or may be recognized by the hand externally applied; the uterine souffle and foetal heart-beat may be heard; and in most cases, the dusky color of the vagina and the dark abdominal line will be distinctly perceptible, and ballottement is available.

The os uteri is now much changed, as are also the breasts, on which we may expect to find the areola fully formed, and, in some instances, the peculiar mottled appearance, or secondary areola, already described; not unfrequently, a lymphy or sero-lactescent fluid is found exuding from the nipple, or the extremity of this part is covered with the little bran-like scales.

3dly. In the sixth and subsequent months, the development of the abdomen, and the size of the uterine tumor, within which we may be able to distinguish different parts of the child's body, the umbilicus raised to the level of the surrounding surface, or projecting above it, the patulous and otherwise greatly altered state of the os uteri and shortened cervix, above which we feel the bulging body of the uterus, and the head of the child lying against its anterior wall, if distinctly recognized, afford proofs which leave no room for doubt, which would, of course, be equally removed, if we detected the phenomena derivable from auscultation.

In investigations of this kind, an invariable rule should be: to collect every possible proof before we venture to pronounce an opinion; not trusting to the evidence of any particular sign or sympathy, however distinct, or whatever may be our faith in its value; but taking all the evidence together, and judging of it collectively and comparatively; except we have distinctly and unequivocally heard the pulsations of the foetal heart, or felt the child move in utero, which ought, of course, to be completely decisive of the question.

Should the case be one occurring in an unmarried female, or into which legal considerations enter, whether of a civil or criminal character, and involving property, reputation, or life, our decision ought to rest on no evidence that admits of doubt, and if we cannot have such proofs as will rigidly satisfy our judgment, and enable us to decide without hesitation, our uncertainty must be candidly and fearlessly expressed, and our decision postponed until a further lapse of time shall remove the obscurity of the

case; and, in the meantime, no treatment should be adopted which could interfere injuriously with the state of pregnancy.

Roederer has given a summary of the signs of pregnancy so truthful, and so admirably condensed, that I trust I may be excused if I subjoin it here, in his own words.

"Ex supra dictis sequentia corollaria eliciuntur."

"Ium. Ante tertium mensem certum graviditatis signum non facile datur. Probabilia tantum criteria sunt: orificii uterini descensus, ventris complanatio, menstruorum suppressio, tumor mammarum, symptomata a suppressione hac, vel a novo stimulo inducta."

"IIdum. A tertio ad quintum mensem, exploratio abdominalis recte instituitur. Ad quam si accedit suppressio menstruorum continua, successiva symptomatum morbosorum remissio, mammarum tumor crescens, lympha lacteis striis distincta, orificium uteri crassius, mollius, spongiosum, motus embryonis, &c., de graviditate, admodum certi esse possumus."

"IIIum. Post quintum mensem, status orificii uterini omnium minime fallit: precedentia recensita signa si continuantur, et augentur, nullum plane graviditatis dubium est reliquum. Simul etiam cervicis tumor tunc tangitur."

"IVum. Sub initium, mediumque septimi mensis, caput plerumque tactui offertur. Unam, duas, tres, quin quatuor ante partum, hebdomades, uteri ora inferior tenditur, aperturæ pelvis superiori apprimitur et caput pone istam oram hærens pressioni in altum resistit."-Elem. Art. Obstet., pp. 51, 52.

CHAPTER IX.

EXAMINATION OF SUBSTANCES EXPELLED FROM THE UTERUS.-AN EARLY OVUM.-MOLES.-HYDATIDS.-THE MEMBRANE FORMED IN DYSMENORRHEA, AND IN OTHER CONDITIONS OF UTERINE DERANGEMENT.-MEMBRANOUS FORMATIONS FROM THE VAGINA.

