Medical literature upon the subject of "Missed Abortion" is exceedingly scant. I presume this is accounted for by the comparative rarity of its occurrence. In my own practice of eighteen years I have had, to my knowledge, three cases. I do not know whether this is above or below the average frequency.

CASE 1.-The first of my cases dates back to 1895. The patient was a multipara, aet. 30 years. She menstruated regularly until October, when her menses, which should have recurred October 11th, did not appear. At Christmas (ten weeks after she missed her period) she had a sharp uterine hemorrhage, but did not call a doctor. The blighting of the ovum probably occurred at this time. After this she had a slight flow at irregular intervals, consisting, as she described it, of menstrual fluid (improbably so) and blood clots. On May 11th, about five months after the period of "missed abortion" probably began, she had another rather profuse hemorrhage, after which I was called in. I found the os dilated and only slight oozing of blood when I arrived. The following day, after removal of the vaginal gauze packing, a body could be seen presenting itself at the external os. It was easily removed with a pair of uterine dressing forceps. It consisted of a mass 2 1-2 inches in length, rolled upon itself. Unfolding it, in the centre, there was a small membrane, but the embryo had become absorbed or extruded. The patient made an uneventful recovery.

CASE 2. Mrs. B., nullipara, 30 years of age, five years married, anaemic, menses regular, but scant; menstruated June 2, 1902, then

* Read at Ontario Medical Association, Hamilton, May, 1908.

menses ceased; during July and August she vomited persistently, after that the vomiting subsided, amenorrhoea continued, the tension and size of the breasts increased, colostrum was present, the nipple areola grew darker, and discoloration of the mucous membrane of the vagina and vulva were marked. October 1st, four months after menstruation ceased, after a heavy day's work, patient complained of feeling chilly and nervous, was nauseated and dizzy. I found the pulse rapid, but no elevation of temperature. Slight pain in the pelvic region, but not intermittent. Abdominal muscles were rigid, there was no bloating and no hemorrhage. I gave her a hypodermic of morphia sulph., and in a day or two she was up and around again. I think the death of the ovum occurred at this time. Thereafter she was not herself. She complained of anorexia and general malaise, while considerable despondency was apparent, and the former signs of pregnancy gradually disappeared. On February 3rd, eight months after the last menstrual period, and four months after the supposed death of the foetus, the patient sent for me, complaining of uterine pains, not severe or regular, however, and accompanied by nausea and ringing in the ears. She said she had a feeling of impending death, which she could not account for. On bimanual examination, I found the uterus only slightly enlarged, and the os neither dilated nor much softened. There was a slight sanious discharge from the uterus, but no hemorrhage. As there was no temperature, and no urgency, I waited for 48 hours, in expectation that the uterus might empty itself, if any foetal remains were retained. As no expulsion took place in the meantime, the patient was prepared, and under an anaesthetic the uterus was relieved of its contents, which consisted of an elongated mass, 3 inches in length and 1 inch in breadth. The decidual membranes were wrapped round a partly mummified foetus. The patient soon regained her usual health, none too rugged at the best, and fortunately has not become pregnant since.

age.

CASE 3.-Mrs. H., aet. 28 years, mother of one child 2 years of No history of miscarriages or abortions. Well nourished. Last regular menstruation January 6th, 1907. Following this date she had the early symptoms of pregnancy. I visited her by request on March 13th, about ten weeks after menstruation ceased. She had passed a restless night, with nausea and dizziness, but no hemorrhage, and no uterine pains. At this time, and throughout the entire history of the case, the most persistent symptom complained of was a sensation simiar to the aura which so often precede an epileptic attack. I was next called May 4th, owing to a severe uterine hemorrhage, which alarmed the patient, four months

after her menses ceased. The uterus was enlarged and contained a fibro-myoma the size of an orange in the left antero-lateral wall, and another one-quarter that size more anteriorly. The cervix was soft and dilated. The vaginal and breast symptoms of pregnancy were quite marked. After a week's rest in bed the patient got about as usual. The death of the foetus apparently took place at this time, as there was no further enlargement of the abdomen, and the vaginal and breast symptoms disappeared. The aura continued as before, the abdomen felt distended at times, slight hemorrhage occurred at intervals. On August 30th, four months later, she had another rather copious hemorrhage, and I was again sent for. On September 2nd I had her taken to the hospital, and removed under anaesthesia what appeared to be a four months' placenta; no foetus. was found, the membranes were ruptured, but only partially absorbed. The structures were undergoing maceration. The patient made a speedy recovery, and has menstruated regularly the last three months, without dysmenorrhoea or hemorrhages, although the flow is very profuse and recurs every three weeks, due, of course, to the presence of the fibro-myomata.

In reviewing the history of these cases, I observe that the period of "missed abortion" was of about the same duration in all three, viz., three to five months. In one case expulsion took place naturally, in the other two artificially.

