death is; as a rule, protracted, such as in chronic diseases of the heart, kidneys, and lungs, and in phthisis, the patients often, as in the case I have related, being in a dying state for days or weeks together. On one of these occasions, when the patient is apparently at the point of death, coagulation takes place; from this moribund state he rallies for a time, the clot, however, remains, and undergoes the softening process already described. In short, they are produced in the same way, and from the same cause, as the clots formed immediately before death, which are so frequently found in the cavities of the heart, and which only require an equal length of time to elapse for similar changes to take place in them, as are observed in those under consideration. II.-ON STRICTURE OF THE INTERNAL OS AS A CAUSE OF MISCARRIAGE. By WILLIAM MARSHALL, M.D., Mortlake, Surrey. MRS D., aged 30, a delicate woman, five months advanced in pregnancy, was taken with labour pains about 6 o'clock one evening. I saw her at 8.30. The pains were strong and forcing, very similar in character to those which immediately precede the expulsion of the head in a primipara. I was told that when pregnant last she had miscarried at the fifth month, and that the pains then, for three hours, had been very severe -much worse than she had ever had them in any confinement, and similar to what they were now. On examination, I found the os uteri dilated to the size of half-a-crown, and very soft. On passing my finger further up in order to feel the fœtus, I found the canal of the cervix becoming decidedly narrower, when suddenly she cried out that I was cutting her, and jerked herself away. On a second attempt the same thing was repeated; but on a third, being prepared for her moving, I ascertained that a tight resisting constriction existed at the internal os, which would not admit the tip of the finger. As soon as I touched the constricted part, she complained of a severe cutting pain; and on attempting to pass the finger through it, she became hysterical, and on my persisting, per fectly maniacal. On withdrawing my finger she immediately became rational, and complained of the agonizing pain I had caused her. As she was quite positive that in her previous miscarriage she had suffered for three hours as much as she was doing now, I waited for a couple of hours. During this time the pains were very strong, and the suffering greater than I had ever seen in any confinement. In order to make a thorough examination, I put her under chloroform. The external os was very soft and dilated; but at the internal os there existed a constriction which still readily allowed the finger to pass through, and which seemed now quite dilatable. The breech was presenting, and I had no doubt that when a pain came it would be pushed through, and the whole thing soon be at an end. The pains, however, did not return as long as I kept her under chloroform, so that I was forced to discontinue it. The stricture returned with the first pain, firmly grasping the tip of my finger, which I had retained in the uterus. I now gave her a dose of ergot, and waited until one o'clock, when, finding that little or no progress had been made, I determined to notch the stricture in one or two places, under chloroform, as it was impossible to touch it without causing intense pain, and bringing on a maniacal paroxysm. I went home for a probe-pointed bistoury, and on my return in halfan-hour, found the strictured part, with the breech forced into it, protruded through the external os, which was drawn up around it. After a few pains, the breech passed through the constriction: I pulled down the body, and finding that the head would not come, pushed my finger past it, hooked it over the crown, and pulled the head through the stricture. Without withdrawing my finger, I detached the placenta, and withdrew it and the finger at the same time. While doing all this, the patient was perfectly maniacal—she shrieked, kicked, struck and bit at those around her. Immediately on withdrawing the finger she became rational, and apologised for what she had done; the agony had been so intense, she said, as to drive her for the time out of her senses. She recovered without a bad symptom. To one interested in uterine pathology, this case is, I think, of considerable interest. Firstly, With regard to the stricture itself, it is remarkable (1) that a stricture should have existed in such a spot; (2) that it should have been so exquisitely painful to the touch; (3) that the pain should have given rise to paroxysms of hysterical mania. May not some forms of puerperal mania depend upon a uterine lesion acting on an hysterical system? Secondly, That the stricture was the cause of the miscarriage in this and the previous pregnancy I have no doubt. I have never seen this mentioned as a cause of premature labour. The uterus, up to the fifth or sixth month of pregnancy, grows and expands almost entirely in its upper part. At that time it enlarges downwards from the internal os; but in this case the stricture would not allow it to expand, and by continued irritation, induced labour pains. Thirdly, If this be true, it throws some light upon "What is the cause of labour?"