menstruation returned, and continued to do so at irrégular intervals for the following year. In this case, the age of the patient, the prolonged irregularity of the menstrual flow, the persistency of pseudo-narcotism, of the flushes and perspirations, made it probable that these symptoms were produced by the change of life.

The sanguineous discharge caused by fibrous tumors and polypi, and the flooding they determine, are often confounded with the menstrual discharge and with the flooding of cessation, and this may be correct if the flooding be periodical. In a case of fibrous tumor, which I shall hereafter relate, flooding lasted for eight years without intermission; but there is no ascertaining whether this was caused by the change of life.

V. The following case puzzled me exceedingly:

CASE 5.-Uterine hydatids supposed to be the change of life. -Anne H., a tall, delicate-looking woman, with light hair and blue eyes, was thirty-nine when she first consulted me at the Paddington Dispensary, June 17th, 1850. The menstrual flow first appeared at fifteen, with great pain. She married at twenty, had six children, and was regular up to the last year, since which time the flow came at two, three, five, or eight weeks' interval, with greater pain, and with nervous fits, in which, though conscious, she would remain from six to eight hours in a powerless and speechless state. On examination, I found nothing the matter with the womb, so I imagined the change of life was approaching, and treated her accordingly, but without affording much relief. The menstrual flow stopped for three months, up to which period nothing had caused me to alter my diagnosis; but in December flooding came on, and I have seldom witnessed greater sufferings than she endured for a year, flooding frequently occurring, with intense abdominal pains and hysterical fits. The womb was patulous, but not ulcerated, and its body was not much enlarged. I gave opium and ergot of rye in repeated doses for a long time with decided benefit, for on May 10th, 1851, the menstrual flow appeared at the proper time, and without much pain. The abdomen was much swollen. After walking home, on June

23d, dreadful forcing pains brought away from the vagina about a pint of sticky, rose-colored water, without smell. This was followed by a sanguineous discharge, lasting for several days. A digital examination was very painful, but I ascertained that the body of the womb was anteverted, much enlarged, and so high that it was difficult to reach the os uteri. I gave opium enemata, which relieved the pains; alum injections were used, but when they stopped the flow, the pains returned, which were only relieved by flooding. To obtain parish relief, it became necessary that the patient should be attended by Mr. Howlett; but I learned that, after very violent pain, half a pint of glutinous liquid was again passed from the vagina on July 5th, after which she continued to lose blood. It sometimes dribbled, at others came as a flooding. When the uterine discharge stopped for two or three days, the pains became excruciating, notwithstanding the exhibition of sedatives inwardly and outwardly; and this state of things continued until I was sent for to see the patient on December 6th, when, after labor pains, she brought away a large mass of hydatids, which well explained the frequent floodings and the patient's protracted sufferings. Ergot of rye induced bearing-down pains, and brought away dark, offensively-smelling blood. Opium relieved the sufferings; the patient recovered, and had another child a year after.

Uterine hydatids is a rare disease, generally occurring earlier in life, and its diagnosis is often very obscure. The enlarged womb, the continued flooding without ulceration of its neck, alternated with the limpid or rose-colored glutinous discharge the best sign of uterine hydatids-was absent in the early part of this case. The diagnosis of uterine hydatids being clearly established, it would have been better to have dilated the cervix and to have brought on the expulsion of the hydatids, and to thereby save the patient six months' suffering.

VI. The floodings of cancer are not unfrequently considered indications of the change of life, particularly when they occur in young women presenting a healthy appearance-an error which can only be prevented by an examination.

VII. Pregnancy occurring late in life is often taken for cessation, the more so as, at whatever age, it is not unfrequently accompanied by the flushes, perspirations, and many of the nervous symptoms which characterize cessation. Under these circumstances it is better to give a very guarded opinion. Thus De la Motte relates, that a lady, for fear of having children, would not marry before fifty-one; and when she became pregnant, all the symptoms were considered to depend on the change of life. It much more frequently occurs, however, that the first symptoms of the change of life are mistaken for pregnancy. This is sometimes the effect of imagination; for many women have such a dislike to becoming old that, if married, they would rather persuade themselves they are with child; and they indulge this persuasion, until, like Harvey's widow, all hope vanishes in wind. Sometimes, however, the patient's belief in pregnancy is founded on data which puzzle the faculty. The menstrual flow stops, the abdomen gradually enlarges, and women, who have had children, are convinced they feel the moving of the child, the breasts swell and distil a milky fluid, there is sickness and impulsive desires; if a flooding takes place, the symptoms abate, but may again recur, to be again relieved by flooding, and these floodings of cessation are looked upon as miscarriages. B. de Boismont relates three cases of this description, and Fodéré two. The following are instances that have occurred in my own practice:

CASE 6. Cessation mistaken for pregnancy.-Mary C., married, aged forty-five, a tall, delicate-looking woman, with blue eyes and dark hair, thinks herself pregnant, and has been told so by several practitioners. The menstrual flow came at eleven, and was attended by little disturbance both before and after marriage. She married at twenty-seven, but she never conceived. For a year the menstrual flow has been either abundant, with large clots, or very pale, and for the last six months it has been altogether absent, the abdomen gradually enlarging, the breasts becoming swollen and sore, with leucorrhoea and hysterical sensations in the throat. On examination, I found the abdomen enlarged, but without the centrally situated, uniformly round tumor of a pregnant womb. The

womb was small, with a virgin orifice. That the patient was not pregnant I felt convinced, and I inferred the change of life from the long continuance of menstrual irregularities, the continued epigastric faintness, the flushes and sweats. My usual treatment relieved the patient; for many successive months she had an abundant vaginal mucous discharge, which was not interfered with. When I last saw the patient she was fifty, and there had been no return of the menstrual flow.

CASE 7. Cessation supposed to be pregnancy.-—Sarah B., a tall, thin woman, of a sanguine temperament, says she is thirty-five, but looks forty, applied at the Farringdon Dispensary for a lying-in-letter, on May 7, 1851. The flow first appeared at fourteen, was unattended by pain. She married at eighteen, has had five children, but has never been well since her last confinement two years ago. Hypogastric pains were habitual, the menstrual flow irregular, for the last six times it had the appearance of dirty water, and ceased entirely seven months back, when the abdomen enlarged, and she now feels a fluttering similar to what she felt when pregnant. The breasts are swollen and discharge moisture, and the nipples are surrounded by a dark circle interspersed with a few pseudofollicles. Notwithstanding these signs of pregnancy, and the patient's assertions, I did not think her pregnant; for there was no solid umbilical tumor, no softening of the neck of the womb; and the irregularities of the menstrual flow, and the appearance it last assumed, coupled with a great liability to flushes and perspirations for the last three months, were my reasons for thinking the change of life had occurred, and I ascertained that I was right upon inquiry several years after.

I have notes of three similar cases.

In the preceding cases, I believe that connection taking place during the change of life, induced a nervous condition of the ovaries and womb, capable of determining most of the symptoms of pregnancy; and when the abdominal swelling, the nausea, the enlarged breasts persist for months, the supposition of pregnancy might be easily admitted, and the rightful heir to an estate might be defrauded without the possibility of detection, if the woman had already borne children, unless

an investigation were made soon after the supposed event. Gooch has noticed another class of cases simulating pregnancy occurring at the change of life. The uterus is torpid, the intestines are flatulent, and the omentum and abdominal parietes have grown very fat, women having then, what Baillie called, "a double chin in the belly." The most notorious blunder of this description was in the case of Joanna Southcott, who, although sixty-four, was thought pregnant by many medical men. The walls of her abdomen were coated with four inches of fat, and the omentum was one lump of fat, and four times the usual size. It is evident that if women marry about the time of cessation, and are fat, and anxious to have children, they may have most of the subjective symptoms of pregnancy -morning sickness, painful breasts, the sensation of something moving in the abdomen, so that it is impossible to affirm the contrary, unless after examination, when the body of the womb will be found of the usual size and the cervix, hard as in its unimpregnated state. I have known women led to believe themselves pregnant on account of an enormous and rapid deposit of fat in the abdomen and breasts only.

Dusourd has met with several cases of uterine exfoliation at the change of life, the membrane being passed without flooding, but with great pain; and this might lead to belief in conception. I have always observed the exfoliation of the uterine mucous membrane to occur in much younger women, but in the first case of the kind recorded, Morgagni distinctly states, that the woman continued to exfoliate the mucous membrane of the womb, up to the cessation of menstruation.

In other women, unmarried or married, where no such membrane can be detected, the solid constituents of the blood unite, and come away as an ovoid "mole" in the midst of parturient pains. Then the womb really enlarges, and is able to cause all the sympathetic disturbance of pregnancy, as in the following

case:

CASE 8. Cessation and spurious pregnancy mistaken for pregnancy.-Five years ago I was consulted by a lady who moved in good society, was forty-five, unmarried, stout, and of a florid complexion. The menstrual flow came at fourteen, had