The first and last cases had a history of uterine hemorrhage; the second case had no such history throughout. This case was a nullipara, the only case I have found recorded in which "missed abortion" took place in a nullipara. It was that of a patient with a debilitated constitution. Case 1 and 3 were patients ordinarily in robust health. Case 3 was complicated by a fibroid tumor, which, doubtless, was a factor in inducing the hemorrhage, which blighted the ovum. This case is still a problem on my hands. Notwithstanding the presence of a multiple fibroid, and the frequent and profuse menstruation, am I justified in letting the case alone while the health is not further impaired? She is a young woman, and I do not feel warranted in unsexing her, unless indications become more urgent than at present. Am I pursuing the best course? Further, in the event of her unfortunately becoming pregnant again, should pregnancy be interrupted early or allowed to go on? Although these questions are only incidental to my subject, I would like an expression of opinion upon them.

But to return in conclusion to the subject of "missed abortion," I am unable to throw much light upon its etiology. Lack of sensitiveness, or irritability of the uterus, to the dead ovum is a factor,

whether the only one or not I cannot say, in the causation of "missed abortion." This lack of uterine susceptibility is rare. The tendency of the average uterus is to part easily with its contents, especially at certain recurring periods during pregnancy.

The interference with the foetal circulation incidental to threatened abortion from hemorrhage I take to be the most frequent cause of the death of the ovum. The large majority of the cases which I have found recorded give a history of early pregnancy, then one or more hemorrhages, followed by the arrest of the symptoms and development of pregnancy-without expulsion of the uterine contents. The knotting of the umbilical cord or the coiling of the cord about the neck of the foetus may sometimes be a cause of its death. In one of my cases, and some of those which I found recorded, there is no history of hemorrhage, merely a history of feeble health, normally as well as during pregnancy. The maternal constitution is apparently unequal to the added task of sustaining the life of the foetus, and it dies from inanition. But, while these and various other reasons might be given to account for the death of the ovum, it is much more perplexing to account for its retention by the uterus, contrary to the normal habit of that organ. None of the authors to which I have had access discuss the etiology, much less give any satisfactory reason for its occurrence, and to myself the relative non-irritability of the uterus in exceptional cases is the only reason that appeals to me.

It is noticeable how generally no trace of the foetus is found, the ovum having either been absorbed or casually expelled. The placenta usually remains intact, and is found intimately adherent to the uterus. Mummification only takes place when the membranes have remained unruptured. If the membranes are ruptured or absorbed, maceration and latterly putrefaction takes place. This happens because the vernix caseosa is no longer secreted for the protection of the foetus.

I have not gone into the subject of differential diagnosis in this paper, and I have not made any distinction between "missed abortion" and "missed miscarriage," nor have I discussed that still rarer occurrence, "missed labor."

I am inclined to think "missed abortion" occurs oftener than is usually supposed, as doubtless many cases are not detected, since nature sometimes empties the uterus spontaneously in cases of "missed abortion," the expelled product never coming under the observation of doctor or nurse. As there is no known limit to the duration of "missed abortion," the subject is one not only of medical interest, but of moral and medico-legal importance as well.

Perhaps some of you may recall the case of the distinguished obstetrician and author, Playfair, who is said to have been mulcted in a fine of £5,000 for implicating inadvertently a family friend in a scandal, through the occurrence of an abortion ten months after her husband had left his home and wife for service in India. The case, I believe, was afterwards conceded to be a case of "missed abortion," but the occurrence is said to have blighted the after life of Dr. Playfair.

EXPERT MEDICAL TESTIMONY.*

BY J. J. MCEVOY, BARRISTER, LONDON, ONT.

At the outset let me say that I am entirely at issue with the Western judge who divided witnesses into three classes, the liar, the damned liar and the expert witness. So far as my own experience goes, my deliberate judgment is that there is no class of witness more conscientious and reliable than the medical expert. One hears in loose talk, "If you get half a dozen doctors to swear one thing, I will get you half a dozen to swear the opposite." In my experience and reading I know of no such case, although I have been concerned in several cases in which I have known such statements to be made with a pretended knowledge of the facts. I particularly recall a celebrated murder trial, on account of which, it is said, a limit was put upon the number of experts who might be called in any case, and I venture to say that if I read to you gentlemen the cross-examination of the Crown doctors and the chief examination of the defence doctors, you would not be able to say which were witnesses for the defence and which were for the Crown, speaking from the substance of the answers given, though by the form you might detect a difference. In that case there was in the totality no difference of testimony on behalf of the medical witnesses for the Crown and the defence, although the press and the public almost made a scandal of it.

There is too much thoughtless, too much prejudiced and too much malicious abuse of the medical expert witness; and there is much more ignorant than well-informed criticism of him. This is true not only in our own country, but in many other countries. I speak more particularly of Anglo-Saxon communities, where the

* Read before the London, Ontario, Medical Association.