The Placenta.-The placenta was 14 cms. by 7 cins., and the cord was only 21 cms. long. The placenta was located to the right and over the middle zone of the uterus, encroaching upon the lower or danger zone. Membranes were quite firmly attached at the fundus and had to be removed by manual curettage. The whole placenta was also removed manually.

The obstetrical and puerperal conditions are not without interest, and may be added to the report with profit:

Ten minutes after delivery a severe hemorrhage began, the blood poured out of the vagina, and the uterus was relaxed. In as much as massage and Crede failed to bring about uterine contractions and expel the placenta, I scrubbed my hands immediately, and removed the placenta by manual curettage.

The other measures used to aid in controlling the hemorrhage and in keeping up the strength of the patient were, to hold the abdominal aorta, raise the foot of the bed, and have an assistant massage the uterus. One-thirtieth of a grain of strychnine was given three times, and brandy was also used. Twice while working to free the placenta the patient seemed to be at the point of collapse, the pulse was weak, and her strength failed utterly; it was at these times that the strychnine was given.

As soon as the placenta and membranes were removed, the hemorrhage ceased, the uterus contracted, and the patient regained courage and strength.

After the removal of the placenta, a vaginal douche of plain water, as hot as could be borne, was used, in order to help uterine contraction and prevent further bleeding, and to wash the vagina and vulva.

One dram of the fluid extract of ergot was also administered. The foot of the bed was kept raised for several days, and ergot was given1⁄2 dram t.i.d. for three days.

The pulse and temperature chart ran as follows:

During the time that the temperature was high, the patient had a little headache, there was some pain in the abdomen, and the lochia had a bad odor, the color dark red.

Three grains of calomel and vaginal douches of bychloride of mercury 1-3000 followed by douches of plain water relieved all these symptoms.

The patient gave a history of a chronic purulent leuchorreal discharge of a greenish color that had existed for some time, and which became profuse during pregnancy. This may account for the character of the lochia, which, together with the reaction from the severe hemorrhage and the consequent anemia, may account for the headache, the pain and high fever on the third and fourth days after delivery. There was at no time pain or tenderness in the pelvic region. A pill of iron, arsenic and strychnine was given

for the anemia.

Labor.-Pains existed for three days; time of actual labor was short, perhaps two hours, and the third stage occupied one and a half hours owing to causes above referred to. The patient made an excel'ent recovery.

The question naturally arises, What are the causes of this faulty intra-uterine development?

Lewis, in his article previously referred to, says, "that it may be due first, to pressure from without, the pressure of a contracted amnion upon the cephalic region, so that adhesions form between the cephalic end of the amnion and the underlying tissues of the cephalic end of the embryo at an early period in embryonic life; or second, from pressure within the skull, the circulatory disturbances which result in fetal hydrocephalus."

Some writers go further, and find an underlying cause in maternal impressions, alcoholism' or syphilis in one or both parents. In this case, there are no positive indications of syphilis, but the mal-development, premature birth, might point to a specific infection.

Pre-menstrual Pregnancy in a Girl Aged 13 Years. AUGUSTUS W. ADDINSELL, M.B., C.M. (EDIN.), M.R.C.P. (LOND.), Physician to the London Temperance Hospital, in The Lancet.

A girl, aged thirteen years, was taken to the London Temperance Hospital by her mother early in January last, suffering from abdominal pain and slight vaginal hemorrhagic discharge. The breasts were well developed and contained milk. There was an abdominal tumor. The pubic hair was very slight in quantity. As vaginal examination was extremely painful, an anesthetic was given. It was found that an arm and the cord were presenting. There was no pulsation in the cord. Mr. T. G. Ward, the senior resident medical officer, performed version and removed a welldeveloped seven months child, which showed no signs of life. Convalescence was without incident.

The interest of this case lies in the fact that impregnation took place before the outward signs of sexual maturity had manifested

themselves. The evidence of the mother had been carefully taken ; the girl herself was very positive that "she had never seen anything," and remained unshaken when questioned by the medical Registrar or by the sister of the ward in private conversation; she was at school, and professed entire ignorance of her condition; moreover, she positively denied any intimacy with man or boy.

There is nothing very remarkable in the age of this young mother. Plenty of cases of precocious maternity are to be met with. A girl, nine years old, gave birth to an infant in France ; others of eleven and three-quarters, twelve, and twelve and a half years, respectively, are recorded in this country, but in these cases. previous menstruation has been noticed. The testimony of the patient and her mother in this instance is so definite as to make it quite certain that the usual monthly flow had never taken place. After all, is this very wonderful? The signs of sexual maturity in the female are well known to be development of the mammary glands, growth of pubic hair, and finally menstruation. Whilst these are the outward signs of sexual maturity, cellular activity within the ovary has been proceeding regularly since the birth of the individual. A very interesting and instructive contribution towards the study of the fate of the ovum and Graafian follicle in premenstrual life has been published by Dr. T. G. Stevens in vol. xlv. of the "Transactions of the Obstetrical Society" for 1903. He there traces the history of the follicles and the series of changes they undergo, together with the fate of the ovum and its ultimate removal by the phagocytic agency of the cells of the membrana granulosa. This cellular activity within the ovary of the female is precisely similar to that which goes on within the testis of the male leading to the development of the spermatozoa.

