5, for sustaining the parts in hernia intestino-vaginalis in pregnant women; 6, bringing on premature labor; and 7, as a substitute for the dangerous action of secale in the dilatative stages of parturition.

It appears to me unnecessary here to add anything on the subject of Braun's most useful instrument. I shall in subsequent pages have to speak of its various other applicabilities.

I have met with three cases of extra-uterine pregnancy in the tube, all of which proved fatal about the third month, and I should expect the death of the patient to take place, at or before the third month, in any case; since it is improbable that the tube can ever furnish the material for a matrix for more than some ninety days, at which time the tube-sac must become so much thinned and extenuated by its expansion as to burst. The rupture of the tube will be attended with fatal hemorrhage, because, being the seat of gestation, it has become highly vascular, in order to the carrying on of the gestation within its walls. I do not believe that a tubal pregnancy will ever be suspected until it has burst and begun to bleed. One of these cases I have just related, as drawn up by Dr. Yardley, under the head of retroversion.

If a woman should experience the signs of pregnancy, as to change of the aureole, as to nausea, pica and malacia, as to growth of the breasts, extraordinary sensation within the pelvis, &c., and thereupon, when having attained to the middle of the second or to the third month, be seized with horrible pain in the hypogastrium and pelvis, turn pale, lose the pulse, and faint—I should suspect the rupture of a tube-sac of extra-uterine pregnancy. It is true that the above symptoms might be expressions of affections of the ureter, perforation of the bowel, or fatal typhlitis calculosa; but, in case they should continue and increase, with signs of concealed hemorrhage, so as to leave no doubt of imminent death, I think the diagnosis could not be other than a ruptured tube-sac of gestation.

Such a diagnosis would not lead to any hopeful therapeutic or chirurgical intervention, for nothing is to be done in these melancholy cases beyond the adoption of mere palliative measures. No man would be mad enough, under such diagnostic, to perform a gastrotomy operation.

CASE.-I had, some years ago, a young woman under my care who supposed herself to be pregnant some two or three months. One morning she took the broom to sweep her chamber-carpet, when suddenly she felt agonizing pain in the left iliac and pelvic region, which extended through the belly. She fainted, and became mortal pale and

pulseless; the agony was terrible. I supposed she had ruptured the sac of a tubal pregnancy. She expired in the course of a few hours, with all the symptoms of hemorrhage in the abdomen. I could not obtain permission to examine the body.

CASE. I saw another case, which I shall relate in this place as follows:

Mrs. -, aged thirty-two, a healthy woman, mother of four children, was in excellent health on Sunday, October 7th. At six o'clock in the morning, she was singing and playing with her children. At seven o'clock, her husband, who was sick up stairs, heard her ascending the staircase, and groaning heavily; when she entered his room, she appeared alarmingly ill. A physician, Dr. —, was sent for, and found her with a pulse one hundred and forty; in violent pain, extending from the top of the thorax on the right side, quite down to the iliac region. He attended her all day, applied a blister to the right side of the belly, gave a cathartic, &c. She passed a dreadful night, but was easier at eight o'clock next morning; the pulse then one hundred and twenty. He left her for a short time, but found her worse on returning to the house. I was sent for, and arrived at half past two o'clock. She appeared to be dying at the time of my arrival. As she had vomited very much, and had a most excessive tympany, with violent pain in the whole belly, she got an enema, which brought off a great deal of stercoraceous matter, without sensible relief. In half an hour, she said: "Raise me up-my breath is leaving me." I raised her a little on the pillows, and she swooned and died. Twenty hours after death, I opened the abdomen, and found it filled with about thirty ounces of blood, and bloody serum. The whole pelvis was filled with coagula, while a great quantity of blood was among the bowels.

This blood came from a ruptured left Fallopian tube, which contained a foetus of six or seven weeks. The ovarium was somewhat enlarged. The womb had a deciduous lining, and the canal of the cervix was filled with a claret-colored mucus or lymph. The womb was larger than a non-gravid womb, though not a great deal larger.

I have had under my care only one case of ventral or abdominal pregnancy, though I have had opportunities to witness the examination of bodies of persons perishing from this dreadful accident. I shall merely express some doubt that I feel as to the propriety of any gastrotomy operations in such cases save mere incisions for the easier escape of the contents of the suppurating sac and the remains of the foetus.

I refer the Student to the records for samples of life not only continued long after the complete establishment of the extra-uterine pregnancy, but of good health enjoyed notwithstanding. The late distinguished incumbent of the chair of Midwifery in the University of Pennsylvania, Prof. James, published in the Eclectic Repertory an account of a lady who carried out a normal pregnancy, notwithstanding she had in the abdomen an extra-uterine foetus, which she carried many years.

Signs of Pregnancy.-I have been, on several different occasions, both vexed and amused upon observing how prone are some medical practitioners to overlook the signs of pregnancy even in married women, their patients.

