contained pulpy sebaceous material; but there were no hairs or teeth seen in it. The cyst-wall was fairly thick and fibrous.

It is now a well-recognised fact that, if a pregnant woman requires abdominal section, one need have no hesitation in performing the operation. The risk to the woman is undoubtedly somewhat increased by the pregnancy, but not to a very great extent. There is greater risk to the pregnancy than to the woman, but in a large proportion full time is reached. Fibroids have even been enucleated without any interruption of the pregnancy. Some women are very prone to abort or miscarry, and in such even a simple operation may cause the uterus to expel its contents. Others, again, will stand a great deal of even actual violence without the pregnancy being affected.

As to the best time to operate, one will often have no option; but, if possible, one should operate sufficiently long before full time to allow of the formation of a firm cicatrix. I am inclined to the view that the earlier the operation is done the less risk there will be.

In the case described I wished to operate fully a month earlier, but the patient would not consent until she began to feel discomfort from pressure.

The foetus, I think, perished during the operation. Its death may have been caused by the chloroform. I can recall one case at full time where we thought the chloroform had caused foetal death. The heart was beating well when the chloroforming was commenced, but stopped in a short time, and the child was quite dead when delivered. The delivery was perfectly easy, and the cord had not been subjected to any pressure.

III-CASE OF PRECOCIOUS PREGNANCY IN GIRL OF 13 BEFORE THE ESTABLISHMENT OF THE MENSTRUAL FUNCTION.

BY DR. G. BALFOUR MARSHALL.

J. M., æt. 14, was brought to the Royal Infirmary on 10th May, 1898, for distension of the abdomen. The girl's mother had noticed a gradual enlargement of the lower part of the abdomen during the previous three months. She had never menstruated, but was well developed for her age. Examination showed that the uterus was between seven and eight months pregnant, the fundus being fully 3 inches above the umbilicus. The foetal heart was audible, and the foetus itself could be easily palpated.

As usual, the girl denied that she could possibly be pregnant; the hymen, however, was ruptured, proving penetration.

This case is interesting owing to the youth of the girl, as she was impregnated when only 13 years old. It also goes to prove that ovulation is independent of menstruation, and that pregnancy can occur about the time of puberty and before the menstrual flow is established. Gould and Pyle, in their book on Anomalies and Curiosities of Medicine, quote a number of instances of precocious impregnation between 9 and 12 years of age, as well as several cases of pregnancy before the appearance of menstruation.

Dr. Carstairs Douglas said that Dr. Marshall's case of pregnancy at the age of 13 was quite worth while recording, as there were not many authentic cases of gestation at this

The matter was interesting from a medico-legal standpoint. At least two cases of delivery of girls before the thirteenth year had been reported in this country, while the earliest known case in Britain is probably that reported by Dodd (Lancet, 1881), where a female child began to menstruate at 12 months, became pregnant at 8 years and 10 months, and was delivered of a 7 lb. infant.

IV. CASE OF RUPTURED TUBAL GESTATION ASSOCIATED WITH TWIN-PREGNANCY IN UTERUS.

BY DR. G. BALFOUR MARSHALL.

Mrs. X., aged 30, was admitted to the Royal Infirmary on 27th July, 1900, having been sent by train from Ardrossan by her medical attendant, who certified her as a case of ruptured tubal gestation.

History of case. She had had four children, the last twenty months previously, all the labours being easy and the recovery good. Her last menstrual period was in the middle of April, and she stated she had never felt well since, suffering from pain in the lower abdomen, slight vaginal discharge, and occasionally faint turns. She considered herself three months pregnant at date of admission.

A severe attack of pain-the first-occurred about the middle of May in the lower abdomen. It was so severe as to cause her to faint, but she did not take to bed.

On 23rd July she had another very severe attack of painthe second-and noticed the abdomen swollen. Her condition did not improve during the succeeding four days, so her

medical adviser sent her to hospital, where she was admitted at 9 P.M. on 27th July. The patient was constipated, and next forenoon, the 28th, the nurse gave an enema, which did not empty the bowel. This was followed by severe pain-the third attack-in the left iliac region, and the patient collapsed with pallor, cold sweat, vomiting, and great thirst. The pulse at midday was 142, respirations 30, temperature 98. I was telephoned for, and arrived at hospital about 1 P.M. The patient now showed all the signs of great loss of blood. There was a feeling of restlessness and great anxiety; she complained much of thirst and coldness, and her respiration (30 per minute) was sighing in character. There was great pallor, the mucous surfaces were colourless, the temperature was subnormal (974), the radial pulse very rapid, about 150, and so feeble that it was difficult to count.

