented in suffi- 
 cient detail for the student of pathology. We cannot 
 at this time undertake a formal analysis of this trea- 
 tise, as it would involve a separate and lengthy 
 consideration of nearly every subject discussed; nor 
 would such analysis be advantageous to the medical 
 reader. The work is of such a character that every 
 physician ought to obtain it, both for reference and 
 study. — N. Y. Journal of Medicine. 
 
 Its importance to the physician cannot be too highly 
 estimated, and we would recommend our readers to 
 add it to their library as soon as they conveniently 
 can. — Montreal Med. Chronicle. 
 
 TDOKITANSKY [CARL). M.D., 
 
 Curator of the Imperial Pathological Mu-ie^im, and Professor at the University of Vienna. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. Translated by 
 
 W. E. SwAiNE, EnwARD SiEVEKiNG, C. H. MooRE, and G. E. Day. Four volumes octavo, 
 bound in two, of about 1200 pages, extra cloth. $7 50. 
 
 GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 
 
 Tratislaled, with Notes and Additions, by Joseph 
 Leidy, jr. D. In one volume, very large imperial 
 quarto, with 320 copper-plate figures, plaiu and 
 colored, extra cloth. $t 00. 
 
 SIMON'S GENERAL PATHOLOGY, as conducive to 
 the E-t.iblishment of Rational Priuciples for tbe 
 Prevention and Cure of Disease. lu one octavo 
 volume of 212 pages, extra cloth. $1 2.5. 
 
 TyiLLIAMS- [CHARLES J. B.), M.D., 
 
 Professor of Clinical Medicine in University College, London. 
 
 PRINCIPLES OF MEDICINE. An Elementary View of the Causes, 
 
 Nature, Treatment, Diagnosis, and Prognosis of Disease ; with brief remarks on Hygienics, 
 or the preservation of health. A new American, from the third and revised London edition. 
 In one octavo volume of about 500 pages, extra cloth. $3 50. 
 
 A text-book to which no other in our language is 
 comparable. — Charleston Med. Journal. 
 
 The lengthened analysis we have given of Dr. Wil- 
 liams's Principles of Medicine will, we trust, clearly 
 prove to our readers his perfect competency for the 
 task he has undertaken — that of imparting to the 
 student, as well as to the more experienced practi- 
 tioner, a knowledge of those general principles of 
 pathology on which alone a correct practice can be 
 founded. The absolute necessity of such a work 
 must be evident to all who pretend to more than 
 mere empiricism. We must conclude by again ex- 
 pressing our high sense of the immense benefit which 
 Dr. Williams has conferred on medicine by the pub- 
 lication of this work. We are certain that in the 
 present state of our knowledge his Principles of Medi- 
 cine could not possibly be surpassed. Wliile wo 
 regret the loss which many of the rising generation 
 of practitioners have sustained by bis resignation o 
 the Chair at University College, it Is comforting to 
 feel that his writings must long continue to exert a 
 powerful influence on the practice of that profes.siou 
 for the improvement of which he has so assiduously 
 and successfully labored, and in -which he holds so 
 distinguished a position. — London Jour, of Medicine 
 
 The unequivocal favor with which this work has 
 been received by the profession, both in Europe aud 
 America, is one among the many gratifying evidences 
 which might be adduced as going to show that there 
 is a steady progress taking place in the science as well 
 as in the art of medicine. — St. Louis Med. and Surg. 
 Journal. 
 
 No work has ever achieved or maintained a more 
 deserved reputation. — Virginia Med. and Surg. 
 Journal. 
 
 One of the best works on the subject of which it 
 treats iu our language. 
 
 It has already commended itself to the high regard 
 of the profession ; and we may well say that we 
 know of no single volume that will afford the source 
 of so thorough a drilling in the principles of practice 
 as this. Students an<l practitioners should make 
 themselves intimately familiar with its teachings — 
 they will find their labor and gtudy most amply 
 repaid. — Cincinnati Med. Observer. 
 
 There is no work in medical literature which can 
 fill the place of this one. It is the Priiwr of the 
 young practitioner, the Koran of the scientific one. — 
 Stethoscope.
 
 Henry C. Lea's Publications — {Practice of Medicine). 
 
 15 
 
 A 
 
 'PLINT [A USTJN), M. D., 
 
 Professor of the Principles and. Practice of Medicine in Bellemie Med. College, N. Y. 
 
 TREATISE OX THE PRINCIPLES AXD PRACTICE OF 
 
 MEDICINE ; designed for the use of Students and Practitioners of Medicine. Second 
 edition, revised and enlarged. In one large and closely printed octavo volume of nearly 
 ]II00 pages ; handsome extra cloth, $6 50; or strongly bound in leather, with raised bands, 
 $7 50. [Just Issued.) 
 
 From the Preface to the Second Edition. 
 Four months after the publication of this treatise, the author was notified that a second edition 
 was called for. The speedy exhau.?tion of the first edition, unexpected in view of its large size, 
 naturally intensified the desire to make the work still more acceptable to practitioners and 
 students of Medicine; and, notwithstanding the brief period allowed for a revision, additions 
 have been made which, it is believed, will enhance the practical utility of the volume. 
 
 We are happy in being able once more to commend 
 this work to the students and practitioners of medicine 
 who seek for accurate information conveyed in lan- 
 guage at once clear, precise, and expressive. — Am,er. 
 journ. Med. Sciences, April, ]S67. 
 
 Dr. Flint, who has been known in this country for 
 many year.s, both as an author and teaclier, who has 
 discovered truth, and pointed it out clearly and dis- 
 tinctly to others, investigated the symptoms and na- 
 tui'al history of disease and recorded its language and 
 
 ranked among heavy and common-place works, while 
 the unmistakable way in which Dr. Flint gives his 
 own views is quite refreshing, and far from common. 
 It is a book of enormous research ; the writer is evi- 
 dently a man of observation and large experience; 
 his views are practically sound and theoretically 
 moderate, and we have no hesitation in commending 
 his raognv.m opus to our readers — Dublin Medical 
 Press and Circular, May 16, 1S66. 
 In the plan of the work and the treatment of indi- 
 
 facts, and devoted a life of incessant study and , vidual subjects there is a freshness and an originality 
 thought to the doubtful or obscure iu his profession, : which make it worthy of the study of practitioners 
 has at length, in his ripe scholarship, given this work as well as students. It is, indeed, an admirable book, 
 to the profession as a crowning gift. If we have spoken i and highly creditable to American medicine. For 
 highly of its value to the profession and world ; if we , clearness and conciseness in style, for careful reason- 
 haTve said, all considered, it is the very best work i Ing upon what is known, forlucid distinction between 
 upon medical practice in any language; if we have ; what we know and what we do not know, between 
 spoken of its excellences in detail, and given points ' what nature does in disease and what the physician 
 of special value, we have yet failed to express in any can do and should, for richne.-^s in good clinical ob- 
 degree our present estimate of its value as a guide in servation, for independence of statement and opinion 
 the practice of medicine. It does not contain too much on great points of practice, and for general sagacity 
 or too little ; it is not positive where doubt should be and good judgment, the work is most meritorious, 
 expressed, or hesitate where truth is known. It is It is singularly rich in good qualities, and free from 
 philosophical and speculative where philosophy and faults. — London Lancet, June 2.3, 1866. 
 speculation are all that can at present be obtained. 
 
 but nothing is admitted to the elevation of established 
 truth, without the most thorough investigation. It 
 is truly remarkable with what even hand this work 
 has been written, and how it all shows the most care- 
 ful thought and untiring study. We conclude that, 
 though it may yet be susceptible of improvement, it 
 still constitutes the very best which human knowledge 
 can at present produce. "When knowledge is in- 
 creased," the work will doubtless be again revised; 
 meanwhile we shall accept it as the rule of practice. 
 — Buffalo Med. and Surg. Journal, Feb. 1867. 
 
 He may justly feel proud of the high honor con- 
 ferred on'him by the demand for a second edition of 
 his work iu four months after the issue of the first. 
 No American practitioner can afford to do without 
 Flint's Practice. — Pacific Med. and Surg. Journal, 
 Feb. 1867. 
 
 Dr. Flint's book is the only one on the practice of 
 medicine that can benefit the young practitioner.— 
 NoMhville Med. Journal, Aug. 3S66. 
 
 We consider the book, in all its essentials, as the 
 best adapted to the student of any of onr numerous 
 text-books on this subject. —iV.r Med. Journ.. Jsin.'67 . 
 
 Its terse conciseness fully redeems it from being 
 
 In following out such a plan Dr. Flint has suc- 
 ceeded most admirably, and gives to his readers a 
 work that is not only very readable, interesting, 
 and concise, but in every respect calculated to meet 
 the requirements of professional men of every class. 
 The student has presented to him, in the plainest 
 possible manner, the symptoms of disease, the prin- 
 ciples which should guide him in its treatment, and 
 the difficulties which have to be surmounted iu order 
 to arrive at a correct diagnosis. The practitioner, 
 besides having such aids, has offered to him the con- 
 clusion which the experience of the professor baa 
 enabled him to arrive at in reference to the relative 
 merits of different therapeutical agents, and different 
 methods of treatment. This new work will add not 
 a little to the well-earned reputation of Prof. Flint as 
 a medical teacher. — N. Y. Med. Record, April 2, 1866. 
 
 We take pleasure in recommending to the profession 
 this valuable and practical work on the practice of 
 medicine, more particularly as we have had oppor- 
 tunities of appreciating from personal observation 
 the author's preeminent merit as a clinical observer. 
 This work is undoubtedly one of great merit, and we 
 feel confident that it will have an extensive circula- 
 tion.— The N. 0. Med. and Surg. Journal, Sept. 1866. 
 
 B 
 
 TJNGLISON, FORBES, TWEED IE, AND CONOLLY. 
 
 THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 
 
 Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics, 
 Diseases of AV omen and Children, Medical Jurisprudence, Ac. &c. In four large super-royal 
 octavo volumes, o 13254 double-columned pages, strongly and handsomely bound in leather, 
 $15; extra cloth, $11. 
 *jt* This work contains no less than four hundred and eighteen distinct treatises, contributed 
 
 by sixty-eight distinguished physicians. 
 
 The most complete work on practical medicine 
 extant, or at least in our language.— .Bw/aZo Medical 
 and Surgical Journal. 
 
 For reference, it is above all price to every practi- 
 tioner.— Wt stern Lancet. 
 
 One of the most valuable medical publications of 
 
 the day. As a woi'k of reference it is invaluable. — 
 We.^tern Journal of Medicine and Surgery. 
 
 It has been to us, both as learner and teacher, a 
 work for ready and fi-equent reference, one in which 
 modern English medicine is exhibited in the most ad- 
 vantageous light. — Medical Exarainer. 
 
 BVRLOW.S MANUAL OF THE PRACTICE OF 
 MEDICIXE. With Additions by D. F. COSDIE, 
 M. D. 1 vol. Svo., pp. 600, cloth. ^2 50. 
 
 HOLLAND'S MEDICAL NOTES AND REFLEC- 
 TI0XJ3. From the third and enlarged English edi- 
 tion. In one handsome octavo volume of about 
 500 pages, extra cloth. $3 50.
 
 16 
 
 Henry C. Lea's Publications — {Practice of Medicine). 
 
 TTARTSHORNE [HENRY), M.D., 
 
 -*—*- Professor of Hygiene in the University uf Pennsylvania. 
 
 ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 
 
 CINE. A handy-book for Students and Practitioners. In one handsome royal ]2mo. 
 
 volume of about 350 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. 
 
 {Just Issued.) 
 The very cordial reception with which this work has met shows that the author has fully suc- 
 ceeded in his attempt to condense within a convenient compass the essential points of scientific 
 and practical medicine, so as to meet the wants not only of the student, but also of the practi- 
 tioner who desires to acquaint himself with the results of recent advances in medical science. 
 
 As a strikingly terse, full, and comprehensive em- 
 bodiment in a condensed form of the essentials in 
 medical science and art, we hazard nothing in sayin 
 
 that it is incomparably in advance of any work of the 
 kind of the past, and will stand long in the future 
 without a rival. A mere glance will, we think, im- 
 press others with the correctness of our estimate. Nor 
 do we believe there will be found many who, after 
 the most cursory examination, will fail to possess it. 
 Ho w one could be able to crowd so much that is valu- 
 able, especially to the student and young practitioner, 
 within the limits of so small a book, and yet embrace 
 and present all that is important in a well-arranged, 
 clear form, convenient, satisfactory for reference, with 
 so full a table of contents, and extended general index, 
 with nearly three hundred formulas and recipes, is a 
 marvel. — Western Journal of Medicine, Aug. 1807. 
 
 The little book before us has this quality, and we 
 can therefore say that all students will find it an in- 
 valuable guide in their pursuit of clinical medicine. 
 Dr. Hartshorne speaks of it as "an unambitious efl'ort 
 to make useful the experience of twenty years of pri- 
 vate and hospital medical practice, with its attendant 
 study and reflection." That the effort will prove suc- 
 cessful we have no doubt, and in his study, and at 
 the bedside, the student will find Dr. Hartshorne a 
 safe and accomplished companion. We speak thus 
 highly of the volume, because it approaches more 
 
 nearly than any similar manual lately before us the 
 standard at which all such books should aim — of 
 teaching much, and suggesting more. To the student 
 we can heartily recommend the work of our transat- 
 lantic colleague, and the busy practitioner, we are 
 sure, will find in it the means of solving many a 
 doubt, and will rise from the perusal of its pages, 
 having gained clearer views to guide him in his daily 
 struggle with disease. — Dub. Med. Press, Oct. 2, 1S67. 
 Pocket handbooks of medicine are not desirable, 
 even when they are as carefully and elaborately com- 
 piled as this, the latest, most complete, and most ac- 
 curate which we have seen. — British Med. Journal, 
 Sept. 21, 1867. 
 
 This work of Dr. Hartshorne must not be confound- 
 ed with ^he medical manuals so generally to be found 
 in the hands of students, serving them at best but as 
 blind guides, better adapted to lead them astray than 
 to any useful and reliable knowledge. The work be- 
 fore us presents a careful synopsis of the essential 
 elements of the theory of diseased action, its causes, 
 phenomena, and results, and of the art of healing, as 
 recognized by the most authoritative of our profes- 
 sional writers and teachers. A very careful and can- 
 did examination of the volume has convinced us that 
 it will be generally recognized as one of the best man- 
 uals for the use of the student that has yet appeared. 
 — American Journal Med. Sciences, Oct. 1867. 
 
