5 cases, beyond three months in 9 cases, beyond four months in 6 cases. Reckoning from the cessation of menstruation, the gestation had lasted from four to six weeks in 6 cases, six to eight weeks in 5 cases, three months in 2 cases, four months in 1 case, five months in 1 case. Thus in far the greater number of cases, the fatal catastrophe happens within the first eight. weeks.

The Professor believes a common cause of tubal gestation to be inflammatory adhesions impeding the free course and connexion of the tubes with the ovaries. He supports this opinion by eight dissections, in which adhesions, the result of partial peritonitis, were formed, by the fact of the frequent sterility antecedent to tubal gestation, by the well-known sterility of prostitutes, which follows upon colic-the colica scortorum.

Attendant changes of the uterus are frequent. Thus of 40 cases there was marked enlargement of the uterus in 24. The development of a decidua is mentioned in 25 instances.

A case of tubal gestation is then cited, which we reproduce. A woman aged thirty-three had borne five children, and in the course of her sixth pregnancy, suddenly died under symptoms of internal rupture. In her abdomen was found a fœtus of four to five months, which had escaped from a rent in the right tube. The uterus was five inches and a half long, three broad, provided with decidua and gelatinous plug. The right Fallopian tube which had carried the foetus was not, as is usual, united to the uterus between the fundus and body, but between the body and cervix; and there was this remarkable circumstance, that the corpus luteum was found not in the right, but in the left ovary.

II. Interstitial Gestation.-The total number of known cases of development of the ovum within the uterine portion of the Fallopian tube is 26. In all the course was fatal, but the probability of a more protracted duration is greater than in ordinary tubal gestation. The time of survival after setting-in of fatal symptoms is twenty-six hours in 16 cases. In the majority of cases here also the gestation was on the left side. The duration of gestation was generally less than three months. Two cases in which the duration exceeded this time are cited. In the majority of cases it appears that the cavity formed in the walls of the uterus for the ovum is shut off by a distinct septum from that of the uterus proper.

III. Abdominal Gestation.-Professor Hecker has collected 132 instances in which the ovum had attached itself to some spot in the abdomen. In 90 out of 105 cases, the patients were pluriparous. Of the 132 cases, 76 ended in recovery, and 56 in death. Thus the prognosis of abdominal gestation is more favourable than might be supposed. The foetus may preserve its life for a long period. In Schmitt's case, the abdominal gestation lasted three years, and the child was, on the death of the mother through the Cæsarean section, taken out asphyxiated but living; in a case of Grossi, the movements of the child were felt for twenty-three months.

A remarkable physiological phenomenon is the frequent appearance of labourpains when the abdominal gestation has lasted nine months. That these pains have their seat in the uterus is probable from the development this organ mostly, but not always assumes; but it is more probable that these pains arise in the abnormal sac which holds the foetus. Frequently it is found that the walls of this sac are partly composed of organic muscular fibres. Recovrey took place after the expulsion of the foetus in 28 cases, through stony conversion in 17 cases, after expulsion of the foetus through the anterior abdominal wall in 15 cases, after abdominal sections in 11 cases, after vaginal incisions in 3 cases, and in 2 cases by modes not well determined.

The termination of abdominal gestation by discharge of the foetus through the rectum is frequent and mostly a very tedious process. The elimination of the fœtus through the abdominal wall is generally a still slower process; for in

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15 cases there are 7 in which the women went through one or more intrauterine pregnancies before being disburdened of their extra-uterine child. But when the process is begun, its course is shorter, and admits of being assisted by art, as by dilating the perforated opening and extraction of the fœtus.

The following is a summary of the 56 fatal cases: death followed hectic in 18, peritonitis in 12, rupture and hæmorrhage in 7, fæcal vomiting in 2, dropsy in 1 case. It followed operative measures in 12 cases-namely, Cæsarean section 5 times, puncture of the sac and cauterization 4 times, section through vagina in 2 cases. In 5 cases the mode is undetermined.

