minute. He left her for a short time, but found her symptoms aggravated upon his return. I was invited to see her with him, and met him at half past 2 o'clock, when she appeared to be dying.

As she had vomited very much, and labored under excessive tympanitis, with violent pain in the whole belly, she got an enema, which brought off a great deal of stercoraceous matter, but without any relief of pain. In half an hour she said "raise me up, my breath is leaving me," and she was slightly elevated on a pillow, when she immediately swooned, and died.

Twenty hours after her death I inspected the abdominal cavity, which contained about thirty ounces of blood and bloody serum. The pelvis was filled with coagula, and much blood was lying among the intestinal convolutions.

This blood escaped from a rupture in the left Fallopian tube, which contained a fœtus of six or seven weeks. The ovary was somewhat enlarged. The womb contained a deciduous lining, and the canal of the cervix contained a claret-colored mucus or lymph. The womb was larger than a non-gravid womb, though not much larger.

There is a lithographic print which very faithfully represents the appearance of the specimen, which you may see at page 107 of my "Philadelphia Pract. of Mid.," 2d edition.

What, alas! can we do in these cases? We could make an incision in the abdomen and clear away the coagula and the serum. But who is he bold enough to do so? Who is he astute enough to discriminate betwixt all the possible causes of such phenomena, with so much clearness as to warrant him in the performance of a gastrotomy for Fallopian pregnancy? There is no such wise and bold surgeon; and, therefore, nothing remains for us but to extend all the relief within the narrow boundaries of our power, and calmly await and submit to the inevitable end. Such are painful scenes to the sensitive mind. They cast a color of gloom over the pathway of the medical man, whose whole walk, indeed, is among those who are in pain, in weakness, in fear, or in the valley of the shadow of death. A physician may be calm, and even cheerful, but a merry doctor is a very singular phenomenon.

The diseases of the Fallopian tube then, you perceive, are obscure, and very unmanageable where they become serious.

Doubtless they are many times unsuspected, while they are the true causes of disorders treated under another name, and doubtless their inflammations, spasms, neuralgias, and engorgements, may yield to constitutional and local remedies addressed to symptoms supposed to depend on modifications of other tissues.

I did not say anything as to ovarian pregnancy when I wrote to you my meagre letter on the ovaries, because I intended to say what I have now said on tubal pregnancy, and preferred to reserve my remarks on ovarian gestation for this connection.

You know, for I have many times spoken with you of it, M. Pouchet's opinion that ovarian pregnancy cannot exist. M. Pouchet says, at p. 421, Theorie positive de l'Ovulation spontanée, &c.: "I formally deny the existence of ovarian pregnancy. I admit, indeed, that the egg in the act of escaping from its capsule, may become fecundated by the sperm brought into contact by means of the fimbria, and that it may subsequently be developed at the surface of the ovarium in consequence of adhesions contracted with that organ. But I have no idea of an ovarian pregnancy as understood by writers, that is to say, a development of an ovulum still contained within its Graafian vesicle, and which by its development engenders a foetus enclosed within the very ovary itself."

M. Pouchet, to whom we are indebted for the fruits of very great labor and research on this subject, can hardly, we would think, escape from the necessity of admitting a true ovarian pregnancy, if he will consult Dr. Granville's account of the case published by him in the Lond. Phil. Trans., Part 1, 1820. In July, 1845, I had the honor of an interview with M. Pouchet, at his house at Rouen, and a conversation took place, among other topics, upon this very one of the ovarian pregnancy. I stated my own conviction, that it is impossible to deny the existence of the ovaric gestation, and that the embryo might well be developed in the Graafian follicle, which I see M. Pouchet, in the above sentence published in 1847, does not admit-he adhering to the opinion that the development can occur only at the surface of the organ.

It seems to ine, gentlemen, that if you assert the mutual presence and contact of the generative elements to be necessary to fecundation, you have no occasion to doubt the presence of the male element in the tube, in all cases of tubal pregnancy at least, and M. P. himself says, that it may be possible for fecundation

to take place on the surface of the ovary, by the contact of the germ with sperm brought into the fimbria.

My opinion at Rouen was, and is still, that the porule being formed for the escape of the ovule, which being retained within the capsule by the granular retinacula, it might be the subject of impregnation by sperm brought to it in the fimbria of the tube.

Let us suppose the impregnation to have been effected-then some change of position covering the porule with a peritoneal superficies allowing of adhesion, the ovulum would be necessarily shut up in the crypt or cell, which having now become again a shut sac, development of the germ would go on absolutely in the interior of the ovulum, and Granville's fact, for facts are stubborn things, would be explained without at all shaking the conclusions as to the oviponte.

