several pages back, on the subject of spurious menstruation. The extract, which we now give, will serve to throw additional light upon the views then propounded:

"A considerable number of cases, similar to the preceding, have occurred to myself, and have been submitted, whenever practicable, to specular examination.” P. 222.

"On examination with the speculum, inflammation or ulceration of one or both labia, or of the cervix uteri, complicated, in some instances, with warty excrescences growing from the cervix, or from some part of the vaginal membrane, vaginitis, &c., was met with in every case, without an exception. Fifteen cases were submitted to this kind of examination at the time the blood was flowing. In not one of these did any fluid whatever escape from the interior of the uterus; the orifice being completely occupied at the time by a plug of transparent mucus. On removing the accumulated secretion by means of a piece of lint, the parts were immediately afterwards covered by a coating of blood, which was distinctly seen issuing from innumerable pores on every part of the diseased surfaces, and soon being in sufficient quantity to trickle down into the speculum. This blood was widely different, in its sensible properties, from that collected in the tube during its introduction, or at the os externum; being more florid, more strongly alkalescent, and soon subsiding into a dryish clot, which could be separated from the interior of the instrument in form of a small cake of crassamentum. This was never the case with the former, which remained fluid or soft, for a considerable time.

"The evidence now produced appears sufficient to establish, as a general rule, to which I am not as yet acquainted with an exception, that the blood discharged in cases of alleged menstruation during pregnancy, is furnished, not by the lining membrane of the uterus, nor by any healthy secreting surface-except sometimes perhaps the inferior part of the inner cervix; but by the lower extremity of the uterus external to its cavity, or by the contiguous vaginal reflection, being in a state of suppurative inflammation. The fact is always demonstrable by the aid of the speculum. And where specular investigation is found impracticable, there is still no difficulty in forming a diagnosis, so long as the linen of the patient can be submitted to ocular inspection." P. 223.

In a subsequent passage he maintains

"1. That menstruation during pregnancy is, for the most part, perhaps always, associated with an abnormal condition, generally with ulcerative disease, of the uterus; requiring, at all times, active remedial interference.

"2. That hæmorrhage during pregnancy is not necessarily associated with an altered relation of the parts within the uterus, and, by timely care, need not interfere with the integrity of the ovum.

"3. That menstruation, during the early periods of lactation, is not always normal menstruation, but that it is generally associated with morbid conditions which are amply adequate to the satisfactory explanation of the phenomenon; that secondary hæmorrhage is, in the majority of instances, not owing to imperfect contraction, or atony of the uterine fibres; and that the discharge very probably proceeds, under these circumstances, not from the inner surface of the uterus, but from diseased surfaces situated upon parts external to the cavity of the organ." P. 332.

It remains to be seen whether the observations of other obstetrical physicians will warrant the accuracy of these somewhat novel positions.

It is scarcely necessary to say that pregnancy has been repeatedly known to occur before the catamenia had ever made their appearance. Mr. W. relates a good many instances in point. One will suffice; it is instructive.

1847]

Abortion, its Statistics and Causes.

395

"A young woman, seventeen years of age, a dressmaker, was brought to me by her mother, in June, 1844. She had been, for several months previously, in a weak state of health, the principal symptoms being languor, nausea, loss of appetite, and swelling of the belly. She was thought to be suffering from retention, never having menstruated. From some hints that escaped in her relation of a previous course of treatment, which had been administered by a female practitioner, and with which circumstance the mother had been hitherto unacquainted, I expressed my suspicions of the existence of pregnancy; this was strenuously denied, however, by the patient. The breasts were considerably developed , although flaccid; the nipples and areolæ dark and well defined. The abdominal tumour was hard, circumscribed, without fluctuation, and situated low in the cavity. The umbilicus was prominent. No sound was elicited by the stethoscope. An active saline aperient was prescribed. The following morning labour pains came on, and in due time, she was delivered of a still-born fœtus, about seven months grown." P. 225.

CHAP. VI.-Statistics of Abortion.

The following table gives the respective periods of abortion in 602 cases, which have occurred in our author's experience. It may be observed 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. And, as abortions happening earlier than the seventh week of uterine life are often so nearly simulated by certain menorrhagic discharges, events said to have taken place at this early period-except when an ovum had been clearly made out-have not been included in the report.

