fore menstruation is well authenticated.1 The most interesting, from a medico-legal point of view, are those of precocious menstruation. 159. Precocious menstruation.- Mr. Whitmore relates an interesting instance of precocious development of a female child. The menses appeared a few days after birth, and continued to recur at regular intervals of three weeks and two or three days until her death, at the age of four years. The development at this age was equal to that usual at ten or eleven. The mammæ were unusually large; the mons veneris was covered with hair, and the development of the genitals was considerable. It is stated that she manifested at her monthly periods the reserve usual to women at such times.2 Dr. Charles Wilson of Pennsylvania, met with a child five years old who had menstruated irregularly from the fifth month of her life. She was of the usual stature of children of her age, but very stout and fat. Her breasts were about the size of a well-developed adult virgin's, and the pudendum was thinly covered with black hair.3 Velpeau quotes the case of a young girl, in Havana, whose menses appeared at the age of eighteen months, and continued regularly afterwards. The child, moreover, exhibited in her development all the characteristics of puberty. A girl in New Orleans was born in 1837 with her breasts developed and the mons veneris covered with hair. Her catamenia appeared at the age of three years, and continued to return every month thereafter. A case is mentioned in the Lancet where menstruation commenced at the age of two years.*

160. Precocious pregnancy.- Another case is reported where menstruation began in the tenth year; the girl became pregnant between the eleventh and twelfth, and bore a child. A similar case is reported by Dr. J. B. Walker, in which menstruation commenced at the age of eleven and a half years, and the girl was delivered of a child when only twelve years and eight months of age. Ahlfeld refers to a case by Haller of a girl whose menses were regular after the second year, and who was delivered at term at nine years of age. D'Outrepont met with other cases of pregnancy, at the ages of thirteen and nine. Dr. Rowlett reports a case that occurred in Kentucky of a

8

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girl whose menstruation began in the first year and pregnancy in the ninth. Within two weeks after her tenth birthday anniversary, she was delivered of a child weighing seven and three quarters pounds. Hofmann1o describes a case of precocious menstruation, with hair on the mons veneris, at two and a half years, but the internal genitals were undeveloped. He also reports a case from Boulet of a girl pregnant at ten years, who had menstruated since her first year, and another from Kussmaul of a girl who was pregnant in her eighth year and delivered in her ninth year.11 Dodd12 speaks of a girl nine years and eight months old who was delivered of a living child weighing seven pounds. The labor pains did not continue over six hours. 161. Late pregnancy; postponed menopause. The usual age for the cessation of the menses and child-bearing capacity is from forty-five to fifty years; but here, too, there are many exceptions, and here again pregnancy may occur after the cessation of the menses. Barker18 reports the case of a woman, the mother of six children, whose menopause appeared at the forty-second year of her age; but she became pregnant again four years later. He also reports another case where the woman became pregnant in her forty-seventh year, three years after the cessation of her menses. He also mentions three cases of pregnancy after the fiftieth year. Hofmann14 also cites a case reported by Dr. Mayer, in 1894, of a woman fifty-nine years old and already a great grandmother, who was delivered of a child. Her menses had occurred at long intervals since her fifty-fifth year. Kennedy describes15 the case of a woman of sixty-three who at that age gave birth to her twenty-second child, and afterwards continued to menstruate. Orfila1 quotes a case from Bernstein of a woman who began to menstruate at twenty years of age, and continued until her ninety-ninth year. Her first child was born when she was forty

Vol. I., p. 601. For many other instances of precocious impregnation, see Gould and Pyle's Anomalies and Curiosities of Medicine, p. 34.

13 Virchow's Jahresber., 1874, Vol. II., p. 728.

14 Hofmann, p. 72. "Cited by Williams, from Edin. Med. Journ., Vol. XXVII., pp. 1085, 1882.

"Hofmann, Gericht. Med., 8te Aufl. 1902, p. 70. Hofmann also refers to a collection of cases by Howitz, Petersburger Med. Ztg., VIIte Jahrgang, XIII. "La Semaine Medical for February 9th, 1898, Vol. XVIII., p. 59, contains a list of about thirty cases of pregnancy in girls under fourteen years of age. Three younger than that of Dr. Rowlett. One of them from D'Outrepont, in 1825, Méd. Lég., 4th ed., 1848, Vol. I., p. of a girl in her ninth year, who had a 257; also Briand, Man. de Méd. Lég., miscarriage; the one from Dodd, and the 1846, p. 137; and for many other cases third from Molitor, of the Grand Duchy see Gould and Pyle's Anomalies and of Luxemburg, where a girl of eight Curiosities of Medicine, 1897, pp. 32 years and ten months was delivered of a and 38.

dead seven-months fetus.

