A MEMOIR ON EXTRA-UTERINE GESTATION. By Dr. Wm. Campbell, of Queen's College, Edinburgh, &c. &c. Edinburgh, Black; Longman, London.

THE author of this memoir has been long known as a zealous and successful cultivator of obstetric science. During the many years he has devoted himself to this important division of medicine, he has shewn how earnestly he entered into the spirit of its duties both as a teacher and operator. In the parturient chamber, often the poorest and most destitute, when the best resources of the art are most urgently wanted, but most scantily supplied, he has long laboured with highly beneficial results to the afflicted, because he was armed in his endeavours, by the scientific application of means and unwearying humanity. In the lectureroom he has brought the abundant stores of a mind eager in the acquisition of knowledge, long occupied in accumulating, and arranging it, together with the power of communicating it agreeably and effectually to others, thus obeying, and in an important sense, the important injunction, to "do good and communicate." The many who have had the advantage of his public prelections knows how deeply his mind is imbued with the learning and resource of his art, deduced from laborious study and close observation, quickened and polished by critical acuteness; and his published works have proved them to the world.

In preceding publications Dr. Campbell occupied himself chiefly with great practical points in the female economy, endeavouring to shew in what manner and by what means its important maladies might best be combated. The work before us, though practical to a certain extent, is, from the nature of the affection handled, so only in a limited degree. Extra-uterine gestation, though scarcely in strict language deserving the name of disease, is one of the most fearful evils to which woman is exposed. The subject is shrouded in mystery, and is pregnant with interesting matter of a very powerful kind. It is therefore a seductive subject to the inquisitive mind, and highly worthy of investigation; but it must be admitted, after all that has been attempted, that art supplies little in the way of remedy, and judging from the nature of things, never can accomplish much; and that, in defiance of the best efforts of genius, backed by laborious research, it is, and is likely to continue, in a great measure, one of the curiosities-an absorbing and distressing one-of medical literature. Dr. Campbell, in this memoir, has brought together an immense amount of information on the subject. Every available light has been seized for its elucidation, and much pains have been taken so to arrange and convey the various streams, as to exhibit it in the clearest and most intelligible form. From the time of Albucasis to the present day, he has laid under contribution every appliance which could conduce to the object which he wished to accomplish; and the whole shews the great extent of his labors, and how familiar he is with the matter he discusses. As a historical record of extra-uterine gestation, it appears to us complete; and we may safely affirm that, in this respect at least, he has completely exhausted the subject.

We pass over the first section, that on embryology, to notice briefly the contents of the sections on the varieties of extra-uterine gestation, which, as might be expected from the obscurity involving the subject, have led to much doubt and disputation. Three or four distinctions, dependent on difference in the position occupied by the misplaced foetus, have by many writers of note, such as Breschet, Meyer, Blundell, and Granville, been considered sufficient to express all that is known of the matter; but Dezeimeris, in his love of precision, aided perhaps by love of display, proposes ten or eleven divisions; while G. St. Hilaire admits but two, only one of which is included in the arrangement of the former author. Dr. C. says that "the arrangement of Dezeimeris is unnecessarily

minute, and in a practical point of view, useless; since a large majority of the varieties particularised by him cannot be recognised by any diagnostic marks we are acquainted with; and some in the remainder, though there be some symptoms which are very characteristic, yet these even, as must be conceded by every man who has studied the subject, are by no means infallible." He (Dr. C.) proposes the four following divisions of the affection, viz. ovarian, ovario-tubal, tubal, and tubo-uterine. For the adoption of this arrangement he adduces many pathological facts, and states his reasons fully and distinctly, and we are bound to say that the classification appears to us, as far as can be determined, correct, and therefore good. He excludes the ventral variety in the sense generally employed; believing that, in all cases of fœtation not within the uterus, the misplaced product is originally attached to some part of the uterine appendages, not precipitated into the abdominal space, and therefore left in isolated being; and for this belief we think he has offered sufficient arguments. But while we willingly admit this, as well as the accuracy of his arrangement, we are disposed to say to him, though of course with much limitation, what he says to Dezeimeris, "that his arrangement is unnecessarily minute," &c. We do not often ask the scientific enquirer the sordid question cui bono? because good often comes from quarters, and through channels, where it is little expected. Still we fear that little benefit will come from the most elaborate and skilful discrimination of the exact tissue, or portion of tissue, implicated in extra-uterine gestation. The section occupied with the causes need not detain us; because they are simply conjectural in the present state of our knowledge, and will most probably ever remain so; because such an inquiry can lead to no determinate benefit, and cannot even gratify a reasonable curiosity.