 OP 
 
 TU'ATSON {THOMAS), M. D., ^"c. 
 
 LECTURES ON THE PRINCIPLES AND PRACTICE 
 
 PHYSIC. Delivered at King's College, London. A new American, from the last revised 
 and enlarged English edition, with Additions, by D. Francis Condie, M. D. , author of 
 " A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty- 
 five illustrations on wood. In one very large and handsome volume, imperial octavo, of 
 over 1200 closely printed pages in small type ; extra cloth, $6 50 ; strongly bound in 
 leather, with raised bands, $7 60. 
 Believing this to be a work which should lie on the table of every physician, and be in the hands 
 of every student, every eifort has been made to condense the vast amount of matter Avhich it con- 
 tains within a convenient compass, and at a very reasonable price, to place it within reach of aU. 
 In its present enlarged form, the work contains the matter of at least three ordinary octavos, 
 rendering it one of the cheapest works now offered to the American profession, while its mechani- 
 cal execution makes it an exceedingly attractive volume. 
 
 DICKSON'S ELEMENTS OF MEDICINE; a Compen- 
 dious View of Pathology and Therapeutics, or the 
 History and Treatment of Diseases. Second edi- 
 tion, revised. 1 vol. 8vo. of 750 pages, extra cloth. 
 $4 00. 
 
 WHATTO OBSERVE ATTHE BEDSIDE AND AFTER 
 De.-vth IX Mkdical Cases. Published under tlio 
 authority of the London Society for Medical Obser- 
 
 1 vol. 
 
 vation. From the second London edition, 
 royal 12mo., extra cloth. $1 00. 
 LAYCOCK'S LECTURES ON THE PRINCIPLES 
 AND Methods of Medical Observation and Re- 
 search. For the use of advanced students and 
 junior practitioners. In one very neat royal 12mo. 
 volume, extra cloth. $1 00. 
 
 -nARCLAY [A. W.), M. D. 
 A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the 
 
 Signs and Symptoms of Disease. Third American from the second and revised London 
 edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. 
 
 A work of immense practical utility. — London \ The book should be in the hands of every practical 
 Med. Times and Gazette. man. — Duhlin Med. Press. 
 
 rpULLER [HENRY WILLIAM), M. D., 
 
 -*- Physician to St. Ge.orge\s Hospital, London. 
 
 ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 
 
 Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
 Engli-sh edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. 
 {Now Ready.) 
 
 Dr. FuUer'-s work on diseases of the chest was so 
 favorably received, that to many who did not know 
 tlie extent of his engagements, it was a matter of won- 
 der that it should be allowed to remain three years 
 out of print. Determined, however, to improve it, 
 Dr. Fuller would not consent to a mere reprint, and I 
 
 accordingly we have what might be with perfect jus- 
 tice styled an entirely new work from his pen, the 
 portion of the work treating of the heart and great 
 vessels being excluded. Nevertheless, this volume is 
 of almost equal size with the first. — London Medical 
 Times and Gazette, July 20, 1867.
 
 Henry C. Lea's Publications — {Practice of Medicine). lY 
 
 JPLINT {AUSTIN). 31. D., 
 
 Pnifessor of the Principles and Practice of Ifedicine in Sellevue Hospital Med. College, N. T. 
 
 PRACTICAL TREATLSE ON THE PHYSICAL EXPLORA- 
 TION OP THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
 KESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
 of 595 pages, extra cloth, $4 50. (Just Issued.) 
 
 A 
 
 Prpmising this observation of the necessity of each 
 student and practitioner making himself acquainted 
 ■with auscultation and percussion, we may state our 
 honest opinion that Dr. Flint's treatise is one of the 
 most trustworthy guides which he can consult. The 
 style is clear and distinct, and is also concise, heing 
 free from that tendency to over-refinement and unne- 
 cessary minuteness which characterizes many works 
 on the same subject. — Dxiblin Medical Press, Feb. 6, 
 1S67. 
 
 In the Invaluable work before us, we have a book 
 oi facts of nearly 600 pages, admirably arranged, 
 clear, thorough, and lucid on all points, without pro- 
 lixity; exhausting every point and topic touched ; a 
 monument of patient and long-continued observation, 
 which does credit to its author, and reflects honor on 
 
 American medicine. — Atlanta Med. and Surg. Jour- 
 nal, Feb. 1S67. 
 
 The chapter on Phthisis is replete with interest ; 
 and his remarks on the diagnosis, especially in the 
 early stages, are remarkable for their acumen and 
 great practical value. Dr. Flint's style is clear and 
 elegant, and the tone of freshness and originality 
 which pervades his whole work lend an additional 
 force to its thoroughly practical character, which 
 cannot fail to obtain for it a place as a standard work 
 on diseases of the respiratory system. — London 
 Lancet, Jan. 19, 1S67. 
 
 This is an admirable book. Excellent in detail and 
 execution, nothing better could be desired by the 
 practitioner. Dr. Flint enriches his subject with 
 much solid and not a little original observation. — 
 Ranking'' s Abstract, Jan. 1S67. 
 
 ^Y THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 
 
 AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume of 
 nearly 500 pages, with a plate j extra cloth, $3 50. 
 
 We question the fact of any recent American author 
 in our profession being more extensively kuown, or 
 more deservedly esteemed in this country than Dr. 
 Flint. We willingly acknowledge his success, more 
 particularly in the volume on diseases of the heart, in 
 
 making an extended personal clinical study available 
 for purposes of illustration, in connection with cases 
 which have been reported by other trustworthy ob- 
 servers. — Brit, and For. Med.-Ghir. Review. 
 
 pUAMBERS [T. K.), M. D., 
 
 ^ C'ons^Uting Physician to St. Mary's Hospital, London, &c. 
 
 THE INDIGESTIONS; or, Diseases of the Digestive Organs Functionally 
 
 Treated. Second Edition, revised. In one handsome octavo volume of over 300 pages, 
 extra cloth, $3 00. [Now Ready.) 
 
 He is perhaps the most vivid and brilliant of living ' and practical skill — that his success as a teacher or 
 medical writers; and here he supplies, in a graphic i literary expositor of the medical art consists; and the 
 series of illustrations, bright sketches from his well- | volume before us is a better illustration than its au- 
 stored portfolio. His is an admirable clinical book, | thor has yet produced of the rare degree in which 
 like all that he publishes, original, brilliant, and in- \ those combined qualities are at his command. Next 
 teresting. Everywhere he is graphic, and liis work ' to the diseases of children, there is no subject on 
 supplies numerous practical hints of much value. — ! which the young practitioner is oftener consulted, or 
 Edinburgh Med. and Surg. Journal, Nov. 1867. I on which the public are more apt to form their 
 
 Associate with this the rare faculty which Dr. i opinions of his professional skill, than the various 
 
 Chambers has of infusing an enthusiasm in his sub- 
 ject, and we have in this little work all the elements 
 which make it a model of its sort. We have perused 
 it carefully; have studied every page; our interest 
 in the suliject has been intensified as we proceeded, 
 and we are enabled to lay it down with unqualified 
 praise. — N. Y. Med. Record, April 1.5, 1867. 
 
 It is in the combination of these qualities — clear and 
 vivid expression, with thorough scientific knowledge 
 
 phenomena of indigestion. Dr. Chambers comes most 
 opportunely and effectively to his assistance. In fact, 
 there are few situations in which the commencing 
 practitioner can place himself in which Dr. Cham- 
 bers' conclusions on digestion will not be of service. 
 — London Lancet, February 23, 1867. 
 
 This is one of the most valuable works which it 
 has ever beea our good fortune to receive. — London 
 Med. Mirror, Feb. 1S67. 
 
 -DRINTON {WILLIAM), M.D., F.R.S. 
 
 LECTURES ON THE DISEASES OF THE STOMACH; with an 
 
 Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
 tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, 
 extra cloth. $3 25. (Just issued.) 
 
 The most complete work in our language upon the 
 diagnosis and treatment of these puzzling and impor- 
 tant diseases. — Boston Mtd. and Surg. JournaJ, Nov. 
 1865. 
 
 Nowhere can be found a more full, afenrate, plain, 
 and instructive history of these diseases, or more ra- 
 tional views respecting their pathology and therapeu- 
 tics. — Am. Joum. of the Med. Sciences, April, 1865. 
 
 E 
 
 ABERSHON {S. 0.), 3LD. 
 
 PATHOLOGICAL AND PRACTICAL OBSERYATIONS ON DIS- 
 EASES OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH, CyECUM, AND 
 INTESTINES. With illustrations on wood. In one handsome octavo volume of 312 
 extra cloth. $2 50. 
 
 JTUDSON {A.), 3LD.,M.R.LA., 
 
 J-J- Physician to the Mealh Hospital. 
 
 LECTURES ON THE STUDY OF FEYER. In one vol. 8vo. (Pub- 
 lishing in the "Medical News and Library" for 1867 and 1868.) ,
 
 Henry C. Lea's Publications — {Practice of Medicine). 
 
 jyUMSTEAD {FREEMAN J.), M.D., 
 
 J-^ Lecturer on Materia Medica and Venereal Diseases at the Col. of Phys. and Surg., New York, &c. 
 
 THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 
 EASES. Including the results of recent investigations upon the subject. A new and re- 
 vised edition, with illustrations. In one large and handsome octavo volume of 640 pages, 
 extra cloth, $5 00. {Lately Issued.) 
 During the short time which has elapsed since the appearance of this work, it has assumed the 
 position of a recognized authority on the subject wherever the language is spoken, and its transla- 
 tion into Italian shows that its reputation is not confined to our own tongue. The singular clear- 
 ness with which the modern doctrines of venereal diseases are set forth renders it admirably 
 adapted to the student, while the fulness of its practical details and directions as to treatment 
 makes it of great value to the practitioner. The few notices subjoined will show the very high 
 position universally accorded to it by the medical press of both hemispheres. 
 
 Well known as one of the best authorities of the which has long been felt in English medicalliteratnre. 
 
 present day on the subject. — British and For. iled.- 
 Chirurg. Review, April, 1S66. 
 
 A regular store-house of special information. — 
 Londoyi Lancet, Feb. 24, 1S66. 
 
 A remarkably clear and full systematic treatise on 
 tlie whole subject. — Lond. Med. Times and Gazette. 
 
 The best, completest, fullest monograph on this 
 subject in our language. — Br itish American Journal. 
 
 Indispensahle in a medical library. — Pacific Med. 
 and Surg. Journal. 
 
 We have no doubt that it will supersede in America 
 every other treatise on Venereal. — San Francisco 
 Med. Press, Oct. 1864. 
 
 A perfect compilation of all that is worth knowing 
 on venereal diseases in general. It fills up a gap 
 
 — Brit, and Foreign Med.-Chiriirg. Review, Jan., '6.5, 
 
 We have not met with any which so highly merits 
 our approval and praise as the second edition of Dr. 
 Bumstead's work. — Glasgoio Med. Journal, Oct. 186-1. 
 
 We know of no treatise in any language which is 
 its equal in point of completeness and practical sim- 
 plicity — Boston Medical and Surgical Journal, 
 Jan. 80, 1864. 
 
 The book is one which every practitioner should 
 have in his possession, and, we may further say, the 
 onlyhod^ upon the subject which lie should acknow- 
 ledge as competent authority. — Buffalo Medical and 
 Surgical Joitrnal, July, 1864. 
 
 The best work with which we are acquainted, and 
 the most convenient hand-book for the busy practi- 
 tioner — Cincinnati Lancet, July, 1864. 
 
 (lULLEBIER [A.), and 
 
 ^-^ Surgeon to the Hopital du Midi. 
 
 T?Uj\ISTEAD [FREEMAN J.), 
 
 -*-^ Professor of Venereal Diseases in the College of 
 Physicians and Surgeons, N. Y. 
 
 AN ATLAS OF VENEREAL DISEASES. Tran.slated and Edited by 
 
 Freeman J. Bumstead. To be issued in five parts, at Three Dollars each, making a large 
 imperial 4to. volume, with 26 plates, containing about 150 figures, beautifully colored, many 
 of them the size of life. {Parts I. and II. nniu ready.) 
 In charge of the celebrated Hopital du Midi, where M. Ricord gained his immense experience, 
 M. Cullerier is known as one of the most profound syphilographers of the present day. This 
 work presents the results of his observations and reflections on the whole round of venereal acci- 
 dents and affections, and is illustrated with a complete series of colored plates, more minute and 
 extensive than anything of the kind that has yet been laid before the profession. The translator 
 and editor, Dr. Bumstead, is so well known in this country as an authority on the subject, and 
 as a clear and elegant writer, that his connection with the work is sufBcient guarantee that its 
 value will be increased in passing through his hands. 
 
 *^* A specimen of the plates and text sent free by mail, on receipt of 25 cents. 
 
 BUCKLER ON FIBRO-BEONCHITIS AND RHEU- 
 MATIC PNEUMONIA. In one octavo vol., extra 
 cloth, pp. 1.50. $1 2.1. 
 
 FISKE FUND PRIZE ESS.iY.S.— LEE ON THE EF- 
 FECTS OF CLIMATE ON TUBERCULOUS DIS- 
 EASE. AND WARREN ON THE INFLUENCE OF 
 PREGNANCY ON THE DEVELOPMENT OF TU- 
 BERCLES. Together in one neat octavo volume, 
 extra cloth, $1 00. 
 
 HUGHES' CLINICAL INTRODUCTION TO AUS- 
 CULTATION AND OTHER MODES OF PHYSICAL 
 DIAGNOSIS. Second edition. One volume royal 
 12mo., extra cloth, pp. 304. $1 2.5. 
 
 WALSHE'S PRACTICAL TREATISE ON THE DIS- 
 EASES OF THE HEART AND GREAT VESSELS. 
 Third American, from the third revised and much 
 enlarged London edition. In one handsome octavo 
 volume of 420 pages, extra cloth. $3 00. 
 
 TA ROCHE [R.), 31. D. 
 
 B 
 
 YELLOW FEVER, considered in its Historical, Pathological, Etio- 
 logical, <nnd Therapeuticnl Relati<ms. Including a Sketch of the Disease as it has occurred 
 in Philadelphia from 1699 to 1854, with an examination of the connections between it and 
 the fevers known under the same name in other parts of temperate as well as in tropical 
 regions. In two large and handsome octavo volumes, of nearly 1500 pages, extra cloth, $7 00. 
 
 r THE SAME AUTHOR. 
 