Examination.-The abdomen was much distended and rounded. Both flanks were dull to percussion from pelvis to costal margin as far forward as a vertical line from the middle of Poupart's ligament. The whole lower abdomen was also dull as high as the lower umbilical region. Palpation showed an ovoid tumour, which proved to be the uterus extending upwards to about 3 inches below the umbilicus, and deviated to the right. Bimanually, the uterus was felt enlarged to the size of a four or a four and a half months' pregnancy. To the left side lay a large fist-sized, partly cystic, partly boggy, fixed tumour, very tender to touch, which lay deep in the pelvis, the lower rounded border being about the level of the cervix, the upper border reaching above the pelvic brim. The pouch of Douglas was free.

Diagnosis.-Uterine pregnancy and ruptured ectopic gestation, left side, with copious intra-abdominal hæmorrhage. I had no hesitation in deciding to operate at once, although the patient was very collapsed, indeed, I feared she would die on the table. The patient was hastily prepared, one-thirtieth of a grain of strychnine being at the same time injected hypodermically.

Operation.-As soon as the peritoneum was opened, blood welled forth. The abdomen was found full of fluid blood, which was removed. The pregnant uterus was deviated to the right and on passing the hand into the left side of the pelvis a large ruptured sac was felt, from which a well-developed three months' foetus was removed (see illustration). To control the hæmorrhage, which was still active, the ovarian artery was ligated close to the uterus and at the infundibulopelvic ligament. The upper part of the gestation sac was

formed by dense broad adhesions firmly matting the small intestines together. The small placenta was adherent to the posterior aspect of the sac, the upper surface of the sigmoid, and the meso-sigmoid. It was removed without injury to the bowel. The cavity of the sac extended deeply in the pelvis to the level of the cervix, and there was extensive copious oozing of blood, especially from its lower half. As the hæmorrhage could not be controlled without ligating both ovarian and both uterine arteries, and as the patient could not possibly stand a certain abortion with its further loss of blood, the uterus was removed, Doyen's clamps being used, instead of

ligatures, to save time. The oozing from the sac was now slight, and to control this the cavity was firmly plugged with sterilised iodoform gauze, the ends being brought into the vagina. The abdomen was closed with silkworm-gut sutures. Immediately after operation a saline and brandy enema was given, and a pint of saline solution infused. The hypodermic of strychnine (one-thirtieth of a grain) was also repeated. Saline infusions and strychnine were repeated, when indicated, during the following evening and night. The pulse greatly improved, and by midnight was down to 124.

Next day, the 29th, the patient felt better, though very thirsty, and, fortunately, there had been no sickness.

The

pulse was stronger, 128 per minute, and the temperature 100° F.

On the morning of the 30th the clamps and gauze packing were removed. There had been no hæmorrhage. The pulse remained fuller and better. There were strong hopes of recovery, but at 7 P.M. the patient became collapsed, she complained of colicky pains in the abdomen, and the pulse became feeble, rising to 142. Saline infusions and strychnine injections were given at intervals during the night, but the patient gradually sank, and died at 5:50 A.M., the pulse before death being 160.

A post-mortem examination was made, and the following report given:-The wound area was clean. There were no signs of peritonitis nor hæmorrhage. Each pleural cavity contained 12 oz. of blood-stained fluid. The heart was almost bloodless, and all the organs were extremely anæmic. Death was due to excessive loss of blood.

The uterus, when opened, revealed a twin pregnancy, each foetus lying in the transverse, one above the other (see illustration). Each foetus corresponded in size to a three or three and a half months' pregnancy, and this is probably correct, calculating from the last menstrual period in the middle of April.

The anatomical relationship of the pelvic structures was so distorted that it was at first difficult to be certain whether it was a rupture of a secondary abdominal, i.e., tubo-peritoneal sac, or of a sub-peritoneal pelvic gestation. I am inclined to think the former, owing to the fact that the placenta was adherent to the sigmoid, and that the upper part of the sac was formed by dense peritonitic adhesions, and roofed in by adherent small intestines. The primary rupture of the pregnant left tube probably occurred about the fourth or fifth week, in the middle of May, as the patient at that time had a severe attack of pain in the lower abdomen, and the seat of rupture was probably on the posterior aspect of the tube, the commonest site. Some nine weeks later, on 23rd July, she had a second attack of abdominal pain, which continued, so that her medical attendant sent her to Glasgow as a case of ruptured tubal gestation. I am a little doubtful if a rupture really occurred then, but if so, the quantity of blood effused into the abdomen must have been small. There is no doubt, however, that the enema given on the 28th caused the final rupture, and this is readily understood from the fact that the sigmoid formed part of the sac wall, and had the placenta adherent to it.