TABLE OF SEVEN CASES OF COMPLETE NEPHRO-URETERECTOMY FOR TUBERCULOSIS.

DIAGNOSIS

AFTER

DIAGNOSIS
BEFORE
OPERATION OPERATION

EARLY
SYMPTOMS

right kidney
and ureter
Tubercular
bladder,
right kidney
and ureter

kidney

DISCUSSION.

DR. HORACE G. NORTON, of Trenton.-The Society is certainly to be congratulated on the presentation of such papers as this. Undoubtedly more attention should be given by the general practitioner to the diagnosis of tuberculous disease of the genito-urinary tract. I am very sorry indeed that Dr. Ill did not have time to enter into the matter of the diagnosis of these forms of disease. Operations on cases in which the disease is confined to one kidney are apparently very successful--sometimes a nephrectomy and sometimes a nephrotomy. Ordinarily more cases of tuberculous disease of the urinary tract occur in the male. I understand that the author does not think the kidney is likely to become infected through the bladder, or that the disease proceeds upward from the bladder through the ureter. This is a mooted question, but I believe the kidney and bladder may be infected both by an ascending and a descending degeneration. I have seen some cases of tuberculosis of the bladder that so closely simulated stone in the bladder that a good deal of unnecessary and harmful sounding of the bladder has been done.

DR. ILL.—I did not mean to say that the kidney is not affected through the blood current, but that the bladder exhibited great resistance to tuberculous disease, and that the bladder is less liable to infection from the blood current.

DR. PHILIP MARVEL, of Atlantic City.--I should like to ask Dr. Ill with reference to the bacilli. The author stated that it was difficult at times to find the tubercle bacilli, but he did not mention in his paper the danger of mistaking other bacilli, and especially the smegma bacillus, for the tubercle bacillus. I should like to know if there is any better means of differentiating between the two than washing out the preparation with pure alcohol. There is such a great similarity between the two bacilli that it is with difficulty that the ordinary observer is able to differentiate them. We have employed the method I mention, and so far it has apparently yielded trustworthy results. Of course the catheter is another means used.

DR. ILL.-One method is to wash out the coloring matter from the bacilli with alcohol. Another method is to very carefully catheterize the patient, in order to obtain a specimen for examination, and never to make use of urine that has been passed by the natural channels for such an examination. If the catheterization is carried out with aseptic precautions the smegma and other bacilli should not be present.

TWO UNIQUE MALFORMATIONS OF THE FEMALE GENERATIVE ORGANS; ABSENT VAGINA WITH ATRESIA UTERI; UTERUS DIDELPHIS

WITH LEFT HEMATOMEtra.

BY EMERY MARVEL, M. D., ATLANTIC CITY, N. J.

While many types of malformations of the female generative organs are not uncommon, the two cases which I wish to report(1) An absent vagina with atresia of uterus; (2) Uterus didelphis with left hematometra—seem each sufficiently unique in itself to merit record. When we consider the development of these organs through the fusion of the Müllerian ducts, the two canals coming together to form one canal, and this common canal segmenting to form the respective organs, it is surprising that malformations of these organs are not more commonly met. The failure of the Müllerian ducts to unite, results in one of two conditions, either further development is made, with duplication of that organ, or atrophy takes place leaving only a rudiment or no prestige of the organ at all. If a given segment does not coalesce, but continues to grow, two separate canals develop. Such a condition is normal in the upper segment which forms two fallopian tubes. When, however, the first of the lower segments fails to unite and further development takes place, some form of a double uterus, such as uterus bisepta, uterus bifida, uterus bicornis, or as in the case here to be reported, uterus didelphis results. Should atrophy take place, an atresia of the segment, or its obliteration, as in the absent vagina, is the consequence. When, however, defective formation takes place, an impaired or disturbed function is consequent and sooner or latter a marked pathological condition results. Such was the manifestation in the following cases:

ABSENT VAGINA WITH UTERINE ATRESIA. (Figure 1.)

In February, 1901, a patient called at my office, saying that he and his wife wished me to arrange to remove his wife's ovaries. When asked the reason for this unusual request, he said that every month his wife suffered most severe pains for about five days, and that two days of this time, she was most like a mad woman with the agony. Upon further inquiry, he told me his wife had never had her sickness, and I learned that complete coitus had not been

attained. I immediately thought of an imperforate hymen or atresia of the vagina. I arranged to see his wife the next day, and found a well-nourished and apparently, perfectly developed woman, with the following history:

Age, 23; married 5 months; never menstruated; at 17 she experienced an attack of pains, which are described to have been a feeling of burning with fullness and bearing down in the lower abdomen. The pains continued for five days and disappeared to return again every twenty-eight days for three consecutive months. Subsequent to this time, six months passed without recurrences, when the pains again returned and have since regularly recurred every twenty-eight days. These painful periods have progressively grown worse. For the past year she has been obliged to remain in bed each time. More recently they have been so severe, that her husband claims she is delirious for a part of the time. Morphine is reported to have been the only treatment that has given any relief whatever, and it has been necessary to frequently repeat it each period to secure any benefit.

Gynecological examination: The labiæ majoræ are well developed; clitoris fully formed and free from adhesions, urethral meatus in normal position and condition. The labia minoræ are normal to external appearances, when separated, however, they are found more intimately approximated than is usual. The inner surfaces are continuous one with the other, giving the appearance of an imperforate hymen. There being no entrance to the vagina, the rectum is utilized for a digital examination. The rectum is free, and for a distance nearly the length of the examining finger, no intervening resistance could be felt between the finger in the rectum and the palpating hand above the symphysis pubes except the bladder. The tip of the examining finger in the rectum impinges upon a resisting mass which can be felt by the opposing hand, but not definitely circumscribed. This mass is taken to be either the uterus or retained menses in an atresed vagina. Both ovaries are palpable and enlarged.

Operation, March 10th, 1901:-The abdomen was opened to determine more clearly the condition of the uterus and ovaries. The mass felt by the finger in the rectum proved to be the uterus of full normal size. The tubes seemed normal in appearance, although no attempt was made to determine positively the patulosity of their lumen. Both ovaries were enlarged by several small cysts. Each was de