In the section containing an account of the symptoms there is much curious, and some instructive matter, on which, however, our limits forbid us to enter; but we would call particular attention to, and quote from, the section on diagnosis, containing as it does the more peculiar and striking symptoms of the affection. Before, however, giving an extract or two we beg the reader to notice the following, by way of preliminary caution. "A case occurred at Berlin in 1828, in which the section of the abdominal parietes was performed, upon the supposition of a tumor which was felt adjacent to them being an extra-uterine fœtus; instead of which, it proved to be an accumulation of fæcal matter." From Siebold's Journal. This shews the importance of correct diagnosis, especially before we resort to such an operation as ripping up the belly, and may suggest to some the notion, which it will confirm to others, namely, that more than one of the many cases cited under the head of extra-uterine gestation, in this memoir, were abdominal tumors independent of fœtation.

"Although, as in other subjects pertaining to the department of midwifery, much difficulty will occasionally be experienced in establishing a diagnosis, yet assuredly in many instances which may be met with, I should unhesitatingly say, that when the patient is four or five months pregnant, the task is not unsurmountable; but at an earlier stage of gestation, although there may be some striking phenomena, yet we should not be justified in considering them infallible. The nature of the gestation is to be decided, certainly not by a reference to any single symptom, but by a strict analysis of all the most prominent features of any given case. If, after suppression of the catamenia and other phenomena of pregnancy for one or more periods, an individual were to be suddenly seized with uncontrollably acute pains in either iliac region, even antecedently to the period of quickening, accompanied by a well-defined swelling at a corresponding point, sanguineo-mucous discharges per vaginam; frequent desire for, and pain attending micturition, tenesmus, with a sense of fainting, such ailments ought certainly to warrant a practitioner in suspecting an ovarian or tubal pregnancy.*

* "Ce chirurgien célèbre dit avoir vu deux femmes enceintes de quatre mois,

Were the uterus found in an elevated position in the pelvis, and besides this organ, an additional body detected in the same cavity, such a discovery might certainly be viewed as a corroboration of our suspicions.

When, after the presence of fœtal movement cannot be questioned, the cervix uteri is found directed towards the pubis, so much elevated in the brim, that it can be felt with difficulty, or that it cannot be reached at all, there need, generally speaking, be very little doubt as to the presence of an extra-uterine gestation. An additional support to this diagnostic is an undeveloped state of the cervix, and of the corpus uteri when it can be felt. Another point which deserves particular attention is, whether the abdominal tumefaction was observed to have commenced at one side, and whether foetal movement was remarked to have for a time occupied a corresponding point. When gestation is far advanced, and the adventitious cyst occupies a large share of the abdominal cavity, these diagnostics cannot be relied on, though of great value at an earlier stage. In connexion with the foregoing remarks, we must not overlook the importance of occasional paroxysms of acute pains, in different regions of the abdomen, as very characteristic of extra-uterine gestation. Of all the phenomena which may be particularized, none has commanded attention so frequently, as the altered position and undeveloped condition of the uterus, as may be observed in the histories of many of the cases which have been offered in illustration.