 PNI]UMONIA ; its Supposed Connection, Pathological, and Etiological, 
 
 with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of 
 Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. 
 
 YONS [ROBERT D.), K. C. C. 
 
 A TREATISE ON FEVER; or. Selections from a Course of Lectures 
 
 on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo 
 volume, of 362 pages, extra cloth. $2 25. 
 
 CLYMER ON FEVERS; THEIR DIAGNOSIS, PA- 
 THoi.oGT AND Trrat.hent. Iu oue octavo volume 
 of 600 pages, leather. $1 75. 
 
 TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
 Diseases. In one neat octavo volume, of 320 pages 
 extra cloth. $2 50.
 
 Henry C. Lea's Publications — {Practice of 3Iedicine). 
 
 19 
 
 A 
 
 /ROBERTS ( WILLIAM), M. D.. 
 
 Lecturer on Medicine in the Manchester School of Medicine, &c. 
 
 PRACTICAL TREATISE ON URINARY AND RENAL DIS- 
 
 EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. In 
 one very handsome octavo volume of 516 pp., extra cloth. $4 60. {Just Issued.) 
 In carrying out this design, lie has not only made sive work on urinary and renal diseases, considered 
 
 good use of his own practical knowledge, but has i in their strictly practical aspect, that we possess in 
 
 brought together from various sources a vast amount I the English language. — British Medical Journal, 
 
 of information, some of which is not generally pos- ' Dee. 9, lSti.5. 
 
 sessed by the profession in this country. We must | We have read this book with much satisfaction. 
 
 now bring our notice of this book to a close, re- 
 gretting only that we are obliged to resist the temp- 
 tation of giving further extracts from it. Dr. Roberts 
 has already on several occasions placed before the 
 profession the results of researches made by him on 
 various points connected with the urine, and had thus 
 
 It will take its place beside the best treatises in our 
 language upon urinary pathology and therapeutics. 
 Not the least of its merits is that the author, unlike 
 some other book-maker.s, is contented to withhold 
 much that he is well qualified to discuss in order to 
 impart to his volume such a strictly practical charac- 
 
 led us to expect from him something good — in which j ter as cannot fail to render it popular among British 
 expectation we have been by no means disappoiuted. i readers. — London Med. Times and Gazette, March 
 The book is, beyond question, the most comprehen- j 17, 1S66. 
 
 ^*^ " Bird on Urinary Deposits," being for the present out of print, gentlemen will find in the 
 above work a trustworthy substitute. 
 
 MORLAND ON RETENTION IN THE BLOOD OF 
 THE ELEMENTS OF THE URINARY SECRE- 
 TION. 1 vol. 8vo., extra cloth. 7.5 cents. 
 
 BLOOD AND URINE (MANUALS ON). By J. W. 
 
 Griffth, G. 0. Reese, and A. Markwick. 1 vol. 
 12mo , extra cloth, with plates, pp. 4«0. f 1 25. 
 BUDD ON DISEASES OF THE LIVER. Third edition. 
 1 vol. Svo.pxtra cloth, with four beautifully colored 
 plates, and numerous wood-cuts. pp. 500. $1 00. 
 
 nUCKNILL {J. C.),M.D., and T)ANIEL H. TOKE,M.D., 
 
 -'-'Med. Superintendent of the Devon Lunatic A.sylum.-*-^ Vi-iiting Medical Officer to the York Retreat. 
 
 A MANUAL OF PSYCHOLOGICAL MEDICINE; containmg the 
 
 History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of In- 
 sanity. With a Plate. In one handsome octavo volume, of 636 pages, extra cloth. §4 25. 
 
 TONES [C. HANDFIELD). M. D., 
 
 ^ Phyxician to St. Mary's Hospital, A-c. 
 
 CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS 
 
 DTSORDEPvS. In one handsome octavo volume of 348 pages, extra cloth, $3 25. 
 {Just Issued.) 
 
 Taken as a whole, the work before us furnishes a I We must cordially recommend it to the profession 
 short but reliable account of the pathology and treat- ' of this country as supplying, in a great measure, a 
 went of a class of very common but certainly highly deficiency which exists in the medical literature of 
 obscure disorders. The advanced student will find it the English language. — New York Med. Journ., April, 
 a rich mine of valuable facts, while the medical prac- , 1867. 
 titioner will derive from it many a suggestive hint to 1 
 
 aid him in the diagnosis of "nervous cases," and in The volume is a most admirable one— full of hints 
 determining the true indications for their ameliora- and practical suggestions. — Ca/jarfa Med. Journal, 
 tion or cure. — Arner. Journ. Med. Sci., Jan. 1867. j April, 1867. 
 
 HARRISON'S ESSAY TOWARDS A CORRECT 
 THEORY OF THE NERVOUS SYSTEM. In one 
 octavo volume of 292 pp. $1 .50. 
 
 SOLLY ON THE HUMAN BRAIN; its Structure, 
 
 Physiology, and Diseases. From the Second and 
 much enlarged London edition. In one octavo 
 Volume of .iOO pages, with 120 wood-cuts; extra 
 cloth. .$2 50. 
 
 ^MITH [EDWARD), M.D. 
 
 CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. 
 
 one neat octavo volume of 254 pages, extra cloth. $2 26. 
 
 gALTER [H. H.), M.D. 
 
 ASTHMA ; its Pathology, Causes, Consequences, and Treatment. 
 
 one volume, octavo, extra cloth. $2 50. 
 gLADE [D. D.), M.D. 
 
 In 
 
 In 
 
 DIPHTHERIA; its Nature and Treatment, with an account of the His- 
 tory of its Prevalence in various Countries. Second and revised edition. In one neat 
 royal 12mo. volume, extra cloth. $1 25. {Just issued.) 
 
 L 
 
 ALLEMAND AND WILSON. 
 
 A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, 
 
 AND TREATMENT OF SPERMATORRHCEA. By M. Lallemand. Translated and 
 
 edited by Henrv J. McDocgall. Fifth American edition. To which is added ON 
 
 DISEASES OF THE VESICUL^ SEMINALES, and their associated organs. With 
 special reference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. 
 By Mauris Wilson, M-D. In one neat octavo volume, of about 400 pp., extra cloth, $2 75,'
 
 20 
 
 Henry C. Lea's Publications — (Diseases of the Skin). 
 
 T^ILSON ( ERASM US), F. E. S., 
 
 OX DISEASES OF THE SKIX. The sixth American, from the fifth 
 
 and enlarged English edition. In one large octavo volume of nearly 700 pages, extra 
 cloth. $4 50. Also— 
 
 A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
 EASES OP THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
 teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
 and embracing accurate representations of about one hundred varieties of disease, most of 
 them the size of nature. Price, in extra cloth, $b 50. 
 Also, the Text and Plates, bound in one handsome volume, extra cloth. Price $9 50. 
 This classical work has for twenty years occupied the position of the leading authority on cuta- 
 neous diseases in the English language, and the industry of the author keeps it on a level with the 
 advance of science, in the frequent revisions which it receives at his hands. The large size of the 
 volume enables him to enter thoroughly into detail on all the subjects embraced in it, while its 
 very moderate price places it within the reach of every one interested in this department of practice. 
 
 Such a work as the one before us is a most capital 
 and acceptable help. Mr. Wilson has long been held 
 as liigh authority in this department of medicine, and 
 his book on disease.s of the skin has long been re- 
 garded as one of the best text-books extant on the 
 subject. The present edition is carefully prepared, 
 and brought up in its revision to the present time In 
 this edition we have also included the beautiful series 
 of plates illustrative of the text, and in the last edi- 
 tion published separately. There are twenty of these 
 plates, nearly all of them colored to nature, and ex- 
 hibiting with great fidelity the various groups of 
 diseases treated of in the body of the work. — Cin- 
 cinnati Lancet, June, 1S63. 
 
 No one treating skin diseases should be without 
 a copy of this standard work. — Canada Lancet. 
 August, 1863. 
 
 >T THE SAME AUTHOR. — 
 
 We can safely recommend it to the profession as 
 the best work on the subject now in existence in 
 the English language. — Medical Times and Gazette. 
 
 Mr. Wilson's volume is an excellent digest of the 
 actual amount of knowledge of cutaneous diseases ; 
 it includes almost every fact or opinion of importance 
 connected with the anatomy and pathology of the 
 skin. — British and Foreign Medical Review. 
 
 These plates are very accurate, and are executed 
 with an elegance and taste which are highly creditable 
 totheartisticskill of the American artist who executed 
 them. — St. Lmii.s Med. Journal. 
 
 The drawings are very perfect, and the finish and 
 coloring artistic and correct; the volume is an indis- 
 pensable companion to the book it illustrates and 
 completes. — Charleston Medical Journal. 
 
 B' 
 
 THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 
 
 EASES OF THE SKIN. In One very handsome royal 12mo. volume. $.3 50. {Now Ready.) 
 This new class-book will be admirably adapted to ( Thoroughly practical in the best sense. — Brit. Med. 
 
 the necessities of students. — Lancet. 
 
 Jiiurnal. 
 
 »r THE SAME AUTHOR. 
 
 HEALTHY SKIN; a Popular Treatise on the Skin and Hair, their 
 
 Preservation and Management. One vol. 12mo., pp. 291, with illustrations, cloth. $1 00 
 
 JYELTGAN [J.MOORE), M.D.,M.R.I.A., 
 
 A PRACTICAL TREATISE ON DISEASES OF THE SKIN. 
 
 Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M.D. 
 
 In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. {Just Issued.) 
 Of the remainder of the work we have nothing be- : This instructive little volume appears once more, 
 ynnd unqualified commendation to ntfer. It is so far Since the death of its distinguished author, the study 
 the most complete one of its size that has appeared, ' of skin diseases has been considerably advanced, and 
 and for the student there can be none which can com- the results of these investigations have been added 
 pare with it in practical value. All the late disco- by the present editor to the oiiginal work of I)r. Keli- 
 veries in Dermatology have been duly noticed, and gan. This, however, has not so far increased its bulk 
 their value justly estimated ; in a word, the work is [as to destroy its reputation as the most convenient 
 fully up to the times, and is thoroughly stocked with manual of diseases of the skin that can be procured 
 most valuable information. — New York Med. Record, by the student. — Chicago Med. Journal, Dec. 1S66. 
 Jau. 1.5, 1867. 1 
 
 or THE SAME AUTHOR. 
 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful qnarto 
 
 volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of 
 
 disease. Extra cloth, $5 50. 
 
 of the pathology and treatment of eruptive diseases. 
 It possesses the merit of giving short and condensed 
 descriptions, avoiding the tedious minuteness of 
 many writers, while at the same time the work, as 
 its title implies, is strictly practical. — Glasgow Med. 
 Journal. 
 
 A compend which will very much aid the practi- 
 tioner in this difficult branch of diagnosis. Taken 
 with the beautiful plates of the Atlas, which are re- 
 markable for their accuracy and beauty of coloring, 
 it constitutes a very valuable addition to the library 
 of a practical man. — Buffalo Med. Journal. 
 
 The diiignosis of eruptive disease, however, under 
 all circumstances, is very difllcult. Nevertheless, 
 Dr. Neligan has certainly, "as far as possible," given 
 a faithful and accurate repre.sentation of this class of 
 diseases, and there can be no doubt that these plates 
 ■will be of great use to the student and practitioner in 
 drawing a diagno8i.s as to the class, order, and species 
 to which the particular case may belong. While 
 looking over the "Atlas" we have been induced to 
 examine also the "Practical Treatise," and we are 
 inclined to consider it a very superior work, com- 
 bining accurate verbal description with sound views 
 
 H 
 
 ILLIER [THOMAS), M.D., 
 
 Physician to the Skin Department of University College Hospital, &o. 
 
 HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 
 
 In one neat royal 12mo. volume of about 300 pages, with two plates; extra cloth, $2 25. 
 (Just Issued.)
 
 Heney C. Lea's Publications — (Diseases of Children). 
 
 21 
 
 rjONDIE [D. FRANCIS), M.D. 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREX. 
 
 Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
 printed pages, extra cloth, $5 25 ; leather, $6 25. {Now Beady.) 
 
 Dr. Condie's scholarship, acumen, industry, and 
 )ractical sea.se are manifested in this, as in all his 
 lumerous contributions to science. — Dr. Holmes's 
 Report to the American Medical Association. 
 
 Taken as a whole, in our judgment. Dr. Condie's 
 realise is the one from the perusal of -vrhich the 
 )ractitioner in this country will rise with the great- 
 !st satisfaction. — Western Journal of Medicine and 
 iurgery. 
 
 In the departmentof infantile therapeutics, the work 
 >f Dr. Coudie is considered one of the best in the Eng- 
 isli language. — The Stethoscox>e. 
 
 As we said before, we do not know of a better book 
 m Diseases of Children, and to a large part of its re- 
 !ommendations we yield an unhesitating concurrence. 
 —Buffalo Medical journal. 
 
 The work of Dr. Condie is unquestionably a very 
 kble one. It is practical in its character, as its title 
 mports ; but the practical precepts recommended in 
 
 it are based, as all practice should be, upon a familiar 
 knowledge of di.sease. The opportunities of Dr. Con- 
 die tor the practical study of the diseases of children 
 have been great, and his work is aproof that they have 
 not been thrown away. He has read much, but ob- 
 served more ; and we think that we may safely say 
 that the American student cannot find, in his own 
 language, a better book upon the subject of which it 
 treats. — Am. Joiirnal Medical Sciences. 
 
 We pronounced the first edition to be the best work 
 ou the di.^eases of children in the English language, 
 and, notwithstanding all that has been published, we 
 still regard it in that light. — Medical Examiner. 
 
 The value of works by native authors on the dis- 
 eases which the phy.sician is called upon to combat 
 will be appreciated by all, and the work of 'Dr. Con- 
 die has gained for itself the character of a safe guide 
 for students, and a useful work for consultation by 
 those engaged in practice. — iV. Y. Med. Times. 
 
 JY^ST [CHARLES), 31. D., 
 
 Physician to the Hospital for Sick Children, &c. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILD- 
 
 HOOD. Fourth American from the fifth revised and enlarged English edition. In one 
 large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $4 50; 
 leather, $5 50. (Just issued.) 
 