Professor Hecker then relates the two following cases which came under his own observation :

1st. A woman, who had borne one child at the age of eighteen, began to complain eighteen years later of nausea, want of appetite, and a sense of weight and fulness in the abdomen; menstruation, however, being regular. Two months later than this, December, 1856, her illness became aggravated, and the abdomen enlarged, being painful on moving, Examined on the 17th of January following, she was excessively emaciated and in a hectic condition; the abdomen was so painful, that scarcely could the slightest touch be borne. It was ascertained that a hard body, of irregular form, was present in the right side, feeling like a foetus; the uterus appeared to contain nothing, and a smooth elastic body was felt behind it, which could be pushed upwards. The diagnosis of extra-uterine gestation was confirmed on the 9th of June, before which time, movements of the fœtus were perceived by the patient and by others; on laying the hands on the abdomen, the different limbs of the child could be made out. The movements had now ceased, and it being concluded that the child was dead, the Cæsarean section was set aside. About Christmas, 1857, pains in the abdomen returned with hectic. In the night of the 8th of March, 1858, suddenly a strong effort at defæcation occurred, followed by discharge of half-a-pailful of watery yellow fluid, without admixture with fæces. This discharge, in all probability of liquor amnii, caused a considerable collapse of the before distended abdomen. Great prostration attended; and an abscess opened below the navel on the 26th of March, through which came two cranial bones, and afterwards the rest of the head and the whole child in a putrid state. The woman died in two hours later. No inspection was permitted.

2nd. A woman, aged thirty-eight, who had borne three children, was admitted into the Lying-in Hospital of the Berlin Charité on the 21st of March, 1857. She had believed herself pregnant since October, 1856, and complained of much pain in the abdomen. The abdomen was enlarged as in a seven months' pregnancy, very tender to the touch, and so evenly distended that nothing distinctly could be traced, but movements of the child were sensible both to the eye and to the touch. The fetal heart could not be heard, but a very loud vascular rush was heard to the left of the navel. There was colostrum in the breast. Internal examination was so painful that it had to be carried out under chloroform. The os uteri was close behind the pubes, open, and the finger struck upon a fatty mass feeling like placenta, which gave a carcass-like smell. The posterior vaginal roof was deeply depressed into the pelvis by a round immovable body like a child's head; this, when examined by the rectum, appeared to spring from the sacrum. On the 25th of March the fatal movements ceased, on the 26th peritonitis suddenly set in, and death followed on the 27th. Immediately afterwards, a dead female child, thirteen inches long, was removed by abdominal incision. The autopsy was performed by Virchow. It revealed recent and universal peritonitis; the extra-uterine sac reached to the transverse colon, was united to the anterior abdominal wall, but elsewhere free, The uterus was much enlarged,

2. Dr. Hardee relates an interesting case of tubal gestation. He was called to a negro woman who had general anasarca. On examining the abdomen, he felt a large tumour resting upon the left side; the uterus presented the sensation of a hard bony mass; no os tincæ could be felt. It was reported that the tumour had been growing for fifteen years. The dropsy increased rapidly, so that repeated tapping became necessary before her death. On laying open the abdomen, the uterus and a foetal head, larger than at term, were brought to view. The head resting just below the heart, and on the left side of the body; it was firmly attached to the uterus and intestines. After moving the head, a decayed mass was seen, but what it was could not be determined. All the bones of the foetal head were present, with the exception of the superior and inferior maxillaries. The uterus was about ten inches long, about four inches wide, and four thick, forming one hard bony mass, weighing six or eight pounds.

3. Dr. Steele's case of tubal pregnancy is highly interesting both in a diagnostic and pathological point of view. He was called to a servant woman, aged about twenty-six, who had married a second time-having had a child some years before-two months back. Two weeks prior to her death she had missed her courses for the first time, and suffered no pain up to the night of the 17th (month?), when she was taken with severe pain of the abdomen, which was supposed to be bilious colic. The next day she said she was better; but Dr. Steele found the pulse small, quick, and feeble; she was still complaining of a pain of a spasmodic character over the whole abdomen. She died suddenly about an hour after. On opening the cavity of the abdomen, there was found effused about a gallon and a half of blood; that in the pelvic cavity was coagulated; in removing this, an embryo of about six weeks was found, lying near a rupture in the middle of the Fallopian tube. Dr. Steele conjectures that this accident may happen oftener than is supposed. Unless hæmorrhage be severe, recovery might take place without the occurrence of very formidable symptoms, what had passed being unsuspected.