One gentleman, of great experience, tapped a woman for ascites, but his trocar went into the gravid womb, and penetrated the shoulder of the foetus. She fell into labor, and recovered of the accident; the child had the mark of the trocar on his shoulder. She afterwards suffered from strangulated hernia of a knuckle of intestine, that escaped through the trocar-opening in the linea alba. This hernia being reduced by Dr. Pancoast, she recovered happily. At a subsequent period, the protrusion again occurring, the gut was fatally strangulated. Professor Pancoast, who made the post-mortem examination, preserved the specimen in the Jefferson College Museum. Many instances of the strangest oversight have occurred within my range of observation, instances in which the size of the belly, the married state of the patient, and the obvious evidences of gestation, as well as its probability, ought not to have been overlooked, nor mistaken for diseases requiring troublesome, disgusting, or dangerous therapeutical prescription. The safest rule would be to suppose every married woman as pregnant, if of the proper age, with suspension of the catamenia, and not giving suck, and to treat her as gravid until convinced of the contrary.

CASE.-Mrs.

aged thirty-six, multipara, resident in Philadelphia, was ill on the 15th March, 1850, with diarrhoea, attended with very distressing tenesmus. That able physician, Dr. attended to her during three days, and then left her in apparent good health. She was supposed to be, at the time, one hundred and twelve days gone with child. She had no doubts as to the pregnancy. Ten days after the attack of diarrhoea, March 25th, she began to grow rapidly larger, and the belly soon became so enormous, and so painful from tension, as to induce her to send again for the doctor, who found

her, as he supposed, affected with a vast ascites, consisting of many quarts of fluid contained within the peritoneal sac. I know not on what day Dr. first saw her again. The secretion of urine was nearly abolished. The reins and lower part of the abdomen were very painful, yet there was no pain produced by pressure or by palpation. No signs of pregnancy save that the cylindrical cervix was short as in a woman of seven months, and that the cone of the cervix, felt in the vaginal cul-de-sac, was expanded. The os uteri was well closed. Neither palpation nor auscultation disclosed the reliable evidences of a pregnancy. Still, the woman insisted that she was pregnant and quick with child.

She became affected with nausea and frequent vomiting. She grew thin, and got a haggard expression of the face. She was costive. There was not the least oedema of the limbs or face. Under these circumstances, Dr. announced his desire to tap the patient, which he looked on as the only hopeful means of arresting the vomiting, which now caused her to throw up the whole of the ingesta. The pain from abdominal tension was almost insupportable, and the emaciation extreme.

On Monday, April 22d, I was called in consultation. She vomited everything was in great distress from distension of the belly. Pulse frequent and energetic. Tongue clean. She was tolerant of pressure in every part of the abdomen. The vaginal touch revealed to us nothing to be depended upon, though made with great care. Protracted and anxious auscultation of all the parts of the abdomen, disclosed no foetal sounds, and long palpation no foetal turbulency. The patient insisted upon the gravidity, which I could neither affirm nor deny.

Upon consultation, it was agreed to defer for the present the idea of a tapping. She took citrate of magnesia, which purged her well, and brought an end to the vomiting. She then took acetic tincture of squills, combined with sweet nitre, for I fully believed in the existence of ascites having at least sixteen quarts for the collection, and I gave this as my opinion, concurring with Dr. physician in chief.

I did not deny nor affirm the pregnancy.

was called to her in

On Thursday, May 2d, at noon, Dr. labor, which soon terminated in the birth of twins, of five and a half months, the first born being faintly alive for a few minutes, and the second quite dead.

While Dr.

sat at the bed foot, a vast quantity of water (a great many quarts) gushed from the ruptured membranes;-a very large bucket-full, was the doctor's expression. Soon after which, the

twins were expelled, and then the placentas, united in one disk, were removed.

To-day, May 3, 1850, I saw her at noon. The womb is firmly contracted in the lower part of the belly, though very large; being about five inches in transverse by seven in longitudinal diameter. I do not think there is any, the least degree of effusion in the peritoneal sac, and the patient is in every respect comfortable.

I do not suppose that I have ever been concerned with a more instructive case than this. Dr., an able and most experienced physician, who has had about 6000 labors, mistook the developed belly for an ascitic tumor, an opinion in which I wholly concurred after the most careful observation, the employment of all the proper means of diagnosis, and serious reflection on the history of the case.

I never have met with a more fluctuating dropsy than this one, the waves being most distinctly and clearly perceptible, in whatever direction propagated by the percussions. It was dropsy of the ovum.

My objection to the paracentesis depended upon two points; first, the risk of peritonitis from the wound; and second that of interfering with the uterus, provided she was really pregnant.

But for this hesitation she would have been tapped, and that with my consent, which I was on the point of yielding!!

Let the perusal of this most interesting case serve as a memento for the Student in all instances of such sudden dropsies, complicated with averred gestation. Let the distress of this patient be referred to the same category of influences that occasion so much constitutional irritation from the too rapid growth of the womb, under hydatid gravidity, as in my case, related at p. 244 of this volume. I was greatly shocked, this morning, to find how grave a mistake in diagnosis I had made, and equally relieved to find the patient delivered of her twins and her ascites by the same gush. I beg the Student not to forget this lesson, and I hope he will refer to it before he taps a female of whom it is possible to suppose that she is gravid.

Let the Student also imagine, for a moment, how very disagreeable must be the reflections that follow the clearing up of so egregious an error as that of administering powerful emmenagogues to married women, who, nevertheless, would not miscarry; or who, now and then, are found to miscarry under such a diagnosis. The signs by which a woman knows herself to be pregnant are, the cessation of her regular menses and the subsequent enlargement of the abdomen; the movements of the foetus; certain constitutional or local disturbances or disorders, and modifications of the mamma. A married woman, who has been well regulated, suspects that she has conceived, if she fails to