 This work may now fairly claim the position of a standard authority and medical classic. Five 
 jditions in England, four in America, four in Germany, and translations in French, Danish, 
 Dutch, and Russian, show how fully it has met the wants of the profession by the soundness of its 
 fiews and the clearness with which they are presented. Few practitioners, indeed, have had the 
 opportunities of observation and experience enjoyed by the Author. In his Preface he remarks, 
 " The present edition embodies the results of 1200 recorded cases and of nearly 400 post-mortem 
 examinations, collected from between 30,000 and 40,000 children, who, during the past twenty- 
 six years, have come under my care, either in public or in private practice." The universal favor 
 with which the work has been received shows that the author has made good use of these unusual 
 id vantages. 
 
 Of all the English writers on the diseases of chil- 
 iren, there is no one so entirely satisfactory to us as 
 Dr. West. For years we have held his opinion as 
 judicial, and have regarded him as one of the highest 
 living authorities in the difficult department of medi- 
 sal science in which he is most widely known. His 
 tvritings are characterized by a sound, practical com- 
 mon sense, at the same time that they bear the marks 
 if the most laborious study and investigation. We 
 sommend it to all as a most reliable adviser on many 
 occasions when many treatises on the same subjects 
 will utterly fail to help us. It is supplied with a very 
 copious geueral index, and a special index to the for- 
 mula scattered throughout the work. — Boston Med. 
 rjjid Sxirff. Journal, April 26, 1866. 
 
 Dr. West's volume is, in our opinion, incomparably 
 the best authority upon the maladies of children 
 tliat the practitioner can consult. Withal, too — a 
 minor matter, truly, but still not one that should be 
 neglected — Dr. West's composition possesses a pecu- 
 liar charm, beauty and clearness of expression, thus 
 affording the reader much pleasure, even independent 
 of that which arises from the acquisition of valuable 
 truths. — Cincinnati Jour . of Medicine, March, 1866. 
 
 We have long regarded it as the most scientific and 
 practical book on diseases of children which has yet 
 appeared in this country. — Buffalo 3Iedical Journal. 
 
 Dr. West's book is the best that has ever been 
 written in the English language on the diseases of 
 
 infancy and *hildhood. — Columbus Review- of Med. 
 and Surgery. 
 
 To occupy in medical literature, in regard to dis- 
 eases of children the enviable po.sition which Dr. 
 Watson's treatise does on the diseases of adults is 
 now very generally assigned to our author, and his 
 book is in the hands of the profession everywhere as 
 an original work of great value. — 3Id. and Va. Med. 
 and Surg. Journal. 
 
 Dr. West's works need no recommendation at this 
 date from any hands. The volume before us, espe- 
 cially, has won for itself a large and well-deserved 
 popularity among the profession, wherever the Eng- 
 lish tongue is spoken. Many years will elapse before 
 it will be replaced in public estimation by any similar 
 treatise, and seldom again will the same subject be 
 discussed in a clearer, more vigorous, or pleasing 
 style, with equal simplicity and power. — Charleston 
 Med. -lour, and Review. 
 
 There is no part of the volume, no subject on which 
 it treats which does not exhibit the keen perception, 
 the clear judgment, and the sound reasoning of the 
 author. It will be found a most useful guide to the 
 young practitioner, directing him in his management 
 of children's diseases in tlie clearest possible manner, 
 and enlightening him on many a dubious pathological 
 point, while the older one will find in it many a sug- 
 gestion and practical hint of great value. — Brit. Am. 
 Med. Journal. 
 
 D 
 
 EWEES [WILLIAM P.), M.D., 
 
 Late Professor of Midwifery, &c., in the University of Pennsylvania, &-c. 
 
 A TREATISE ON THE PHYSICAL AND MEDICAL TREAT- 
 
 MBNT OF CHILDREN. Eleventh edition, with the author's last improvements and cor- 
 rections. In one octavo volume of 548 pages. $2 80.
 
 22 
 
 Henry C. Lea's Publications — (Diseases of Women). 
 
 q^HOMAS [T. GAILLARD),M.D., 
 
 •L Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., &c. 
 
 A COMPLETE PRACTICAL TREATISE ON THE DISEASES OP 
 
 FEMALES. In one large and handsome octavo volume of over 600 pages, with 219 illus- 
 trations, extra cloth, $5; leather, $6. (Noiv Ready .) 
 In this work Professor Thomas has endeavored to supply the want of a complete treatise on 
 Gynsecology, embracing both the medical and surgical treatment requisite to the diseases and 
 accidents peculiar to women. The investigations and improvements of the last few years have 
 worked so great a change in this important department of practical medicine that a work like the 
 present, thoroughly on a level with the most advanced condition of the subject, can hardly fail 
 to possess claims on the attention of every practitioner. 
 
 To show the scope of the work, a very condensed summary of the contents is subjoined. 
 
 Chapter I. History of Uterine Pathology. — 11. Etiology of Uterine Diseases in America. — III. Diagnosis 
 of Diseases of Female Genital Organs. — IV. Diseases of the Vulva. — V. Diseases of the Vulva {continued). 
 VI. Vaginismus. — VII. Vaginitis. — VIII. Atresia Vagina;. — IX. Prolapsus Vaginje. — X. Fistiilse of the 
 Female Genital Organs. — XI. Fecal and Simple Vaginal Fistula;. — XII. General Remarks on Inllammatioa 
 of the Uterus. — Xl'll. Acute Eudo-Metritis and Acule Metritis. — XIV. Cervical Endo-Metritis.— XV. Chronic 
 Cervical Metritis. — XVI. Chronic Corporeal Endo-Metritis and Metritis. — XVII. Ulceration of the Os and 
 Cervix Uteri. — XVIII. General Considerations on Displacomeuts of the Uterus. — XIX. Ascent and Descent 
 of the Uterus. — XX. Versions of the Uterus. — XXI. Flexions of the Uterus — XXII. Inversion of the Ute- 
 rus. —XXIII. Peri-Uterine Cellulitis. — XXIV. Pelvic Peritonitis.— XXV. Pelvic Abscess.— XXVI. Pelvic 
 Hiematocele.- XXVII. Fibrous Tumors of the Uterus. — XXVIII. Uterine Polypi. — XXIX. Cancer of the 
 Uterus.— XXX. Cancroid Tumors of the Uterus. —XXXI. Epithelial Cancer of the Uterus. — XXXII. Dis- 
 eases resulting from Pregnancy. — XXXIII. Dysmeuorrhoea. — XXXIV. Menorrhagia and Metrorrhagia. — 
 XXXV. Ameuorrhffia. — XXXVI. Leucorrhoea.— XXXVII. Sterility.— XXXVIII. Amputation of the Cer- 
 vix Uteri. — XXXIX. Diseases of the Ovaries — XL. Ovarian-Tumors. — XLI. Ovariotomy. — XLII. Ovariaa 
 Tumors [continued). — XLIII. Diseases of the Fallopian Tubes. 
 
 JjJ^EIGS [CHARLES D.), M. D., 
 
 Late Professor of Obstetrics, &c. in Jefferson Medical College, Philadelphia. 
 
 WOMAN: HER DISEASES AND THEIR REMEDIES. A Series 
 
 of Lectures to his Class. Fourth and Improved edition. In one large and beautifully 
 printed octavo volume of over 700 p.i.ges, extra cloth, $5 00; leather, $6 00. 
 
 Every topic discussed by the author is rendered so 
 
 That this work has been thoroughly appreciated 
 by the profession of this country as well as of Europe, 
 is fully attested by the fact of its having reached its 
 fourtli edition in a period of less than twelve years. 
 Its value has been much enhanced by many impor- 
 tant additions, and it contains a fund of useful in- 
 formation, conveyed in an easy and delightful style. 
 
 VY THE SAME AUTHOR. 
 
 ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 
 
 FEVER. In a Series of Letters ad<lre.ssed to the Students of his Class. In one handsome 
 octavo volume of 365 pages, extra cloth. S2 00. 
 
 plain as to be readily understood by every student: 
 and, for our own part, we consider it not only one of 
 the most readable of books, but one of priceless value 
 to the practitioner engaged in the practice of those 
 diseases peculiar to females. — N. Am.. Med.-Chir. Re- 
 view. 
 
 rjHURCHILL [FLEETWOOD], M. D., M. R. I. A. 
 
 ON THE DISEASES OP WOMEN; including those of Pregnancy 
 
 and Childbed. A new American edition, revised by the Author. With Notes and Additions, 
 by D. Francis Condib, M. D., author of " A Practical Treatise on the Dise.ases of Chil- 
 dren." AVith numerous illustrations. In one large and handsome octavo volume of 768 
 pages, extra cloth, $4 00; leather, $5 00. 
 
 As an epitome of all that is known in this depart- I fullest and most valuable in the English language, 
 ment of medicine, the book before us is perhaps the | — Dublin Medical Press. 
 
 THE SAME AUTHOR. 
 
 ESSAYS ON THE PUERPERAL FEVER, AND OTHER DIS- 
 EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- 
 ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 
 pages, extra cloth. $2 50. 
 
 ^RO WN (LSAAG BAKER), M. D. • 
 
 ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL 
 
 TREATMENT. With handsome illustrations. One volume 8vo., extra cloth, pp. 276. 
 $1 60. 
 
 ASHWELL'S PRACTICAL TREATISE ON THE DIS- 
 EASES PECULIAR TO WOMEN. Illustrated by 
 Cases derived from Hospital and Private Practice. 
 Third American, from tlie Tliird and revi-sed Lon- 
 don edition. In one octavo volume, extra cloth, 
 of .i2S pages. $3 oO. 
 
 KIGBY ON THE CONSTITUTIONAL TREATMENT 
 OF FE.MALE DISEASES. In one neat royal 12mo. 
 volume, extra cloth, of about 250 pages. $1 00. 
 
 DEWEES'S TREATISE ON THE DISEASES OF FE- 
 MALES. With illu.«trations. Elevearh Edition, 
 with the Author's last improvements and correc- 
 tions. In one octavo volume of 536 pages, with 
 plates, extra cloth, $.3 00. 
 
 COLOMBAT DE L'ISERE ON THE DISEASES OP 
 FEMALES. Translated by C. D. Meius, M. D. Se- 
 cond edition. In one vol. Svo, extra cloth, with 
 numerous wood-cuts. pp. 720. $3 75.
 
 Henry C. Lea's Publications — (Diseases of Wovien). 
 
 23 
 
 TTODGE [HUGH L.), M.D. 
 
 ON DISEASES PECULIAK TO WOMEN; including Displacements 
 
 of the Uterus. With original illustrations. Second edition, revised. In one beautifully 
 printed octavo volume of about 500 pages. {Preparing.) 
 
 Indeed, although no part of the volume is not emi- 
 nently deserving of perusal and study, vre think that 
 the nine chapters devoted to this subject are espe- 
 cially so, and we know of no more valuable mono- 
 graph upon the symptoms, prognosis, and manage- 
 ment of these annoying maladies than is constituted 
 by this part of the woi-k. We cannot but regard it as 
 one of the most original and most practical works of 
 
 the day — one which every accoucheur and physician 
 should" most carefully read: for we are persuaded 
 that he will arise from its perusal with new ideas, 
 which will induct him into a more rational practice 
 in regard to many a suffering female who may have 
 placed her health in his hands. — British American 
 Journal, Feb. 1S131. 
 
 ^EST {CHARLES), M.D. 
 
 LECTURES OX THE DISEASES OF WOMEN. Third American, 
 
 from the Third London edition. In one neat octavo volume of about 550 pages, extra 
 cloth. $3 75; leather, $4 75. {Now Ready.) 
 The reputation which this volume has acquired as a standard book of reference in its depart- 
 ment, renders it only necessary to say that the present edition has received a careful revision at 
 the hands of the author, resulting in a considerable increase of size. A few notices of previous 
 editions are subjoined. 
 
 The manner of the author is excellent, his descrip- 
 tions graphic and perspicuous, and his treatment up 
 to the level of the time— clear, precise, definite, and 
 marked by strong common sense. — Chicago Med. 
 Journal, Dec. 1861. 
 
 We cannot too highly recommend this, the second 
 edition of Dr. Wests excellent lectures on the dis- 
 eases of females. We know of no other book on this 
 subject from which we have derived as much pleasure 
 and instruction. Every page gives evidence of the 
 honest, earnest, and diligent searcher afier truth. He 
 is not the mere compiler of other men's ideas, but his 
 lectures are the result often years' patient investiga- 
 tion in one of the widest fields for women's disea-'es — 
 St. Bartholomew's Hospital. As a teacher. Dr. West 
 is simple and earnest in his lau.guage, clear and com- 
 prehensive in his perceptions, and logical in his de- 
 ductions. — Cincinnati Lancet, Jan. 1862. 
 
 We have thus embodied, in this series of lectures, 
 one of the most valuable treati.>es ou the diseases of 
 the female sexual system uncouuected with gestation, 
 in our language, aad one which cannot fail, from the 
 lucid mauner in which the various subjects have 
 been treated, and the careful discrimination used in 
 dealiug only with facts, to recommend the volume to 
 the careful study of every practitioner, as affording 
 his safest guides to practice within our knowledge. 
 We have seldom perused a work of a more thoroughly 
 practical character than the one before us. Every 
 page teems with the most truthful and accurate infor- 
 mation, and we certainly do not know of any other 
 work from which the physician, in active practice, 
 can more readily obtain advice of the soundest cha- 
 racter upon the peculiar diseases which have been 
 made the subject of elucidation. — British Am. Med. 
 Journal. 
 
 We return the author our grateful thanks for the 
 vast amount of instruction he has afforded us. His 
 valuable treatise needs no eulogy on our part. His 
 graphic diction and truthful pictures of disease all 
 speak for themselves. — Medico-Ohirurg. Sevieio. 
 
 Most justly esteemed a standard work It 
 
 bears evidence of having been carefully revised, and 
 is well worthy of the fame it has already obtained. 
 — Dub. Med. Quar. Jour. 
 
 As a writer. Dr. West stands, in our opinion, se- 
 cond only to Watsou, the "JIacaulay of Medicine;" 
 he possesses that happy faculty of clothing instruc- 
 tion in easy garments ; combining pleasure with 
 profit, he leads his pupils, in spite of tlie ancient pro- 
 verb, along a royal road to learning. His work is one 
 which will not satisfy the extreme on either side, but 
 it is one that will please the great majority who are 
 seeking truth, and one that will convince the student 
 that he has committed himself to a candid, safe, and 
 valuable guide. — N. A. 3Ied.-Chirurg Review. 
 