"Dodd, The Lancet, London, 1881,

seven years of age, and her seventh and last child when she was sixty. In the Lancet, 1866, Whitehead reports that he was called to see a case of profuse menstruation in a woman who was then seventyseven years old, and had always been regular in her menses. In the Amer. Journal of Medical Sciences for July, 1845, page 172, there is the report of a case of a nun who was regular in her menses until fifty-two years of age, when they disappeared, to reappear at sixtytwo. After that they continued regular until the woman was lost sight of at the age of seventy-two. And another case is there reported of another nun who menstruated regularly from fifteen to fifty-two years of age. Then, after a lapse of eight years, they reappeared at the age of sixty, and continued regular until the woman was last seen at the age of ninety years. It would seem, then, impossible to put a definite upper limit on the child-bearing age, or, at least, on the age to which menstruation may continue. But if we take the following figures of Neuermann1 of a thousand births we can see that the probability of pregnancy after a woman is fifty years of age is very slight. Neuermann found one hundred and one children born when the mother was forty-one; one hundred and thirteen at forty-two; seventy at forty-three; fifty-eight at fortyfour; forty-three at forty-five; twelve at forty-six; thirteen at forty-seven; eight at forty-eight; six at forty-nine; nine at fifty; one at fifty-two; one at fifty-three; and one at fifty-four years. Barker, in 1875, said that there was no authentic case of childbirth in a woman over fifty-five. And two legal cases18 are recorded where women of fifty-three were considered as past the child-bearing period of life. On the other hand, a child was born to a woman of fifty-eight years, and the courts considered the child legitimate.19

162. Causes of sterility in woman.- During the normal period of fertility various factors may come in to influence the woman, and produce sterility, for certain congenital defects may become evident as the causes of sterility.

162a. Ovaries atrophic or diseased. The essential female organs may be the seat of the trouble, as in the cases where the ovaries are congenitally absent or atrophic. The ovaries may be diseased so that even though the ova may be formed, they can not be discharged into the Fallopian tubes and carried to the uterus, as in the cases of thick ovarian capsule. Disease of the ovaries, and tumors of the ovaries,

"Méd. Lég., 4th ed., Vol. I., p. 257. "Mem. de l'Acad. de Chir., t. VII., p. 18 Price v. Bousted, and Haynes v. 27. Cited by Montgomery. Haynes, 1866; quoted by Taylor, p. 688.

need not always be associated with sterility unless the entire substance of both ovaries is involved.

162b. Artificial menopause.- In this connection, also, must be mentioned the cases of operative removal of both ovaries, which produces an artificial menopause and sterility. But the remains of even a portion of one ovary is sufficient to supply ova for future pregnancies.20 Recent work in ovarian grafting may also have some bearing upon this question of sterility. Dr. R. T. Morris21 has shown that in rabbits the grafting of the ovaries of another rabbit after the removal of both of the rabbit's ovaries supplied the necessary element, for twice in two cases, after the removal of both ovaries and the implantation of the ovary of another rabbit, pregnancy followed. In one case, in a woman who had ceased menstruating after the removal of both ovaries, an ovarian graft was made and the woman menstruated regularly for several months after this grafting. In another case an ovarian graft was placed in a woman who had never menstruated on account of an infantile uterus. She menstruated for over a year after the operation. Whether such treatment will carry the cases of congenital sterility into the class of remediable sterility remains yet to be proved.

162c. Fallopian tubes.- Disease of the Fallopian tubes which will prevent the passage of the ova into the uterus similarly is a common cause of sterility.