From the foregoing illustrations it may be observed, that in occasional instances extra-uterine gestation has been confounded with retroversion of the uterus; but a little reflection must satisfy the practitioner, that there is a marked difference betwixt the symptoms of each. In retroversion the patient is suddenly seized with almost total inability to void urine, and with tenesmus, but inability to evacuate the rectum, and these symptoms are invariably present; while in extra-uterine gestation, although there is frequent desire, and much pain in performing these functions, yet they are never obstructed, as in retroversion; and, moreover, these complaints supervene in paroxysms, or they are present only in occasional instances. In regard to the malposition of the uterus, the only symptom in which these derangements strikingly resemble each other, this like. wise is but occasionally felt in extra-uterine gestation, while it always happens in retroversion. We have, moreover to remember, in reference to this last point, first, that the pelvic cavity, except in some very rare instances, is not at any time so completely occupied by the tumor of an extra-uterine gestation, as by the uterus in a state of retroversion; and, secondly, that the patient can freely evacuate the bladder, when the pelvic tumor is pushed towards the sacrum."

We omit what the Doctor has written in the three subsequent paragraphs on diagnosis, because we do not see their application to the subject in hand; because we do not intend here to enter on the questio vexata of the viability of children; and because we more than question the taste or utility of introducing the Rev. Dr.

chez lesquelles rien n'indiquait ce que leur etat avait d'extraordinaire, si ce n'est des tiraillements frequents dans l'abdomen et la tumefaction irrégulière du ventre qui se portait d'un côté seulement. Elles eprouvèrent les symptômes suivants lors de la rupture des trompes elles furent attaquées inopinement de douleurs extrémement vives qui durerent deux ou trois heures; une douleur plus forte que les autres fut suivie d'un calme parfait; le ventre s'affaissa et fut comme aplati; une chaleur égale et douce se répandit dans la cavité abdominale; la peau se decolora, il survint des syncopes presques continuelles ; le pouls s'affaiblit et se concentra; une sueur froide se repandit sur toute la surface du corps, et les malades expirèrent; Sebatier, Med. Operat. Iere edition, t. i. p. 343." N

No. LXV.

Chalmers' and the Kinghorn cause into a memoir like this. What he says of ourselves we very freely forgive. We have lived too long amid the storms of the ocean to be much moved by the ripple of a river, or the heavings of a Sylvan lake. In the occasional conflicts in which we have been engaged, and which we could not always, however we might desire it, avoid, we have used the weapons in our hands as gently as was compatible with self-defence, and our championship, though self-constituted, of the truth. When in dealing with distinguished members of the profession, we have felt it our reluctant duty, it might be in error on our part, to find fault, we have done so in kindly feeling and courteous language, certainly with no desire to irritate or provoke; on the contrary, we would, if we could conscientiously, deal only in praise, and eschew altogether, in our intercourse with the genus irritabile vatum, the ungracious and unacceptable task of censuring; but in that case, criticism, whatever it be worth, would be at an end. Having skipped the three paragraphs in question, we give the following and concluding one, from the chapter on diagnosis.

As we might be encouraged to have recourse to gastrotomy by the prospect of emancipating a living child, this essential point must be determined chiefly by the careful application of the stethoscope. The declarations of the parent, that she is conscious of fatal movement, cannot be relied on; since it must be well known to practitioners, that females often persist in stating that they have been sensible of the motions of the child to within a few hours, or indeed minutes, of its birth; while, from the degree of decomposition which it then exhibited, no doubt could be entertained that life must have become extinct several weeks previously. Violent fœtal struggles, preceded or followed by rigors and expulsive efforts, and thereafter total cessation of motion, are proofs of the extinction of fœtal life that will rarely deceive a practitioner. When these are followed by diminished tumidity of the abdomen, the secretion of milk in the mammæ, and the return of the catamenia, another conclusion may be drawn with equal certainty, viz. that the gestation is extra-uterine.”

We can no further enter on the sections on prognosis, termination, and pathology, than to say, that they will well repay perusal, and shall conclude our notice of this very interesting publication, by glancing at the chapter on treatment.