I cannot predict what may be the opinion you shall adopt on this point. I presume, however, there is not one among you to believe that the macula germinativa, which is on the inner wall of the germinal vesicle, which is buried among the vitellary corpuscles of the egg, which itself is in the centre of the granular masses contained within the inner concentric of the Graafian follicle, hid below the tunica albuginea and indusium of the ovary, can be exposed to the sexual presence and contact by any process other than the spontaneous ovi-posit, which M. Pouchet describes. For my own part, I cannot imagine any other way in which the mutual influences of the generative elements can be brought into effectual activity.

I do not, then, believe that in the ovaric pregnancies the fecundation has been effected, except through an opened Graafian cell, which being subsequently closed by adhesive inflammation at the edge of the porule, has allowed the pregnancy to go on in the ovary itself.

The womb is so constituted as to admit of a development continued throughout the nine allotted months of a gestation; its provision of materials being ample for that purpose. No such provision has been made for ovaric or tubal gestation: hence, within three months, probably, in most cases earlier, the fatal rupture of the containing walls will take place, and the patient lose her life.

I have now treated in succession of the maladies and accidents of the external and internal genitalia. There are many points

which I have passed over in silence, because I have wished to avoid expressing an opinion upon subjects, on which I have had no practical or clinical knowledge. Others I have postponed to a future page, in order that I might not be compelled, on the one hand, to anticipate, nor, on the other, to separate subjects that have a sort of natural alliance. For example, ruptures or lacerations of the womb and vagina, it appeared to me, might better be arranged under the head of those diseases and accidents of pregnancy of which it is my intention to treat. It will be my duty to say much upon the subject of the menstrua, an important item in the history of the female, and one whose modifications and disorders exert a mighty influence on her health and happiness. In order to approach this subject properly, I ought to make remarks on that important and interesting crisis, which is called puberty in the female, and, therefore, my next letter shall be on the subject of puberty, or the puberic age.

C. D. M.

LETTER XXVII.

GENTLEMEN:-I know not whether I shall in this letter succeed in setting forth with clearness, the views I have long entertained, or rather those which I have supposed myself to entertain on the subject of puberty in girls; I fear I shall not. A man may think he has clear views on points in physiology, or in general philosophy, and particularly in any metaphysical contemplation, while, in fact, his notions are not clear, but confused, indefinite, dim, and not readily explainable in words. In such a state of his mind, a man will be found unable to set forth a lucidus ordo of thoughts, for there is no such characteristic order in his opinions on the special topic; and if a writer doth in this way fail, you have fair inference that he fails to be distinct and clear and coherent in his exposition because he is himself indistinct, confused, and incoherent in his appreciation of the subject in discussion.

If you had happened to be eye witnesses of a certain historical event, you would, doubtless, expect to be able to relate all the

successive incidents thereof in a regular order, as they occurred; but should you not be able to do so, it would be because you had observed badly, and kept no memorials or records worthy to be depended upon; in fact you would not know or understand the events of which you had been eye witnesses, and which you supposed yourself to understand and remember perfectly well. We see constant examples of this uncertainty and imprecision of knowledge in testimony daily given to our courts and juries by witnesses called in the case. The truth is elicited only by crossexamination.

Now, when in this letter I come to speak to you on the subject of puberty in girls, I consider myself as having been an eye witness in the cases to be taken up, as to the events and circumstances that attend upon the puberic age; for, the major part of a long professional life has been past amidst such scenes and histories. During many years, I have frequently been charged with the conduct of the health of young females entering upon, passing through, or already gone beyond the puberic age; yet, notwithstanding I have witnessed so many cases requiring medical interposition, I confess that to write you a letter on the subject of puberty appears to me a most difficult task. Certainly it is one I should prefer to avoid, both because of the doubts existing in my own mind as to the peculiar nature of the puberic affections, and of the jejune and little practical notions upon it that I find in the authorities, which I take to be a proof of the difficult nature of the subject. I must pray you, therefore, beforehand, to scan very closely the sentiments that I shall express in this letter, and if you find them to coincide with what is true, or probably true, to adopt and apply them; whereas, if they should prove to be hypothetical and unfounded in truth, you ought to reject and condemn them. I desire only that they should be useful, not merely that they should be acceptable.

The writing a letter upon puberty would not be a difficult undertaking, were one to confine himself to pointing out in the usual manner the period and general phenomena of the change from the girlish to the womanly estate. Nothing is easier than to say that at the age of fourteen or fifteen years the pelvis becomes expanded and consolidated, that the internal and external genitalia and the lactiferous apparatus become completed, &c. &c. But such statements, that are to be found in all the books