Now sexual maturity depends for its onset upon a variety of causes, climate, race, nutrition, growth, etc., but there is reason to believe that our remote ancestors matured sexually much earlier and were much more prolific; and that with the advance of socalled civilization the recognized nubile age has been made later and later, until at the present time it represents a grave sociological problem in more than one European country. In Central Africa it is by no means an uncommon thing for a girl to become a mother before she has menstruated, and in certain districts of India, where early marriages are common, the same thing has been recorded. Rachmakoff, a Russian physician, reports a case in a girl, aged fourteen years. A traveller in the remote regions of Australia told me of a case in his own camp of a girl, aged ten year, who had never menstruated, and became pregnant. Metchnikoff, in his book, "The Nature of Man," quotes several cases also. In the warmer and Eastern climates then it would appear to be a well recognized fact, and this doubtless because there is in those countries less sexual restraint; while in the West sexual matu.ity in

both sexes comes later, and when it does come, environment, habit, training, and general oversight make early or precocious impregnation less probable, but that is all; precocity in the East is the rule, in the West it is the exception.

The life-history of the ovum and the follicle in pre-menstrual life, as traced by Dr. Stevens, shows that maturity up to a point is constantly going on in those follicles which come to the surface, and when that point is reached retrograde changes take place in. the infantile ovary. Now, as the age of sexual maturity is being reached and as ovulation is regularly proceeding, it is easy to see how impregnation might occur even though the outward and visible. signs of sexual maturity be absent. The periodic occurrence of ovidation is most assuredly independent of menstruation and certainly precedes its initial onset, and it is not difficult to see how the nervous and circulatory excitement attendant upon the act of coition may bring about the rupture of a ripe follicle and the resulting escape of the ovum.

Assuming the statement of this patient and her mother to be true (and there is no reason to doubt it, for every effort has been made to ascertain the exact facts)—viz., that she had never menstruated-then it is an added proof, were that needed, of the contention that ovulation and menstruation are not interdependent, though they may be coincidental.

There is something curiously akin to a pathological process in the menstruation of women. In every other instance discharges of blood, whether from the intestines, lungs, or kidneys, are evidence of disease. The analogue in the higher vertebrates is "heat," but in very few is this accompanied by a discharge of blood, and where there is a slight staining, the proportion of red blood corpuscles to white is very small, as in those macaque monkeys observed by Heape of Cambridge. In the case of "Johannah," the famous chimpanzee, whose menstrual history I have recorded elsewhere, I made a careful microscopical examination of the menstrual discharge and satisfied myself that the red corpuscles were comparatively small in number, though enough to tinge distinctly and to stain red the monthly flow; still, all these were under the artificial surroundings of captivity. Not only the attendant pain and copiousloss in women, but the general and nervous disturbance occurring at these times are suggestive of a departure from the originally normal line. The amenorrhea accompanying lactation is often regarded by women as a welcome condition of security from impregnation. This we know to be an error, for ovulation is proceeding with the accustomed regularity and impregnation may, and often does, take place. Furthermore, the development of the endometrium every month may be safely regarded as the preparation of the uterus for the implantation of an impregnated ovum, and the

menstruation may be considered as evidence of a failure of these anticipations.

It is quite likely that primitive woman never menstruated, at any rate as we know menstruation to-day, and there is reason to believe that this phenomenon, this heritage of woman, of which she is not proud and for which she is not grateful, has assumed its present proportions as a result of the almost universal practice, begun in the earliest ages, of restraining the excessive uberty of our primeval ancestors.

A Case of Chronic Intestinal Obstruction with Perforation of the Sigmoid Flexure. GEORGE A. CLARKSON, F.R.C.S. (ENG.)

in The Lancet.

The notes of the following case present one or two points of considerable interest. At the time of the first operation the history and the age of the patient led me to believe that I was dealing with a stricture of some part of the colon due to growth, but the distension of the small intestines and cecum was so great and the call for immediate drainage of the distended bowel was so urgent that no prolonged examination of the colon could be made. The subsequent sloughing and perforation of the sigmoid flexure probably occurred at the seat of obstruction, yet here no cause was obvious to account for the condition found. The gut, though in a condition litt'e short of gangrene, was apparently not invaded by growth, and the fact that no fecal matter was found in it rather excluded the idea that retention of a scybalous mass of feces at that point had given rise to inflammatory softening and perforation of its coats.

The patient, a woman, aged fifty-two years, had suffered from disease of the outer surface of the acetabulum for twelve years, and the sinuses on the outer side of the right hip had healed after, a free exploration and scraping in May, 1903. In the spring of 1904 she began to be subject to occasional attacks of vomiting, accompanied by abdominal pain, distension, and constipation, but these attacks were relieved from time to time by aperients and enemata. On May 9th she was seized with a severer attack than usual. The bowels were at first relieved and the sickness would stop for twelve hours at a time, but invariable returned again. The patient was kept in bed, put on a fluid diet, and saline aperients and enemata were given with some result. A rectal examination revealed no stricture within reach of the finger, nor could anything be felt through the abdominal walls to localize the seat of obstruction. On the 15th the symptoms became urgent, the vomiting being persistent and copious, but not offensive in smell, the abdominal distension became very great, and there was obviously