It is astonishing how readily abortion is induced in some women, and how strongly it is resisted in others. As an instance of the latter case, our author tells us of "a poor woman who was admitted in the eighth month of pregnancy into the lying-in hospital, having been recently discharged from the Royal Infirmary, where she had been nine weeks an inmate for fracture of the skull, caused by a blow from a hatchet, which she had received in a quarrel. She was delivered of a healthy child, at the full term of gestation."

With respect to the causes of abortion, the experience of our author is in strict accordance with the observations of Dr. H. Bennet and other

recent writers as to the co-existence of uterine disease in a very great number of cases. This occasionally consists in simple Congestion or vascular plethora of the organ. The symptoms indicative of this state are "immoderate and painful distension of the abdomen, generally attributed by the patients to accumulation of wind in the bowels; a pulsatile movement extending over the whole cavity, the beats being synchronous with the heart's action; sense of weight and bearing-down; intermittent pains of the loins, like those of labour; and, occasionally, escape of blood from the vagina. There is also distension of the pudic, spermatic, hæmorrhoidal, and all the pelvic veins, and sometimes of those of the lower extremities. On examination, the vagina is found hot and turgid, and the cervix uteri tumid and varicose."

But a very much more frequent cause of abortion is disease of the cervix uteri. This is apparent from the following table of the results of our author's observations in 378 cases.

He subsequently remarks, that "of every hundred cases of abortion, not more than thirty could be attributed by the patients themselves to accidental, or any other appreciable agency: the rest being vaguely referred to a weak state of health, especially to the condition denominated an ' inward weakness,' to previous abortion, difficult labour, protracted recovery, and, in some instances, to diseases of a specific nature. The two hundred and seventy-five individuals ranged under this head in Table X., were, with a very few exceptions, examined with the speculum, either before, or within three or four weeks after the event took place; and in every case thus submitted to examination, disease of the lower, or of the internal part of the uterus, and in a few instances, of the vagina, was found to exist. Some of those, who had the disease in a severe form and of long standing, underwent the necessary course of treatment at the time, and recovered: but a great number disappeared after being two or three times prescribed for; unwilling, apparently, to believe that further attention was necessary."

The forms of uterine disease said to predispose to or to induce abortion, are inflammation and superficial erosion of its mouth and cervix; varicose ulceration of one or of both labia of the os tincæ; œdema of the cellular structure of the cervix; fissured ulceration of one or both commissures, of the anterior or posterior labium, or implicating all these parts at the same time, together with inflammatory hypertrophy of the adjacent structures; induration of the cervix, with or without abrasion of surface; endo-uteritis, or inflammation of the lining membrane of the uterus; follicular ulceration; gonorrheal inflammation of the os and cervix, often

1847]

Leucorrhea; Endo-uteritis.

397

extending into the cavity of the uterus; syphilitic disease, both in its primary, secondary, and tertiary stages; and, lastly, prolapsus of the uterus. The symptoms denoting a diseased condition of the lower part of the uterus are the presence of a leucorrhoeal discharge, whether the matter discharged be simply mucous, or have an admixture of pus or blood; a deepseated uneasiness in the hypogastrium; a fixed pain in one or in both inguinal regions; aching of the loins; a sense of distressing" bearing-down;" rigors, lassitude and remittent feverishness. There is often also some uneasiness or other inconvenience in passing water, hæmorrhoids, an acute smarting, or stabbing pain about the coccyx, accompanied with a feeling akin to tenesmus, nausea, loss of appetite, irregularity of bowels, cramps, palpitations, hysteric fits, convulsions, &c. Mr. Whitehead describes with great minuteness the various kinds of leucorrhoea, and points out the different conditions of the uterus and vagina which they serve to indicate. Whenever there is any admixture of puriform matter with the discharge, there is strong reason to suspect some diseased condition of the lower part of the uterus.