162d. Uterus.— Changes in the uterus which make it an unsuitable nidus for the developing ovum are perhaps the most common causes of sterility. The uterus may remain undeveloped or it may atrophy from some cause, or its mucous membrane may become inflamed or the seat of some tumor, as a fibroid, which interferes with the development of the ovum. With these may be grouped the cases of disease or malformation of the cervix, which have the same result. But here the cause of the sterility is not so much the unsuitable nidus for the ovum as the interference with the entrance of the spermatozoa. The changes to be reckoned in this class are the malposition of the entrance into the uterus, due to a long cervix, or to a malposition of the uterus, or stenosis of the mouth, due to congenital formation, or to scars, or to carcinoma. Here, too, inflammation of the cervix must be classed, for many gynecologists consider the plugging of the

Instances of menstruation after the removal of both uterus and ovaries have been reported by Storer, Lancet, London, 1866, Vol. II., p. 471; Clay, Lancet, London, 1880, Vol. I., p. 15; Tait, Med.

Times and Gazette, 1884, Vol. I., p. 662; and Brit. and For. Med. Chir. Rev. No. 22, 1873, Vol. I., p. 296.

Journ. Amer. Med. Ass., Oct. 17, 1903, Vol. XLIV., p. 980.

cervical canal with inflammatory mucus a sufficient cause for sterility. Inflammation of the vagina, with the production of a secretion that kills the spermatozoa which are deposited there, and tears of the perineum, permitting the escape of the seminal secretion, are also recognized causes of sterility.

162e. Vagina.- Of the absolute and incurable causes of sterility, those depending upon malformation are the only ones of practical importance. Dr. Meigs relates a case of entire absence of the vagina, the external sexual organs being perfectly natural. An incision was made, by Dr. Randolph, three inches and a half in depth, but he could find no vagina.22 Dr. Oldham reports the case of a servant girl whose health had been delicate for some time. "She had not menstruated, suffered periodical pains in the pelvis, or any vicarious bleeding. She had a dull, inanimate, and rather timid look, with the voice and articulation of a delicate female. Her mind was apathetic, and she was sexually indifferent. The chest was flat, and the mammary glands scarcely developed. The pelvis was well formed. The mons veneris, external labia, nymphæ, and clitoris were normally developed, and the first covered abundantly with hair. The situation of the orifice of the vagina was occupied by a raised raphe of mucous membrane, but there was no aperture." A catheter being introduced into the bladder, and the finger into the rectum, no solid intervening structure and no trace of uterus could be discovered.23 In the case of a married woman who died at the age of seventy, the internal organs were but slightly developed, and a shallow depression represented the vagina. On inspection from within the pelvis, this organ was found to be totally wanting. Rudimentary ovaries existed in the abdomen, and rudimentary separate halves of the uterus were found in the pelvis.24 Two other examples, in all probability, of the same malformation, are reported, the one by Dr. J. M. Warren,25 and the other by Dr. C. Coates.26 Troschel relates the case of two sisters in whom the uterus was wanting.27 Siebold examined a woman, twenty

Velpeau's Midwifery, p. 114. "Guy's Hosp. Rep., Vol. VI., p. 362. "Edinb. Month. Journ., N. S., Vol. VII., p. 230.

Bost. Med. and Surg. Journ., May, 1857, p. 297.

26 Times and Gaz., July, 1858, p. 6. "Rust's Magazin, Bd. 37, S. 163; Gaz. Méd., 1851, p. 9, by Dr. Zeihl, of Nuremberg. Total absence of uterus in a woman fifty-seven years of age. observed after death. Dr. Meigs relates two cases of total absence of uterus, but with otherwise perfect sexual develop

ment, in his own practice. (Treat. on Obstet., p. 131.) Dr. G. S. Crawford gives another case of absence of uterus. (N. W. Med. and Surg. Journ., Nov. 1850.) Dr. Cummings found the uterus half an inch long, and the ovaries mere lines, in a woman who had never menstruated. (Ed. Month. Journ., Sept. 1854, p. 275.) Dr. Chew, of Baltimore observed a case in which the uterus was absent. The woman was twenty-two years of age, and had never menstruated. (Am. Journ. Med. Sci., 1940, p.

39.)