This, our author considers under four heads :-first, the precautions required to retard or prevent laceration of the cyst; secondly, the measures necessary to moderate the hæmorrhage after laceration; thirdly, the management after the extinction of foetal life; fourthly, the steps to be pursued for the emancipation of the fœtus. On all these points the observations of Dr. Campbell are judicious, though unfortunately, from the nature of the subject, too little satisfactory in a curative view, to induce us to follow them.

PRACTICAL OBSERVATIONS ON ABORTION. By J. S. Streeter, Member of the Royal College of Surgeons, President of the Westminster Medical Society, Honorary Member of the Physical Society, Guy's Hospital, &c. With Plates and Wood-cuts. 8vo. pp. 70. London: Sherwood, Gilbert, and Piper, 1840.

MR. Streeter is a gentleman engaged in an extensive general practice, and it reflects no small degree of credit on him, that, harassed as he must be with calls upon his time and his attention, he should cultivate the science of his profession with such ardour and success. Those who enjoy the pleasure of his acquaintance can best speak to that enthusiasm which he displays, and which alone can conduct to anything great or honourable in medicine.

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Mr. Streeter informs us that, being occupied with the study of the development of the nervous system, he was naturally led to examine such ova, passed by abortion, as came under his notice as an accoucheur. "I experienced," he says, "little difficulty in procuring foetuses which had arrived at the middle periods, but observation soon convinced me that perfect and well-formed embryos were rarely expelled in miscarriage till after the third month had been completed; indeed, in most instances, before that time the ovum when passed entire was found on being opened to contain no fœtus, or one in a blighted or decayed condition; and I noticed that, where such ova were thrown off by abortion, my patients had resisted the usual means of prevention, that they often recovered rapidly, and showed little or no tendency to miscarriage in subsequent pregnancies." Many interesting cases of threatened or of actual miscarriage having occurred to Mr. Streeter, he was induced to review the whole subject, and ultimately to lay the result of his inquiries before the Westminster Medical Society, in the shape of a distinct essay. The present work is that essay in another form, and with some slight additions, and the main object of the author in addressing both the Society and the profession may be gleaned from the following passage.

"The practical points which I was anxious to enforce on the members of the Society were a more exact distinction between the premonitory and the essential symptoms of miscarriage, the impropriety of the use of opium, and the advantage of that of ergot during the presence of the latter, and the disadvantages of a casual or intentional rupture of the membranes during the process of abortion. Lastly, I wished to direct attention to the impossibility of laying down rules for the prevention of miscarriage in any subsequent pregnancy, without first determining, from accurate examination and competent knowledge of embryology, the normal or pathological conditions of the aborted ovum, and hereby arriving at the real cause of the miscarriage, instead of indolently and vaguely assigning it to the last accompanying circumstance."

The work consists of five chapters, the first devoted to some general observations-the second to the structure of the ovum-the third to the nature, symptoms, and causes of abortion-the fourth to the treatment of abortion-and the fifth to the prevention of abortion in any future pregnancy.

1. In his general observations, Mr. Streeter defines what he means by abortion or miscarriage (he employs the terms synonimously). He considers it, with Dr. Granville, as the premature extrusion of the ovum before its fœtus is capable of maintaining life, independent of the parent,-if it is so capable, it is premature labour and not abortion. He eloquently denounces the absurd distinction still preserved in our criminal code, between the procuring abortion before and after the period of quickening, and the staying of execution of pregnant criminals, only after that event has taken place.

2. The chapter on the structure of the ovum affords ample evidence of the industry, and of the judgment of our author. But it is not necessary for us to follow him in his embryological sketch.

3. Mr. Streeter remarks, that abortion may occur from the ovum not forming its normal attachment to the uterus after entering that organ in consequence of a defective formation of the decidual lining. More commonly, however, miscarriage does not occur until after the attachment of the ovum, when it usually consists:

1st,-In the destruction of that membranous and vascular attachment which the ovum normally forms, by means of the uterine envelopes and the placenta, to the interior of the uterus.

2nd,—In the dilatation and opening of the neck and mouth of that organ, and,

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