THE expulsion from the uterus of solid, or organized substances, presenting occasionally very unusual, or anomalous characters, excites not unfrequently suspicions of the existence of pregnancy in the unmarried, and perhaps the perfectly chaste. Under such circumstances, we may be applied to for an opinion as to the nature of the substance expelled, and are expected to declare whether it is, or is not, the product of conception; and, inasmuch as the character and fair fame of the individual depend on our answer, the greatest care will be required in making such an examination, and the utmost caution in forming, or pronouncing an opinion. To this duty, no person can possibly be competent, if he have not previously made himself intimately familiar with the appearance and structure of the ovum, particularly in the earlier periods of its growth; and this knowledge, he may take it for granted, he never will attain to, by descriptions in books or plates, nor by any means except repeated examinations of the structure itself, under every circumstance and condition in which it may be found: more especially, when it is altered in its characters, as it usually is, by abortion, or previous intrauterine lesion.

The substances thus expelled may be, 1, an early ovum; 2, a mole; 3, uterine hydatids; 4, the membrane produced in dysmenorrhoea, or other conditions of uterine derangement; 5, membranous formations from the vagina; to each of which we shall now turn our attention.

1. An Early Ovum.-When the product of conception is expelled within the first month, its component structures are often

so crushed and broken up during its expulsion, that the most careful and skilful examination may fail in detecting its true character. After this period, its structure is sufficiently distinct to be recognized by any one well acquainted with it, and who will take sufficient time to examine it; for this also is absolutely essential to the formation of a correct opinion. The ovum, when thus expelled, is generally infiltrated with firmly coagulated blood, and the pressure which it sustains, while it is being forced through the contracted and rigid cervix of the uterus, so condenses its texture, as to reduce it apparently to the condition of a solid homogeneous mass.

The real structure of the product so altered cannot be ascertained by any examination instituted at the moment, but must be gradually made out, by first immersing it in water for a day or so, and then by agitation and washing, the coagulated blood must be removed, while with delicate blunt instruments we gently separate the component parts of the mass under water, until at length we ascertain its real character. This process may occupy us for a time varying from three or four days to a week, before we are able to satisfy ourselves perfectly. Haste may completely defeat the object of the examination, or, still worse, it may betray us into giving an erroneous opinion, as was done with very sad results in a case in Scotland, which will be noticed more particularly hereafter. (See p. 223.)

If in the progress of such an investigation, we discover a foetus, or even a part of one, it would of course be decisive; but this may not be the case, and yet we may recognize all the other component parts of the ovum, presenting several structures which are never produced by disease.1

If the ovum is expelled entire, we have the uterine decidua covering the substance under examination, and distinguished by its soft, rich, pulpy appearance, and strong red color; its external, or uterine surface being rough and unequal, and, when well freed from the coagulated blood, and immersed in water, exhibiting numerous small round foramina capable of admitting the head of

See a case related by Mr. Lemon in the Edinburgh Medical and Surgical Journal, vol xi. p. 96. The writer has in his museum several specimens illustrative of this absence of the foetus, where the other parts of the ovum exist.

a pin,' while its internal surface is smooth, generally thrown into slight, soft folds, and exhibits to the unassisted eye, little or no appearance of foramina, though they are really very numerous, but are not so easily perceptible, being of very minute size. These characters, which are almost always to be recognized without difficulty, are sufficiently distinctive of the structure under consideration; but there is another, not previously noticed by any one, as far as I am aware, until I described it in 1836," although it is probably one of the most remarkable features in the organization of this peculiar product. Repeated examinations have shown me that there are on the external surface of the decidua vera, a great number of small cup-like elevations, having the 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 cannot say. Some of them, which I have found more deeply embedded 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.

They are not confined to any one part of the surface of the decidua, but I think I have generally found them most numerous and distinct on those parts of it which were not connected with the capillary rudiments of the placenta, and at the period of gestation which precedes the formation of the latter as a distinct organ: they are best seen about the second or

Fig. 7.

See Hunter's plates of the gravid uterus, xxix., fig. 11, and also plates xxviii., XXX., Xxxiii., xxxiv.

2 Dublin Journal of Medicine, vol. x. p. 241.