So frequent is leucorrhoea in one form or another during pregnancy that it was found by Mr. W. to be present in 1116 out of 2000 women; and in 936 of the former number, or 83 per cent., the discharge bore undoubted evidence of the presence of pus or of sanies, and occasionally of blood: of these, 544, or 58 per cent., had previously miscarried. The following data will be read with interest:

"Of forty-five women pregnant for the first time, all suffering under leucor hoal affections, twenty-eight had the discharge of a decidedly purulent character. I examined the uterus in twenty-five of these, and all, with but one exception, had ulcerative disease of the lower part of the uterus; in the exceptional case, the vaginal membrane was studded with warty excrescences which were known to have had a syphilitic origin. I examined several of those also, who declared the discharge to be colourless, and found suppurative disease to be equally prevalent in them. Of more than two thousand individuals labouring under leu corrhoeal affections, in whom I have examined the uterus with the speculum, I have, with comparatively few exceptions, found the existence of structural lesion sufficient in degree to account for all the symptomatic phenomena. In the great majority of the cases, the cervix and labia uteri were the seat of disease; in some there was excoriation, erysipelas, high vascular congestion, or a warty state of the vagina; in others, the labia, free from ulceration, were thickened, with their inner margins callous and flabby; or else they were tense, and presenting a vivid redness around the orifice of the uterus; both which appearances indicate the existence of disease within the organ." P. 287.

We may remark, en passant, that the puriform leucorrhoeal discharge may give rise to blenorrhagia in the husband. The infant too, born under such circumstances, is apt to be affected with purulent ophthalmia, and other affections of a similar nature.

We strongly suspect that a good deal of the description which our author gives of Endo-uteritis (the name tells the nature and seat of the disease) is drawn from fancy:

"The form of disease now proposed for consideration is one of a strictly local character, of every-day occurrence, and very amenable to treatment. It nevertheless acts as a common cause of abortion during the early months of pregnancy; and it constitutes, in the majority of instances, the pathology of that

NEW SERIES, NO. XII.--VI.

E E

species of disordered or difficult menstruation known as dysmenorrhoea. It does not occur as a necessary consequence, however, that dysmenorrhoea, as commonly witnessed in early life, indicates the existence of a condition likely to create an inaptitude for child-bearing afterwards; on the contrary, the symptoms in the virgin are often of a purely nervous, or what is understood in common parlance, of an hysterical character, unaccompanied with inflammatory action, and they frequently undergo complete cure by marriage: an instance of which is given in Case XVI., illustrative of the article on this subject.

"Endo-uteritis is a term employed to signify inflammation of the lining membrane of the uterus. The affection sometimes implicates the cavity of the cervix, or that of the lower part of the organ only; at other times the whole lining membrane is involved, and it not unfrequently extends within the Fallopian canals to their outer extremities. The inflammation is generally of a chronic, although of a very irritable character; and under certain states of excitement, as febrile irritation resulting from the application of cold, or of accidental violence; inordinate venereal indulgence; the action of the gonorrhoeal or syphilitic virus, &c.; the deeper textures of the uterus and neighbouring organs may be seriously implicated." P. 352.

The symptoms of this morbid condition of the uterus are alleged to be "distension of the hypogastrium, accompanied with a constant, deep-seated aching behind the pubis; irritable bladder; pain of the loins, of the inguinal regions, and of one or both sides of the abdomen on a level with the umbilicus; languor; irritative fever; and vaginal discharge. The whole uterus is often found in a state of inflammatory hypertrophy, and, unlike the affections previously noticed, is extremely painful upon pressure, especially at the back part of its body, where it impinges upon the rectum. The cervix is hard and less sensitive, but slight succussion made upon this part develops' a painful sensation about the inguinal or umbilical regions, or across the loins. Examined with the speculum, the labia present a tense, glistening appearance, and a ring of vivid redness surrounds the orifice; this, in some cases, is seen to extend upon the surface of the posterior lip. Sometimes one or both labia are excoriated, eroded, or fissured."

Accumulation of air within the uterus (physometra) is said to frequently accompany inflammation of this organ. "It is commonly discharged in the form of bubbles, which may often be seen to form and burst in rapid succession during specular inquiry. There is reason to believe that it sometimes collects in considerable quantity, causing great suffering by distension of the uterine walls, and being expelled by sudden contraction of the organ, accompanied with severe forcing pains like those of labour. Generally speaking, it emits an offensive odour, owing in most instances, probably, to decomposition of the small coagula liable to be retained after menstruation, or which may also be thrown out at other times. It may possibly be, on some occasions, the product of secretion."

Mr. Whitehead asserts that abortion is, in many cases, owing to inflammation of the lining membrane of the uterus, resulting in an imperfectly organised condition of a portion of the decidual membrane.

The following passage, professing to give a description of Gonorrhœal Inflammation of the Uterus, will be found to contain statements which will require confirmation, before they command general assent.

"Gonorrhoea in the female is much more frequently an affection of the uterus than of the vagina. This, although totally at variance with the opinions hitherto