 We must now conclude this hastily written sketch 
 with the contideut assurance to our readers that the 
 work will well repay perusal. The conscientious, 
 painstaking, practical physician is apparent on every 
 page. — K. Y. Journal of Medicine. 
 
 We have to say of it, briefly and decidedly, that it 
 is the best work on the subject in any language, and 
 that it stamps Dr. West as the facile prineeps of 
 British obstetric authors. — Edinburgh Med. Journal. 
 
 We gladly recommend his lectures as in the highest 
 degree instructive to all who are interested in ob- 
 stetric practice. — London. Lancet. 
 
 We know of no treatise of the kind so complete, 
 and yet so compact. — Chicago Med. Journal. 
 
 B 
 
 T THE SA3IE AUTHOR. 
 
 AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF 
 
 ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. 
 
 ^IMPSON {SIR JAMES Y.), M.D. 
 CLINICAL LECTURES ON THE DISEASES OF WOMEN. With 
 
 numerous illustrations. In one octavo volume of over 500 pages. Second edition, preparing. 
 
 -DENNET {HENRY), M.D. 
 A PRACTICAL TREATISE ON INFLAMMATION OF THE 
 
 UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Dis- 
 ease. Sixth American, from the fourth and revised English edition. In one octavo volume 
 of about 500 pages, extra cloth. $3 75. {Recently Issued.) 
 From the Author'' s Preface. 
 During the past two years, this revision of former labors has been my principal occupation, and 
 in its present state the work may be considered to embody the matured experience of the many 
 years I have devoted to the study of uterine disease. 
 
 Indeed, the entire volume is so replete with infor- 
 mation, to all appearance so perfect in its details, that 
 we could scarcely have thought another page or para- 
 graph was required for the full description of all that 
 is now known with regard to the diseases under con- 
 sideration if we had not been so informed by the au- 
 
 thor. To speak of it except in terms of the highest 
 approval would be impossible, and we gladly avail 
 ourselves of the present opportunity to recommend 
 it iu the most unriualifled manner to the profession. 
 — Dublin Med. Press.
 
 24 
 
 Henry C. Lea's Publications — (llidwifery). 
 
 JJODGE [HUGH L.), 31. D., 
 
 Late Professor of Midwifery, &c. in the University of Pennsylvania, &c. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
 trated with large lithographic plates containing one hundred and fifty-nine figures from 
 original photographs, and with numerous wood-cuts. In one large and beautifully printed 
 quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. {Lately 
 published. ) 
 
 The work of Dr. Hodge is something more than a 
 simple presentation of his particular views in the de- 
 partment of Obstetrics ; it is something more than an 
 ordinary treatise on midwifery ; it is, in fact, a cyclo- 
 pjedia of midwifery. He has aimed to embody in a 
 single volume the whole science and art of Obstetrics. 
 An elaborate text is combined with accurate and va- 
 ried pictorial illustrations, so that no fact or principle 
 is left unstated or unexplained. — Am. Med. Times, 
 Sept. .3, 1S64. 
 
 We should like to analyze the remainder of this 
 excellent work, but already has this review extended 
 beyond our limited space. We cannot conclude this 
 notice without referring to the excellent fini.sh of the 
 work. In typography it is not to he excelled; the 
 paper is superior to what is usually afforded by our 
 American cousins, quite equal to the be.-^t of English 
 books. The engravings and lithographs are most 
 beautifully executed. The work recommends itself 
 for its originality, and is in every way a most valu- 
 able addition to those on the subject of obstetrics. — 
 Canada Med. Journal, Oct. 1864. 
 
 It is very large, profusely and elegantly illustrated, 
 and is fitted to take its place near the works of great 
 obstetricians. Of the American works on the subject 
 it is decidedly the best.— £(Zin6. Med. Jour., Dec. "64. 
 
 *** Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
 on receipt of six cents in postage stamps. 
 
 We have examined Professor Hodge's work with 
 great satisfaction ; every topic is elaborated most 
 fully. The views of the author are comprehensive, 
 and concisely staled. The rules of practice are judi- 
 cious, and will enable the practitioner to meet every 
 emergency of obstetric complication with confidence. 
 — Chicago Med. Journal, Aug. lSti4. 
 
 More time than we have had at our disposal since 
 we received the great work of Dr. Hodge is necessary 
 to do it justice. It is undoubtedly by far the most 
 original, complete, and carefully composed treatise 
 on the principles and practice of Obstetrics which has 
 ever been issued from the American. press. — Pacific 
 Med. and Surg. Journal, July, 1S64. 
 
 We have read Dr. Hodge's book with great plea- 
 sure, and have much satisfaction in expressing our 
 commendation of it as a whole. It is certainly highly 
 instructive, and in the main, we believe, correct. The 
 great attention which the author has devoted to the 
 mechanism of parturition, taken along with the coa- 
 clusions at which he has arrived, point, we think, 
 conclusively to the fact that, in Britain at least, the 
 doctrines of Naegele have been too blindly received. 
 — Glasgow Med. Journal, Oct. 1864. 
 
 rpANNER {THOMAS H.), M. D., _ 
 
 ON THE SIGNS AND DISEASES OF PREGNANCY. Fir.^t, American 
 
 from the Second and Enlarged English Edition. With four colored plates and illustrations 
 on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. {Now 
 Ready.) 
 
 The reputation of Dr. Tanner as a correct observer and skilful teacher is so widely known that 
 anything from his pen necessarily commands the attention of the profession. The present work 
 is one to which he has devoted especial attention in the hope of rendering it a useful guide to 
 practitioners in the important subjects of which it treats. In the systematic treatises on obstet- 
 rics and the diseases of females so little space is usually accorded to the disorders and affections of 
 the gravid state that a treatise devoted to them exclusively would seem to be a necessary addition 
 to the library of every working practitioner. The scope of the work may be judged from the 
 subjoined condensed 
 
 SUMMARY OF CONTENTS. 
 
 Chapter I. General Observations on the State of Pregnancy, — II. The Signs and Symptoms of Pregnairey. 
 — III. The Diseases which Simulate Pregnancy. — IV. The Duration of Pregnancy. — V. The Premature Ex- 
 pulsion of the Fcetus. — VI. The Examination of Substances Expelled from the Uterus, &c. — VII. Extra- 
 Uterine Gestation — VIII. Superfcetation — Missed Labor. — IX. The Diseases which may coexist with Preg- 
 nancy and their Reciprocal Influence. — X. The Sympathetic Disorders of Pregnancy. — XI. The Diseases of 
 the Urinary and Generative Organs. — XII. The Displacements of the Gravid Uterus. 
 
 M' 
 
 ONTGOMERY [W. F.), 31. D., 
 
 Professor of Midwifery in the King's and Queen''s College of Physicians in Ireland. 
 
 AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- 
 
 NANCY. With some other Papers on Subjects connected with Midwifery. From the second 
 and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. 
 In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. 
 
 JJTILLER {HENRY), 31. D., 
 
 Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 
 
 PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.; including 
 
 the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered 
 as a frequent cause of Abortion. With about one hundred illustrations on wood. In one 
 very handsome octavo volume of over 600 pages, extra cloth. $3 75. 
 
 EIGBY'S SYSTEM OF MIDWIFERY. With Notes 
 and Additional Illustrations. Second American 
 edition. One volume octavo, extra cloth, 422 pages. 
 $2o0. 
 
 DEWEES'S COMPREHENSIVE SYSTEM OF MID- 
 WIFERY. Twelfth edition, with the author's last 
 improvements and corrections. In one octavo vol- 
 ume, extra cloth, of 600 pages. $3 50.
 
 Henry C. Lea's Publications — {3Iidwifery). 
 
 25 
 
 AfEIGS {CHARLES D.), M.D., 
 
 ■^''~ Latehj Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelj)hia. 
 
 OBSTETRICS: THE SCIENCE AND THE ART. Fifth edition, 
 
 revised. With one hundred and thirty illustrations. In one beautifully printed octavo 
 volume of 760 large pages. Extra cloth, $5 50; leather, $6 50. (Now ready.) 
 The original edition is already so extensively and i practitioner. Tiie rapidity with which the very large 
 favorably known to the profession that no recom- j editions have heen exhausted is the best test of its 
 mendation is necessary ; it Is sufficient to say, the 1 true merit Besides, it is the production of an Ame- 
 present edition is very much extended, improved, rican who has probably had more experience in this 
 and perfected. Whilst the great practical talents and branch than any other living practitioner of the coun- 
 unlimited experience of the author render it a most try. — St. Louis Med. and Surg. Journal, Sept. 1S67. 
 valuable acquisition to the practitioner, it is so con- j He has also carefully endeavored to be minute and 
 
 densed as to constitute a most eligible and excellent 
 text-book for the student. — Southern Med. and Surg. 
 Journal, -Tuly, lStJ7. 
 
 It is to the student that our author has more par- 
 ticularly addressed himself; but to the practitioner 
 we believe it would be equally serviceable as a. book 
 of reference. No work that we have met with so 
 thoroughly details everything that falls to the lot of 
 tlie accoucheur to perform. Every detail, no matter 
 how minute or how trivial, has found a place. — 
 Canada Medical Journal, July, 1S67. 
 
 This very excellent work on the science and art of 
 obstetrics should be in the hands of every student and 
 
 clear in his details, with as little reiteration as possi- 
 ble, and beautifully combines the relations of science 
 to art, as far as the different classifications will admit. 
 — Detroit Review of Med and Pliarm., Aug. 1S67. 
 
 We now take leave of Dr. Meigs. There are many 
 other and interesting points in his book on which we 
 would fain dwell, but are constrained to bring our ob- 
 servations to a close. We again heartily express our 
 approbation of the labors of \)v Meigs, extending over 
 many years, and culminating in the work before us, 
 full of practical hints for the inexperienced, and even 
 for those whose experience has been considerable. — 
 GUwgoio Medical Journal, Sept. 1S67. 
 
 JDAMSBOTHAM [FRANCIS H.), M.D. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
 
 CINE ANI) SURGERY, in reference to the Process of Parturition. A new and enlarged 
 edition, thoroughly revised by the author. "With additions by W. V. Keating, M. D., 
 Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one large 
 and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
 bands ; with si.xty-four beautiful plates, and numerous wood-cuts in the text, containing in 
 all nearly 200 large and beautiful figures. $7 00. 
 
 To the physician's library it is indispensable, while 
 to the student, as a text-book, from wliich to extract 
 the material for laying the foundation of an education 
 on obstetrical science, it has no superior. — Ohio Med. 
 and Surg. Journal. 
 
 When we call to mind the toil we underwent In 
 acquiring a knowledge of this subject, we cannot but 
 envy the student of the present day the aid which 
 this work will afford him. — Am. Jour, of the Med. 
 
 We will only add that the student will learn from 
 it all he need to know, and the practitioner will find 
 it, as a book of reference, surpassed by none other. — 
 Stetho.scope. 
 
 The character and merits of Dr. Eamsbotham's 
 work are so well known and thoroughly established, 
 that comment is unnecessary and praise superfluous. 
 The illustrations, which are numerous and accurate, 
 are executed in the highest style of art. We cannot 
 
 too highly recommend the work to our readers. — St. 
 Lmuis Med. and, Surg. Journal. 
 
 ffHURCHILL [FLEETWOOD], M.D., M.R.LA. 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 
 
 American from the fourth revised and enlarged London edition. With notes and additions 
 by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
 dren," &c. AVith one hundred and ninety-four illustrations. In one very handsome octavo 
 volume of nearly 700 large pages. Extra cloth, $4 00 ; leather, $5 00. 
 In adapting this standard favorite to the wants of the profession in the United States, the editor 
 has endeavored to insert everything that his experience has shown him would be desirable for the 
 American student, including a large number of illustrations. With the sanction of the author, 
 he has added, in the form of an appendix, some chapters from a little "Manual for Midwives and 
 Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly 
 fail to prove of advantage to the junior practitioner. The result of all these additions is that the 
 •work now contains fully one-half more matter than the last American edition, with nearly one- 
 half more illustrations; so that, notwithstanding the use of a smaller type, the volume contains 
 almost two hundred pages more than before. 
 
 has been added which could be well dispensed with. 
 An examination of the table of contents shows how 
 thoroughly the author has gone over the ground, and 
 the care he has taken in the text to present the sub- 
 jects in all their bearings, will render this new edition 
 even more necessary to the obstetric student than 
 were either of the former editions at the date of their 
 appearance. No treatise on obstetrics with which we 
 are acquainted can compare favorably with this, in 
 respect to the amount of material which has been 
 gathered from every source. — Bostofi Med. and Surg. 
 Journal. 
 
 There is no better text-book for students, or work 
 of reference and study for the practising physician 
 than this. It should adorn and enrich every medical 
 library. — Chicago Med. Journal. 
 
 These additions render the work still more com- 
 plete and acceptable than ever; and with the excel- 
 lent style in which the publishers have presented 
 this edition of Churchill, we can commend it to the 
 profession with great cordiality and pleasure. — Cin- 
 cinnati Lancet. 
 
 Few works on this branch of medical science are 
 equal to it, certainly none excel it, whether in regard 
 to theory or practice, and iu one respect it is superior 
 to all others, viz., in its statistical information, and 
 therefore, on these grounds a most valuable work for 
 the physician, student, or lecturer, all of whom will 
 find in it the information which they are seeking. — 
 Brit. Am. Journal. 
 
 The present treatise is very much enlarged and 
 amplified beyond the previous editions but nothing
 
 26 
 
 Hexry C. Lea's Publications — (Surgery). 
 
 QROSS {SAMUEL I).), 31. D., 
 
 Professor of Surgery in the Jefferson 3Iedical College of Philadelphia. 
 
 A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 
 
 an<l Operative. Illustrnted by upwards of Thirteen Hundred Engravings. Fourth edition, 
 carefully revised, and improved. In two large and beautifully printed royal octavo volumes 
 of 2200 pages, strongly bound in leather, with raised bands. $15 00. 
 The continued favor, shown by the exhaustion of successive large editions of this great work, 
 proves that it has successfully supplied a want felt by American practitioners and students. Though 
 but little over six years have elapsed since its first publication, it has already reached its fourth 
 edition, while the care of the author in its revision and correction has kept it in a constantly im- 
 proved shape. By the use of a close, though very legible type, an unusually large amount of 
 matter is condensed in its pages, the two volumes containing as much as four or five ordinary 
 octavos. This, combined with the most careful mechanical execution, and its very durable binding, 
 renders it one of the cheapest works accessible to the profession. Every subject properly belonging 
 to the domain of surgery is treated in detail, so that the student who possesses this work may be 
 said to have in it a surgical library. 
 