4. Dr. Küneke relates at great length a case of placenta prævia succenturiata. The following are the important facts. A woman, aged twenty-three, said to be pregnant for the first time, was admitted into the Lying-in Hospital of Göttingen on June 4th, 1858. Whilst engaged in field-labour she had been suddenly seized with a profuse flooding, attended with weak labour pains. Forty-five minutes after this flooding she was in the hospital. The os uteri was partially dilated. Auscultation revealed the sounds of the foetal heart. The child was born alive by means of the natural efforts. The afterbirth was removed without difficulty in ten minutes. The placenta consisted of two perfectly distinct parts, the cotyledons being planted in two points of the superficies of the chorion, separated by a space of free chorion between. There was no vascular connexion between the two portions of placenta. The funis was inserted into the edge of the larger oval-shaped portion of placenta ; whilst distinct vessels proceeded from the root of the cord to the placenta succenturiata. Without doubt, says Dr. Küneke, this accessory cotyledon had lain over the os uteri, and had given rise to the hæmorrhage.

5. Professor Scanzoni relates a case which he describes as one of laceration of the sacro-iliac synchondrosis during labour. A woman, aged thirty-two, who had previously borne one child normally, suffered during her second labour with severe pains, accompanied by the most acute pain in the sacral region. The child was unusually large. After delivery, the patient felt much exhausted, and complained of violent pain in the region of the right hip, running along the back of the thigh to the knee. Morphia internally and locally applied

gave no relief. She could not bear the slightest movement without the most acute suffering; and in the seat of pain a crepitation was perceived. On examination of this spot a very painful swelling, the size of the hand, long, flat, and somewhat red, was found in the region of the sacro-iliac synchondrosis. The most intense pain attended lateral pressure on the hip; and also internal examination, through disturbance of the sacral ligaments. Crepitation was felt and heard on moving the patient. The existence of a separation of the sacroiliac synchondrosis through the long-sustained eccentric pressure caused by the large and hard head of the foetus in the pelvic canal was undoubted. The antiphlogistic treatment adopted effected little alteration. On the fourteenth day after labour there appeared along Poupart's ligament a swelling the breadth of two fingers, hard, and which by fomentations and poultices was dissipated in a fortnight. Otherwise the state of the disease was the same. For the first time, in the middle of July, gentle locomotive attempts could be made, by resting the body on both arms on the right knee. At the end of July, violent pain returned in the region of the sacro-iliac synchondrosis. The swelling there exhibited fluctuation at the beginning of August; and on the 7th an incision being made, a pound of thick pus escaped. By means of the probe, the rough bared bones were felt, without, however, the instrument penetrating into the joint. Much relief ensued; when, two days later, about two ounces of limpid albuminous fluid had been discharged, the opening healed, and the patient walked, although somewhat lamely.

6. Dr. Braun proposes another plan, in addition to the many known, for exciting premature labour. He objects to many methods the danger of too easily rupturing the membranes. He employs catgut-bougies of a foot long and two or three lines thick; he steeps the end in hot water to full softening, and passes it, well-oiled, into the uterus, by means of twisting motions, until a length of only one or two fingers' breadth remains in the vagina. Uterine contractions are set up in from six to twenty hours. The bougie never (?) injures the membranes; it may be removed shortly before the rupture of the membranes or the birth of the child. During 1857 or 1858 the author had twelve opportunities of employing this uterine catheterization. By its means eleven children were born alive, five dead; eight mothers recovered, and no one sank from any puerperal process. The modes of death were: one from pneumonia; one from miliary tuberculosis; and two from Bright's discase. In estimating the risk of rupturing the membranes by this method, it is right to bear in mind the author's precautions in using very flexible catgut-bougies and softening them for use.

7. Dr. Kapler's case of rupture of the uterus. A woman in labour with her second child had passed the period of gestation favourably. She had, however, suffered from metritis after her first labour. The pains were good, but labour made no progress; she was therefore taken into the Lying-in Hospital. She was now collapsed; abdomen much distended. The conjugate diameter was shortened by half an inch. The delivery was effected with great difficulty by perforation and turning. The patient died fifty-one hours after delivery. About half a pound of blood was found in the abdominal cavity. The uterus was extremely pale and flaccid. (ne part had a harder consistency, and on being cut reminded one of the non-pregnant uterus; the cut edges retracted and became concave. The right wall of the cervix was in the form of a long irregular gaping rent. Below this rent was a second smaller one in the portio vaginalis. It is conjectured that the rupture in this case was due to the pressure exerted on parts which had undergone an inflammatory change in the first labour.

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