—a point, I believe, still undetermined. If you examine the uterus at the eighth month, you find a considerable portion of the neck still unexpanded; if you examine at the end of the ninth month, you find the neck entirely obliterated. What happens then? Does the uterus stop growing? No: it still continues to enlarge downwards, and it can only do so by dilating the os. Had this stricture been situated at the external os, the uterus would have gone on growing until the end of the ninth month, and then, just as in the miscarriage, by irritation of the stricture, labour pains would have set in. It is not necessary, however, to invoke the aid of a stricture at the external os to induce labour pains. The os is the most sensitive part of the whole organ; to dilate or irritate which is to bring on pains. This the natural growth of the uterus does; then, those contractions of the uterus, sometimes painful and sometimes painless, which occur every hour or two during the latter months of pregnancy, recur with greater frequency; the membranes and the head of the child are pushed down upon the os, exciting it more and more to induce pains by reflex action, until finally the labour is accomplished. This I have long regarded as the explanation of the cause of labour: the natural expansion of the uterus, acting on the sensitive os, begins to dilate it, and through it reflexly the necessary pains are called forth. III-A VISIT TO SOME OF THE GERMAN SPAS. By Dr M'CALL ANDERSON, Professor of Practice of Medicine in Anderson's I. AIX-LA-CHAPELLE. In the course of a professional tour through Germany last summer, in company with my friend Mr Hinton, the eminent aural surgeon, we made a point of visiting some of the more celebrated of the German Spas; and it has been suggested that a short statement of what we saw, and of the opinion we formed of the efficacy of the waters, might not be without interest to some of the readers of the Journal, who have neither the time nor the opportunity to study them for themselves, and who might possibly be led to undervalue their efficacy, owing to the extravagant laudation too often bestowed upon them by interested persons. Aix-la-Chapelle is very accessible, being reached from London, via Brussels, in about 18 hours. It is fully 400 feet above the level of the sea, being situated in a pleasant valley between the Rhine and the Maas, and contains about 50,000 inhabitants. Its environs are agreeable, surrounded as it is by wooded eminences, the most attractive being the Louisberg, which is laid out after the manner of what our neighbours are pleased to term "an English garden," and which commands a very fine and extensive view. The principal springs are four in number, each containing the same ingredients, but in varying proportions. Their temperature ranges from 113° to 131° Fahrenheit. The Kaiserquelle (Emperor's spring) is at once the strongest and the hottest. It contains fully 30 grains of solid, and about 26 cubic inches of gaseous constituents in 16 ounces, and its temperature is about 131° Fahrenheit. There is a large propor tion of chloride of sodium (common salt), and its virtues are due partly to this, and to the other salts which it holds in solution, but in great measure to the large amount of sulphur which it contains, and to its high temperature.* The waters are generally employed both internally and externally. They have a sulphureous odour and taste, mixed with a decided taste of common salt, and at first are rather disagreeable, although not nearly so much so as the sulphur waters of Harrogate. They are taken in the morning, between 7 and 8 o'clock, the amount imbibed varying from about five to forty ounces, in divided doses, and between each the patients walk in the garden adjoining the Elisenbrunnen, where they meet their friends, and listen to the band which plays during the season. They are taken warm, and are not aperient, like the Harrogate sulphur waters; but when an aperient effect is desired, they are often combined with Carlsbad salt, which is neither more nor less than Glauber's salt (sulphate of soda), and which does not improve their taste. The baths are of three kinds-warm, douche, and vapour. They are generally taken in the morning before breakfast, and about half-an-hour after the waters are drunk, but they may be employed with advantage at other times. Their temperature |