 It must long remain the most comprehensive work 
 on thii; important part of medicine. — Boston Medical 
 and iSnrgical Journal, March 2.3, 1S6.5. 
 
 We have compared it with most of our standard 
 Works, such as tliose of Erichsen, Miller, Fergusson, 
 Syrae, and other.s, and we must, in justice to our 
 aiUhor, award it the pre-eminence. As a work, com- 
 plete in almost every detail, no matter how minute 
 or trifling, and embracing every .subject known in 
 the principles and practice of surgery, we believe it 
 stands without a rival. Dr. Gross, in his preface, re- 
 marks "my aim has been to embrace the whole do- 
 main of surgery, and to allot to every subject its 
 legitimate claim to notice;" and, we assure our 
 readers, he has kept his word. It is a work which 
 we can most confidently recommend to our brethren, 
 for its utility is becoming the more evident the longer 
 it is up'in the shelves of our library. — Canada Med. 
 Journal, September, 1863. 
 
 The first two editions of Professor Gross' System of 
 Surgery are so well known to the profession, and so 
 highly prized, that it would be idle for us to speak iu 
 praise of this work. — Chicago Medical Journal, 
 September, 1S6.5. 
 
 We gladly indorse the favorable recommendation 
 of the work, both as regards matter and style, which 
 we made when noticing its first appearance. — British 
 and. Foreign Medico-Chirurgical Review, Oct. lS6j. 
 
 The most complete work that has yet issued from 
 the press on the science and practice of surgery. — 
 London Lancet. 
 
 This system of surgery is, we predict, destined to 
 take a commanding position in our surgical litera- 
 ture, and be the crowning glory of the author's well 
 earned fame. As an authority on general surgical 
 subjects, this work is long to occupy a pre-eminent 
 place, not only at home, but abroad. We have no 
 hesitation in pronouncing it without a rival in our 
 language, and equal to the best systems of surgery in 
 any language. — N. Y. Med. Journal. 
 
 Not only by far the best text-book on the subject, 
 as a whole, within the reach of American students, 
 but one which will be much more than ever likely 
 t<i be resorted to and I'egarded as a high authority 
 abroad. — Am. Journal Med. Sciences, Jan. lS6o. 
 
 The work contains everything, minor and major, 
 operative and diagnostic, including mensuration and 
 examination, venereal diseases, and uterine manipu- 
 lations and operations. It is a complete Thesaurus 
 of modern sjurgery, where the student and practi- 
 
 ■DY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE OX THE DISEASES, INJURIES, 
 
 AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, 
 AND THE URETHRA. Second edition, revised and much enlarged, with one hundred 
 and eighty-four illustrations. In one large and very handsome octavo volume, of over nine 
 hundred pages, extra cloth. $4 00. 
 
 Wlioever will peruse the vast amount of valuable 
 practical information it contains will, we think, agree 
 wnth us, that there is no work in the English lan- 
 
 DY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 
 
 AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations, 
 pp. 468. $2 75. 
 
 tioner shall not seek in vain for what they desioe. — 
 San Francisco Med. Press, .Ian. 186.^. 
 
 Open it where we may, we find sound practical in- 
 formation conveyed in plain language. This bonk is 
 no mere provincial or even national system of sur- 
 gery, but a work which, while very largely indebted 
 to the past, has a strong claim on the gratitude of the 
 future of surgical science. — Edinburgh Med. Journal, 
 Jan. 1865. 
 
 A glance at the work is sufficient to show that the 
 author and publisher have spared no labor in making 
 it the most complete "System of Surgery" ever pub- 
 lished in any country —St. Louis Med. and Surg. 
 Journal, April, ise.j. 
 
 The third opportunity is now offered during our 
 editorial life to review, or rather to indorse and re- 
 commend this great American wcu-k on Surgery. 
 Upon this last edition a great amount of labor has 
 been expended, though to all others except the authoi 
 the work was regarded in its previous editions as so 
 full and complete as to be hardly capable of improve- 
 ment. Every chapter has been revised; the text aug- 
 mented by nearly two hundred pages, and a con 
 siderable number of wood-cuts have been introduced. 
 Many portions have been entirely re-written, and the 
 additions made to the text are principally of a prac- 
 tical character. This comprehensive treatise upon 
 surgery has undergone revisions and enlargements, 
 keeping pace with the progress of the art and science 
 of surgery, so that whoever is in possession of this 
 work may consult its pages upon any topic embraced 
 within the scope of its department, and rest satisfied 
 that its teaching is fully up to the present standard 
 of surgical knowledge. It is also so comprehensive 
 that it may truthfully be said to embrace all that is 
 actually known, thai is really of any value in the 
 diagnosis and treatment of surgical diseases and acci- 
 dents. Wherever illustration will add clearness to the 
 subject, or make better or more lasting impression, it 
 is not wanting; in this respect the work is eminently 
 superior. — Buffalo Med. Jotirnal, Dec. 1864. 
 
 A system of surgery which we think unrivalled in 
 our language, and which will indelibly associate his 
 name with surgical science. And what, in our opin- 
 ion, enhances the value of the work is that, while the 
 practising surgeon will find all that he requires in it, 
 it is at the same time one of the most valuable trea- 
 tises which can be put into the hands of the student 
 seeking to know the principles and practice of this 
 branch of the profession which he designs subse- 
 quently to follow.— r/ie Brit. Am. Journ., Montreal. 
 
 guage which can make any just pretensions to be its 
 equal. — N. Y. Journal of Medicine.
 
 Henry C. Lea's Publications — {Surgery). 
 
 27 
 
 JpRICHSEN [JOHN], 
 
 -LJ Professor of Surgery in University College, London. 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 
 
 gical Injuries, Diseases, and Operations. New and improved American, from the Second 
 
 enlarged and carefully revised London edition. Illustrated with over four hundred wood 
 
 engravings. In one large and handsome octavo volume of 1000 closely printed pages ; extra 
 
 cloth, $6 ; leather, raised bands, $7. 
 
 We are bound to slate, and we do .so without wish- as one of the very best, if not the best text-book of 
 
 ing to draw invidious comparisons, that the worlf of surgery with which we were acquainted, permits us 
 
 Jlr. Erichsen, in most respects, surpasses any that to give it but a passing notice totally unworthy of its 
 
 has preceded it. Mr. Erichsen's is a practical worli, merits. It may be confidently asserted, that no work 
 
 combining a due proportion of the "Science and Art ou the science and art of surgery has ever received 
 
 of Surgery." Having derived no little instruction more universal commendation or occupied a higher 
 
 from it, in many important branches of surgery, we 
 can have no hesitation in recommending it as a valu- 
 able book alike to the practitioner and the student. 
 — Dublin Quarterly. 
 
 position as a general text-book on surgery, than this 
 treatise of Professor Erichsen. — Savannah Journal of 
 Medicine. 
 In fulness of practical detail and perspicuity of 
 
 Gives a very admirable practical view of the sci- style, convenience of arrangement and soundness of 
 
 ence and art of surgery. — Edinburgh Med. and Surg. 
 Journal. 
 
 We recommend it as the best compendium of sur- 
 gery in our language — London Lancet. 
 
 It is, we think, the most valuable practical work 
 on surgery in existence, both for young and old prac- 
 titioRevs.— Nashville Med. and Surg. Journal. 
 
 The limited time we have to review this improved 
 edition of a work, the first issue of which we prized Journal. 
 
 discrimination, as well as fairness and completeness 
 of discussion, it is better suited to the wants of both 
 student and practitioner than any of its predecessors. 
 — Am. Journal of Med. Sciences. 
 
 After careful and frequent perusals of Erichsen's 
 surgery, we are at a loss fully to express our admira- 
 tion of it. The author's style is eminently didactic, 
 and characterized by a most admirable directness, 
 clearness, and compactness. — Ohio Med. and Surg. 
 
 B 
 
 Y THE SAME AUTHOR. {Ready in June.) 
 
 ON RAILWAY, AND OTHER INJURIES OF THE NERVOUS 
 
 SYSTEM. In small octavo volume. Extra cloth, $1 GO. 
 
 We welcome this as perhaps the most practically I to the profession in general, many of whom may be 
 useful treatise written for many a day. — Medical \ consulted in such cases; and it will, no doubt, take 
 Ximes. i'-'' place as a text-book on the subject of which it 
 
 It will serve as a most useful aud trustworthy guide | treats.— -ilfedtcai Press. 
 
 IXflLLER [JAMES], 
 
 JjJL Late Profe.ssor of Surgery in the University of Edinburgh, &c. 
 
 PRINCIPLES OF SURGERY. Fourth American, from the third and 
 
 revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
 two hundred and forty illustrations on wood, extra cloth. $3 75. 
 
 r THE SAME AUTHOR. 
 
 B 
 
 THE PRACTICE OF SURGERY. Fourth American, from the Last 
 
 Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
 
 sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra 
 
 cloth. $3 75. 
 
 It is seldom tliat two volumes have ever made so I acquired. The author is an eminently sensible, prac- 
 
 profound an impression in so short a time as the | tical, and well-informed man, who knows exHctly 
 
 "Principles" and the "Practice" of Surgery by Mr 
 Miller, or so richly merited the reputation they have 
 
 wliat he is talking about and exactly how to talk it. — 
 Kentucky Medical Recorder. 
 
 P 
 
 IRE IE ( WILLIAM), F. R. S. E.. 
 
 Professor of Surgery in the University of Aberdeen. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 
 
 John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
 Pennsylvania Hospital, <fec. In one very handsome octavo volume of 780 pages, with 316 
 illustrations, extra cloth. $3 75. 
 
 8- 
 
 'ARGENT [F. W.), M.D. 
 
 ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- 
 GERY. New edition, with an additional chapter on Military Surgery. One handsome royal 
 12mo. volume, of nearly 400 pages, with 184 wood-cuts- Extra cloth, $1 75. 
 Exceedingly convenient and valuable to all mem- 1 Wo cordially commend this volume as one which 
 bers of the profession.— C/iico^ry Medical Examiner, \ the medical student should most closely study; and 
 May, 1862. 1 to the surgeon in practice it must prove itself instruct- 
 
 _,' , . 1 r «r- a , i,„^« ive on many points which he may have forgotten. — 
 
 The very best tnanual of Minor Surgery we have ^ /J^^^,i, May. 1862. 
 
 seen. — Buffalo Medical Journal. i ^i •-. , j 
 
 MALGAIGNE'S OPERATIVE SURGERT. With nu- 
 merous illustrations on wood. In oue handsome 
 octavo volume, extra cloth, of nearly 600 pp. $2 50. 
 
 SKET'S OPERATIVE SURGERT. In one very hand- 
 some octavo volume, extra cloth, of over 650 pages, 
 with about 100 wood-cuts. $3 25.
 
 28 
 
 Henry C. Lea's Publications — (Surgery). 
 
 J^RDITT\ROBERT), 3LR.C.S., Sfc. 
 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 
 
 A new and revised American, from the eighth enlarged and improved London edition. Illus- 
 trated with four hundred and thirty -two wood-engravings. In one very handsome octavo 
 volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00 ; leather, $5 00. 
 Besides the careful revision of the author, this work has had the advantage of very thorough 
 editing on the part of a competent surgeon to adapt it more completely to the wants of the Ameri- 
 can student and practitioner. Many illustrations have been introduced, and every care has been 
 taken to render the mechanical execution unexceptionable. At the very low price affixed, it will 
 therefore be found one of the most attractive and useful volumes accessible to the American 
 practitioner. 
 
 AH that the surgical student or practitioner could i theoretical surgical opinions, no work that we are at 
 dei-ire.— Dublin Quarterly Journal. i present acquainted with can at all compare with it. 
 
 It is a most admirable book. We do not know ' It is ^ compendium of surgical theory (if we mayn^e 
 
 when we have examined one with more pleasure. ' '^* word) and practice iu itself, and well deserves 
 
 Boston Med. and Surg. Journal. \ tbe estimate placed upon it. — Brit. Am. Journal. 
 
 In Mr. Druitt's book, though containing only some ! Thus enlarged and improved, it will continue to 
 seven hundred pages, both the principles and the rank among our best texi-books on elementary sur- 
 practice of surgery are treated, and so clearly and '• g'irV—ColumUis Rev. of Med. and Surg. 
 perspicuously, as to elucidate every important topic, j We must close this brief notice of an admirable 
 The fact that twelve editions have already been called work by recommending it to the earnest attention of 
 for, in these days of active competition, would of ex e\-y mBdica.\st\xdi^nt.— Charleston Medical Journal 
 itself show it to possess marked superiority. We and' Review. 
 
 have examined the book most thoroughly, and can 
 say that this success is well merited. His book, 
 moreover, possesses the inestimable advantages of 
 having the subjects perfectly well arranged and clas- 
 sified, and of being written in a style at once clear 
 and succinct. — Am. Journal of Med,. Sciences. 
 
 Whether we view Druitt's Surgery as a guide to need any furthe"^r eulogium from us 
 operative procedures, or as representing the latest Journal. 
 
 A text-book which the general voice of the profes- 
 sion in both England and America has commended aa 
 one of the most adrairable "manuals," or, "vade 
 mecura," as its English title runs, which can be 
 placed in the hands of the student. The merits of 
 Druitt's Surgery are too well known to every one to 
 
 Nashville Med. 
 
 JJAMILTON [FRANK H.), M.D., 
 
 Professor of Fractures and Dlilocntions, &c. in Bellevue Hosp. Med. College, New TorTi. 
 
 A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
 TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume 
 of 777 pages, with 294 illustrations, extra cloth, $5 75. {Just Issued.) 
 The demand which has so speedily exhausted two large editions of this work shows that the 
 author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise 
 on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad 
 as well as at home, has pronounced it the most complete work to which the surgeon can refer for 
 information respecting all details of the subject. In the preparation of this new edition, the 
 author has sedulously endeavored to render it worthy a continuance of the favor which has been 
 accorded to it, and the experience of the recent war has afforded a large amount of material which 
 he has sought to turn to the best practical account. 
 
 In fulness of detail, simplicity of arrangement, and American professor of surgery; and his book adds 
 accuracy of description, this work stands unrivalled, one more to the list of excellent practical works which 
 So far as we know, no other work on the subject in have emanated from his country, notices of which 
 the English language can be compared with it. While have appeared from time to time in our columns du- 
 congratulating our trans-Atlantic brethren on the ring the last few months.— iondow Lancet, Dec. 15, 
 European reputation which Dr. Hamilton, along with ISBti. 
 
 many other American surgeons, has attained, we also ' These additions make the work much more valua- 
 may be proud that, in the mother tongue, a classical , ble, and, it must be accepted as the most complete 
 work has been produced which need not fearcompa- monograph on the subject, certainly in our own, if 
 rison with the standard treatises of any other nation, not even in any other language.— America?! Journal 
 —Edinburgh Med. Journal, Dec. lS6ii. j Med. Sciences, Jan. 1S67. 
 
 The credit of giving to the profession the only com ! '^^'^^ '* "^e most complete treatise on the subject in 
 plete practical treatise on fractures and dislocations "^^ ^°slisb language.— iJa?i*i?26r'*.464-^rrtrt, .Tan. 1S67. 
 in our language during the present century, belongs ' A mirror of all that is valuable in modern surgery 
 to the author of the work before us, a distinguished Richmond Med. Journal, Nov. 1S66. 
 
 B 
 
 ARWELL [RICHARD), F. R. C. S., 
 
 Assistant Surgeon Charing Cross Hospital, &e, 
 
 A TREATISE ON DISEASES OF THE JOINTS. Illustrated with 
 
 engravings on wood. In one very handsome octavo volume of about 500 pages ; extra cloth, 
 
 BRODIE'S CLINICAL LECTURES ON SURGERY. 
 1 vol. Svo., 350 pp.; cloth, $1 25. 
 
 COOPER ON THE STRUCTURE AND DISEASES OF 
 THE Testis, aitd o.n the Thymus Gland. One vol. 
 imperial Svo., extra cloth, with 177 figures on 29 
 plates. $2 50. 
 
 COOPER'S LECTURES ON THE PRINCIPLES AND 
 Practice of Sdrgerv. In one very large octav-o 
 volume, extra cloth, of 750 pages. $2 OO" 
 
 GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
 oicRV. Eighth edition, improved and altered. With 
 thirty-four plates. In two handsome octavo vol- 
 umes, abourlOOO pages, leather, raised bauds. $6 50.
 
 Henry C. Lea's Publications — {Surgery). 
 
 29 
 
 rpOYNBEE [JOSEPH], F.R.S., 
 
 -L Aural Surgeon to and Lecturer on Surgery at St. Mary^s Hospital. 
 
 THE DISEASES OF THE EAR: their Nature, Diagnosis, and Treat- 
 
 ment. With one hundred engravings on wood. Second American edition. In one very 
 handsomely printed octavo volume of 440 pages ; extra cloth, $4. 
 
 The appearance of a volume of Mr. Toynbee's, there- 
 fore, in which the subject of aural disease is treated 
 in the most scientific manner, and our knowledge in 
 respect to it placed fully on a par with that which 
 we possess respecting must other organs of the body, 
 is a matter for sincere congratulation. We may rea- 
 sonably hope that henceforth the subject of this trea- 
 tise will cease to be among the opprobria of medical 
 science. — London Medical Review. 
 
 The work, as was stated at the outset of our notice, 
 is a model of its kind, and every page and paragraph 
 of it are worthy of the most thorough study. Con- 
 sidered all in all — as an original work, well written, 
 philosophically elaborated, and happily illustrated 
 with cases and drawings — it is by far the ablest mo- 
 nograph that has ever appeared on the anatomy and 
 diseases of the ear, and one of the most valuable con- 
 tributions to the art and science of surgery in the 
 nineteenth century. — N. Am. Med.-Chirurg. Eeview. 
 
 T AURENCE [JOHN Z.), F. R. C. S., and llfOON {ROBERT C), 
 
 ■^ Editor of the OpWialmic Eevieio, &c. -^-^ House Surgeon to the Southwark Opft- 
 
 thalraic Hospital, &c. 
 
 A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 
 
 Practitioners. With numerous illustrations. In one very handsome octavo volume, extra 
 cloth. $2 50. {Just Issued.) 
 
 No book on ophthalmic surgery was more needed. 
 Designed, as it is, for the wants of the busy practi- 
 tioner, it is the ne plus ultra of perfection. It epito- 
 mizes all the diseases incidental to the eye in a clear 
 and masterly manner, not only enabling the practi- 
 tioner readily to diagnose each variety of disease, but 
 affording him the more imporlant assistance of proper 
 treatment. Altogether this is a work which ought 
 certainly to be in the hands of every general practi- 
 tioner. — Dublin Med. Press and Circular, Sept. 12, 'G6. 
 
 We cordially recommend this book to the notice of 
 our readers, as containing an excellent outline of 
 modern ophthalmic surgery. — British Med. Journal, 
 October 13, 1S66. 
 
 Not only, as its modest title suggests, a "Handy- 
 Book" of Ophthalmic Surgery, but an excellent and 
 well-digested r^sumi of all that is of practical value 
 in the specialty. — New York Medical Journal, No- 
 vember, 1866. 
 
 This object the authors have accomplished in a 
 highly satisfactory manner, and we know no work 
 we can more highly recommend to the "busy practi- 
 tioner" who wishes to make himself acquainted with 
 the recent improvements in ophtlialmic science. Such 
 a work as this was much wanted at this time, and 
 this want Messrs. Laurence and Moon have now well 
 supplied. ^.4m. Journal Med. Sciences, Jan. 1867. 
 
 TA WSON [GEORGE], F. R. C. S., Engl. 
 
 -'--' Assistant Surgeon to the Royd London Ophthalmic Hospital, Moorfields, &c. 
 
 INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 
 
 diate and Remote Effects. With about one hundred illustrations. In one very hand- 
 some octavo volume, extra cloth, $3 50. {Now Ready.) 
 This work will be found eminently fitted for the general practitioner. In cases of functional 
 or structural diseases of the eye. the physician who has not made ophthalmic surgery a special 
 study can, in most instances, refer a patient to some competent practitioner. Cases of injury, 
 however, supervene suddenly and usually require prompt assistance, and a work devoted espe- 
 cially to them cannot but prove essentially useful to those who may at any moment be called upon 
 to treat such accidents. The present volume, as the work of a gentleman of large experience, 
 may be considered as eminently worthy of confidence for reference in all such emergencies. 
 It is an admirable practical hook in the highest and fulness of practical knowledge. We predict for M». 
 
 best sense of the phrase. Copiously illusirated by 
 excellent woodcuts, and with well-selected, well- 
 described cases, it is written in plain, simple lan- 
 guage, and in a style the transparent clearness and 
 
 Lawson's work a great and well-merited success. 
 We are confident that the profession, and especially, 
 as we have said, our country brethren, will feel 
 grateful to him for having given them in it a guide 
 
 frankness, so to speak, of which, add greatly to its ; and counsellor fully up to the most advanced state of 
 value and usefulness. Only a master of his subject j Ophthalmic Surgery, and of whom they can make a 
 could so write; every topic is handled with an ease, ' trusty aud familiar friend. — London Medical Times 
 decision, and straightforwardness, that show the j and Gazette, May 18, 1807. 
 skilful and highly educated surgeon writing from I 
 
 J 
 
 'ONES [T. WHARTON], F R. S., 
 
 Professor of Ophthalmic Med. and Sarg. in University College, London. 
 
 THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDI- 
 CINE AND SURGERY. With one hundred and seventeen illustrations. Third and re- 
 vised American, with Additions from the second London edition. In one handsome octavo 
 volume of 465 pages, extra cloth. $3 25, 
 
 JlfAGKENZIE [W.], 31. D., 
 
 JJjL Surgeon Oculist in Scotland in ordinary to her Majesty, &c. 
 
 A PRACTICAL TREATISE ON DISEASES AND INJURIES OF 
 
 THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal 
 Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the fourth 
 revised and enlarged London edition. With Notes and Additions by Addinell Hewson, 
 M. D., Surgeon to Wills Hospital, Ac. Ac. In one very large and handsome octavo volume 
 of 1027 pages, extra cloth, with plates and numerous wood-cuts. $6 50.
 
 30 Henry C. Lea's Publications — {Surgery). 
 
 -LyALES [PHILIP S.), 31. D., Surgeon U. S. N. 
 
 MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical 
 
 Apparatus, Appliances, and Elementary Operations : embracing Minor Surgerj'. Band- 
 aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred 
 and forty-two illustrations on wood. In one large and handsome octavo volume of about 
 700 pages: extra cloth, $5 75; leather, §6 75. {Now Ready.) 
 The author has attempted in this volume to supply a want which has been generally felt by 
 students and practitioners of a work which should present, minutely, but concisely, the various 
 details in surgical operations, which are apt to be passed over in systematic treatises. It falls 
 to the lot of comparatively few surgeons to perform the major operations, but every physician, 
 especially in the country, is liable at any moment to be called upon to remedy some accident or 
 to prevent some deformity, and the aim of the present treatise is to present that kind of informa- 
 tion with such detail that it may be regarded as an unfailing book of reference. The very com- 
 plete series of illustrations renders the whole easy of comprehension by the student, while the 
 author's practical experience in the naval service, and the care with which he has collected the 
 results of the latest authorities, at home and abroad, give assurance of the value of his teachings. 
 A very condensed summary is subjoined of the 
 
 OOISTTEnSTTS. 
 
 PART I. Of the Apparatus of Dressing. 
 
 Chap. I. Of the Instruments of Dressing. — II. Of the First Pieces of Dressing. — III. On the 
 Use of some Topical Remedies. — IV. On the Use of iVater in Surgical Dressings and Inju- 
 ries. — v. Injections. — VI. On the Use of Gases and Vapors. — VII. Bandages. — VIII. 
 Special or Regional Bandaging. 
 PART II. Mechasical Bandages and Apparatus. 
 
 Chap. I. Apparatus for Remeilj'ing Loss of Parts. — II. Apparatus for Remedying Loss of 
 Function. — III. Apparatus for Remedying Loss of Symmetry. 
 PART III. Fractures; their Reduction, Dressing, and Apparatus. 
 
 Chap. I. General Consideration of Fractures. — II. Fractures of Particular Bones. 
 PART IV. Dislocations; their Reduction, Dressing, and Apparatus. 
 
 Chap. I. Sprains or Strains. — II. Dislocations in General. — III. Particular Dislocations. 
 PART. V. The Minor Operations of Surgery. 
 
 Chap. I. Rubefaction. — II. Vesication. — III. Cauterization. — IV. Moxa. — V. Issues. — VI. 
 Setons, — VII. Acupuncture and Electropuncture. — VIII. Puncturing. — IX. Vaccination. 
 — X. Incisions. — XI. Bloodletting. — XII. Extraction of Teeth. — XIII. Catheterism — 
 XIV. Removal of Foreign Bodies. — XV. On the Modes of Arresting Hemorrhage. — XVI. 
 On the Dressings of Wounds. — XVII. Anaesthesia. 
 
 The adoption of this work for use in both the Army and Navy of the United States is a sufB- 
 cient guarantee of its usefulness to the practitioner. 
 
 A SET ON [T. J.) 
 ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 
 
 THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, 
 from the fourth and enlarged London edition. With handsome illustrations. In one very 
 beautifully printed octavo volume of about 300 pages. $3 25. {Just Issued.) 
 
 We can recummend thi.s volume of Jlr Ashton"^ in 
 the strongest terms, as containing all the latest details 
 of the patliol igy and treiitment of diseases connected 
 with the rectum. — Canada yied. Journ., March, 1S66. 
 
 One of the most valuable special treatise* that the 
 physician and surgeon can have in his library. — 
 Chicago Medical Exaiiiinur, Jan. 1S66. 
 
 The short period which has elapsed since the ap- 
 pearance of the former American reprint, and the 
 numerous editions published in England, are the best 
 arguments we can offer of the merits, aud of the u.-^e- 
 lessness of any commendation on our part of a book 
 already so favorably known to our readers. — Boston 
 Med. and Surg. Journal, Jan. 2.5, l&b6. 
 
 liTORLAND (ir. W.), M.D. 
 
 DISEASES OF THE URINARY ORGANS; a Corapendinm of their 
 
 Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome 
 octavo volume of about 600 pages, extra cloth. $3 50. 
 Taken as a whole, we can rpcornniend Dr. Morland's I of every medical or surgical practitioner. — Brit, and 
 compendiumasaveryde.-5iraljleadditiuu to the library j For. Med.-Chir. Review, April, 18.59. 
 
 fJURLING {T.B.), F.R.S., 
 
 Surgeon to the London Ilo.spitol, Presideiit of the Hunterinn Society, &'c. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, 
 
 SPERMATIC CORD, AND SCROTUM. Second American, from the second and enlarged 
 English edition. In one handsome octavo volume, extra cloth, with numerous illustra- 
 tions, pp. 420. $2 00.
 
 Henry C. Lea's Publications — {Medical Jurisprudence, &c.). 31 
 rPAYLOR [ALFRED S.), M.D., 
 
 -*■ Lecturer on Med. Jurisp. and Chemistry in Gny's Hospital. 
 
 MEDICAL JURISPRUDENCE. Sixth American, from the eighth 
 
 and revised London edition. With Notes and References to American Decisions, by Cle- 
 ment B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, 
 extra cloth, $4 50 ; leather, $5 50. {Now Ready.) 
 Considerable additions have been made by the editor to this edition, comprising some important 
 sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence," 
 as -well as references to American law and practice. The notes of the former editor, Dr. Harts- 
 horne, have likewise been retained, and the whole is presented as fully worthy to maintain the 
 distinguished position which the work has acquired as a leading text-book and authority on the 
 subject. 
 
 A new edition of a work aclcnowledged as a stand- 
 ard authority everywliere witliiu tlie range of tlie 
 Euglisii languiige. Considering tiie new matter intro- 
 duced, on trichiniasis and other subjects, and the 
 plates representing the crystals of poisons, etc., it may 
 fairly be regarded as the most compact, comprehen- 
 sive, and practical work on medical jurisprudence 
 which has issued from the press, and the one best 
 fitted for students. — Pacific Med. and Surg. Journal, 
 Feb. 1S57. 
 
 The sixth edition of this popular work comes to us 
 in charge of a new editor, Mr. Penrose, of the Phila- 
 delphia bar, who has done much to render il useful, 
 not only to the medical practitioners of this country, 
 but to those of his own profession. Wisely retaining 
 the references of the former American editor. Dr. 
 Hartshorne, he has added many valuable notes of his 
 own. The reputation of Dr. Taylor's work is so well 
 established, that it needs no recommendation. He is 
 now the highest living authority on all matters con- 
 nected with forensic medicine, and every successive 
 edition of his valuable work gives fresh assurance to 
 his many admirers that he will continue to maintain 
 his well-earned position. No one should, in fact, be 
 without a text-book on the subject, as he does not 
 
 know but that his next case may create for him an I day, on the peculiar province of medicine on which 
 emergency for its u.se. To those who are not the for- j it treats. The American editor. Dr. Hartshorne, has 
 tunate possessors of a reliable, readable, interesting, | done his duty to the text, and, upon the whole, we 
 and thoroughly practical work upon the subject, we | cannot but consider this volume the best and richest 
 would earnestly recommend this, as forming the best treatise on medical jurisprudence in our language. — 
 groundwork for all their future studies of the more I Brit. Am. Med. Journal. 
 
 elaborate treatises. — JVeto Torlc Medical Record, Feb. 
 1.1, 1S67. 
 
 The present edition of this valuable manual is a 
 great improvement on those which have preceded it. 
 Some admirable instruction on the subject of evidence 
 and the duties and responsibilities of medical wit- 
 nesses has been added by the distinguished author, 
 and some fifty cuts, illustrating chiefly the crystalline 
 forms and microscopic structure of sub.stanees used 
 as poisons, inserted. The American editor has also 
 introduced several chapters fronv Dr. Taylor's larger 
 work, "The Principles and Practice of Medical Juris- 
 prudence," relating to trichiniasis, sexual malforma- 
 tion, insanity as afl'ecting civil responsibility, suicidal 
 mania, and life insurance, &c., which add considerably 
 to its value. Besides this, he has introduced nume- 
 rous references' to cases which have occurred in this 
 country. It makes thus by far the best guide-book 
 in this department of medicine for students and the 
 general practitioner in our language. — Boston Med. 
 and. iSurg. Journal, Dec. 27, ISBti. 
 
 Taylor's Medical Jurisprudence has been the text- 
 book in our colleges for years, and the present edi- 
 tion, with the valuable additions made by the Ameri- 
 can editor, render it the most standard work of the 
 
 T^INSLOW [FORBES], M.D., D.G.L., ^x. 
 
 ON OBSCURE DISEASES OF TIIE BRAIN AND DISORDERS 
 
 OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
 phylaxis. Second American, from the third and revised English edition. In one handsome 
 octavo volume of nearly 600 pages, extra cloth. $4 25. (Jicst Issued.) 
 
 Of the merits of Dr. Winslow's treatise the profes- 
 Bion has sufficiently judged. It has taken its place in 
 the front rank of the works upon the special depart- 
 ment of practical medicine to which it pertains. — 
 Cincinnati Journal of Medicine, March, 1866. 
 
 It is an interesting volume that will amply repay 
 for a careful perusal by all intelligent readers. — 
 Chicago 3Ied. Examiner, Feb. 1S66. 
 
 A work which, like the present, will largely aid 
 the practitioner in recognizing and arresting the first 
 insidious advances of cerebral and mental disease, is 
 one of immense practical value, and demands earnest 
 attention and diligent study on the part of all who 
 have embraced the medical profession, and have 
 thereby undertaken responsibilities in which the 
 welfare and happiness of individuals and families 
 are largely involved. We shall therefore close this 
 brief and necessarily very imperfect notice of Dr. 
 Winslow's great and classical work by expressing 
 
 our conviction that it is long since so important and 
 beautifully written a volume has issued from the 
 British medical press. The details of the manage- 
 ment of confirmed cases of insanity more nearly in- 
 terest those who have made mental diseases their 
 special study ; but Dr. Winslow's masterly exposi- 
 tion of the early symptoms, and his graphic descrip 
 tions of the insidious advances of incipient insanity, 
 together with his judicious observations on the treat- 
 ment of disorders of the mind, should, we repeat, be 
 carefully studied by all who have undertaken the 
 responsibilities of medical practice. — Dublin Medical 
 
 It is the most Interesting as well as valuable book 
 that we have seen for a long time. It is truly fasci- 
 nating — Am. Jour. Med. Sciences. 
 
 Dr. Winslow's work will undoubtedly occupy an 
 unique position in the medico-psychological litera- 
 ture of this country. — London Med. Review. 
 
 L 
 
 EA [HENRY C.) 
 SUPERSTITION AND FORCE: ESSAYS ONT TFIE WAGER OF 
 
 LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. In one hand- 
 some volume royal 12mo., of 406 pages ; extra cloth, $2 50. 
 
 The copious collection of facts by which Mr. Lea has 
 illustrated his subject shows in the fullest manner the 
 constant contlict and varying success, the advances 
 and defeats, by which the progress of humane legisla- 
 tion has been and is still marked. This work fills up 
 with the fullest exemplification and detail the wise 
 remarks which we have quoted above. As a book of 
 ready reference on the subject it is of the highest 
 value. — Westminster Review, Ocl. 1867. 
 
 When — half in spite of himself, as it appears — he 
 sketches a scene or character in the history of legalized 
 
 a humor so fine and good, that he makes us regret it 
 was not within his intent, as it was certainly within 
 his power, to render the whole of his thorough work 
 more popular in manner. — Atlantic Monthly, Feb. '67. 
 This is a book of extraoi'dinary research. Mr. Lea 
 has entered into his subject con a-more ; and a more 
 striking record of the cruel superstitions of our un- 
 happy Middle Ages could not possibly have been com- 
 piled. ... As a work of curious inquiry on certain 
 outlying points of obsolete law, "Superstition and 
 Force" is one of the most remarkable books we have 
 
 wror and cruelty, he betrays so artistic a feeling, and I met with. — London Athenceujn, Nov. 3, 1S66.
 
 32 
 
 Henry C. Lea's Publications. 
 
 INDEX TO CATALOGUE, 
 
 Abel and Bloxam's Handbook of Chemistry 
 Allen's Dissector and Practical Anatomist 
 American Journal of the Medical Sciences 
 Abstract, Half- Yearly, of the Med. Sciences 
 Anatomical Atlas, by Smith and Horner 
 Ashton on the Rectum and Anus . 
 Ashwell on Diseases of Females . 
 Brinton on the Stomach 
 Barclaj^'s Medical Diagnosis . 
 Barlow's Practice of Medicine 
 Barwell on the Joints . 
 Bennet (Henry) on Diseases of the Uterus 
 Bowman's (John E. ) Practical Chemistry 
 Bowman's (John E.) Medical Chemistry 
 Brande & Taylor's Chemistry 
 Brodie's Clinical Lectures on Surgery . 
 Brown on the Surgical Diseases of Women 
 Buckler on Bronchitis .... 
 Bucknill and Tuke on Insanity 
 Budd on Diseases of the Liver 
 Bumstead on Venereal .... 
 Bumstead and Cnllerier's Atlas of Venereal 
 Carpenter's Human Physiology . 
 Carpenter's Comparative Physiology . 
 Carpenter on the Microscope 
 Carpenter on the Use and Abuse of Alcohol 
 Carson's Synopsis of Materia Medica . 
 Chambers on the Indigestions 
 Christison and Griffith's Dispensatory 
 Churchill's System of Midwifery . 
 Churchill on Diseases of Females 
 Churcliill on Puerperal Fever 
 
 Clymer on Fevers 
 
 Colombat de I'lsere on Females, by Meigs 
 Condie on Diseases of Children 
 Cooper's (B. B.) Lectures on Surgery . 
 Cooper (Sir A. P.) on the Testis, &c. . 
 CuUerier's Atlas of Venereal Diseases 
 Curling on Diseases of the Testis . 
 Cyclopedia of Practical Medicine . 
 Baltou's Human Physiology . 
 De Jongh on Cod-Liver Oil 
 Dewees's System of Midwifery 
 Dewees on Diseases of Females 
 Dewees on Diseases of Children . 
 Dickson's Practice of Medicine 
 Druitt's Modern Surgery 
 Dunglison's Medical Dictionary . 
 Dunglison's Human Physiology . 
 Duuglison on New Remedies 
 Dunglison's Therapeutics and Materia Med 
 Ellis's Medical Formulary, by Thomas 
 Erichsen's System of Surgery 
 Erichsen on Nervous Injuries 
 Flint on Respiratory Organs . 
 
 Flint on the Heart 
 
 Flint's Practice of Medicine . 
 Fownes's Elementary Chemistry . 
 Fuller on the Lungs, &c. 
 Gardner's Medical Chemistry 
 
 Gibson's Surgery 
 
 Gluge's Pathological Histology, by Leidy 
 Grai)am's Elements of Chemistry . 
 
 Gray's Anatomy 
 
 Griliith's (R. E.) Universal Formulary . 
 Griffith's (J. W.) Manual on the Blood, &c. 
 Gross on IJrinary Organs 
 Gross on Foreign Bodies in .\ir-Passages 
 Gross's Principles and Practice of Surgery 
 Gross's Pathological Anatomy 
 Hartshorne's Essentials of Medicine . 
 Habershon on Alimentary Canal . 
 Hamilton on Dislocations and •■ ractures 
 Harrison on the Nervous Sysie:_ . 
 Hoblyn's Medical Dictionary 
 
 Hodge on Women 
 
 Hodge's Obstetrics 
 
 Hodge's Practical Dissections 
 Holland's Medical Notes and Reflections 
 Horner's Anatomy and Histology 
 Hudson on Fevers, .... 
 
 Hughes on Auscultation and Percussion 
 Hillier's Handbook of Skin Diseases 
 
 PAGE 
 
 11 
 
 6 
 1 
 3 
 6 
 30 
 22 
 17 
 16 
 15 
 28 
 23 
 10 
 10 
 10 
 28 
 22 
 18 
 19 
 19 
 18 
 IS 
 8 
 S 
 8 
 13 
 13 
 17 
 13 
 25 
 22 
 22 
 IS 
 22 
 21 
 28 
 28 
 18 
 30 
 1.) 
 9 
 13 
 2-t 
 22 
 21 
 16 
 28 
 4 
 9 
 11 
 11 
 12 
 27 
 27 
 17 
 17 
 1,5 
 11 
 16 
 11 
 28 
 11 
 10 
 6 
 12 
 19 
 26 
 26 
 26 
 14 
 16 
 17 
 28 
 19 
 4 
 23 
 24 
 7 
 15 
 6 
 17 
 18 
 20 
 
 Jones's (T. W.) Ophthalmic Medicine and Surg 
 
 Jones and Sieveking's Pathological Anatomy 
 
 Jones (C. Handfield) on Nervous Disorder 
 
 Kirkes' Physiology .... 
 
 Knapp's Chemical' Technology 
 
 Lea's Superstition and Force 
 
 Lallemand and Wilson on Spermatorrhoja 
 
 La Roche on Yellow Fever . 
 
 La Roche on Pneumonia, &c. 
 
 Laurence and Moon's Ophthalmic Surgery 
 
 Lawson on the Eye .... 
 
 Laycock on Medical Observation . 
 
 Lehmann's Physiological Chemistry, 2 vol 
 
 Lehmaun's Chemical Physiology . 
 
 Ludlow's Manual of Examinations 
 
 Lyons on Fever 
 
 Maclise's Surgical Anatomy . 
 Malgaigne's Operative Surgery, by Brittan 
 Markwick's Examination of Urine 
 Mayne's' Dispensatory and Formulary 
 Mackenzie on Diseases of the Eye 
 Medical N^ews and Library . ' . 
 I Meigs's Obstetrics, the Science and the Art 
 Meigs's Letters on Diseases of Women 
 Meigs on Puerperal Fever 
 Miller's System of Obstetrics 
 Miller's Practice of Surgery . 
 Miller's Principles of Surgery 
 Montgomery on Pregnancy . 
 Morland on Urinary Organs . 
 Morland on Ursemia 
 
 Neill and Smith's Compendium of Med. Sc 
 Neligan's Atlas of Diseases of the Skin 
 Neligan on Diseases of the Skin . 
 Prize Essays on Consumption 
 Parrish's Practical Pharmacy 
 Peaslee's Human Histology . 
 Pirrie's System of Surgery 
 Pereira'sMat. Medica and Therapeutics, abridge 
 Quain and Sharpey's Anatomy, by Leidy 
 Rauking's Abstract .... 
 
 Roberts ou Urinary Diseases . 
 Ramsbothara on Parturition . 
 Reese on Blood and Urine 
 Rigby on Female Diseases 
 
 Rigby's Midwifery 
 
 Rokitansky's Pathological Anatomy . 
 
 Royle's Materia Medica and Therapeutics 
 
 Sargent's Minor Surgery 
 
 Sharpey and Quain's Anatomy, by Leidy 
 
 Simon's General Pathology . 
 
 Simpson on Females .... 
 
 Skey's Operative Surgery 
 
 Slade on Diphtheria .... 
 
 Smith (H. H.) and Horner's Anatomical Atlas 
 
 Smith (Edward) on Consumption . 
 
 Solly on Anatomy and Diseases of the Brai 
 
 Stint's Therapeutics .... 
 
 Salter on Asthma 
 
 Tanner's Jlauual of Clinical Medicine . 
 Tanner on Pregnancy .... 
 Taylor's Medical Jurisprudence . 
 Thomas ou Diseases of Females . 
 Todd and Bowman's Physiological Anatom; 
 Todd on Acute Diseases .... 
 Toynbee on the Ear .... 
 
 Wales on Surgical Operations 
 Walshe on the Heart .... 
 Watson's Practice of Physic . 
 West on Diseases of Females . 
 Weston Diseases of Children 
 West on Ulceration of Os Uteri 
 What to Observe. in Medical Cases 
 Williams's Principles of Medicine 
 Wilson's Human Anatomy . 
 
 Wilson's Dissector 
 
 Wilson on Diseases of the Skin 
 Wilson's Plates on Diseases of the Skin 
 Wilson's Handbook of Cutaneous Medicine 
 Wilson ou Healthy Skin 
 Wilson on Spermatorrhoea 
 Winslow on Brain and Mind 
 
 5
 
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