livered and all the cysts incised. The cavities were cauterized with thermo-cautery, and the ovaries replaced. The abdominal wound was closed and an effort made to establish an open way from the cavity of the uterus to the vulva. In the lithotomy position the space between the labia was incised and a dissection was made through the interstitial tissue of the vesico-rectal space. The cervix was found, and with difficulty entrance made through it to what was supposed to be the uterine cavity. Flaps were formed from the scant surface of the labia minora and reflected into the made vaginal space, and the cervix uteri brought down and anchored with cat-gut sutures. Two weeks later, the anchoring stitches were torn out. The uterus had receded and the new vagina was closing. A second attempt to establish a vaginia was made. This time the same dissection was repeated; a glass tube long enough to reach from the cervix to the vulva was inserted through the cervix into what was supposed to be the uterine cavity. This tube was anchored with silver wire, and the patient left the bed in a week. For two months subsequent to this operation she had no pains, although the tube came away in four weeks. The third month the same pains recurred in mild form and continued to recur each month subsequently. Each period grew more severe until I was appealed to again by her husband to try no further experiments but to remove the cause. I had observed these periods of pain several times and they were most severe. More severe than any dysmenorrhea I had ever seen. On September 17th, 1902, the abdomen was again opened and the uterus, tubes and ovaries removed en masse. The left ovary was as large as a hen's egg and the right ovary fully the size of a goose's egg and surrounded with generous adhesions. The enlargements were due to cysts, many of which ruptured in breaking up the adhesions. The uterus seemed much larger than when inspected fifteen months previous and was unusually hard. When a longitudinal section was made, the cervix was found to be fibroid and having no canal. The fundas contained a small slit, about half an inch in length, which was the only cavity in the uterus, and undoubtedly was never entered by any attempt made from below. Peritoneum was brought over all the raw surfaces of the broad ligaments, and the abdomen closed with catgut tiers. An uneventful recovery from this operation was made, the patient leaving the hospital in two weeks. When seen June 8th, two weeks ago, she reports herself free from pain, and absolutely well except for some annoyances occasioned by hot flushes.

UTERUS DUPLEX-LEFT-SIDED HEMATOMETRA. (Fig. 2.)

A nervous but well-nourished white woman, twenty-four years of age, referred by Dr. E. H. Harvey, of Atlantic City. Married two years, no children, no miscarriages. Menstruated first at seventeen. Menstruation was very free and without pain, although preceded

at intervals during the previous two months with headache and bearing-down, left inguinal pains. Did not menstruate again for three months, when menses returned, and during subsequent four years they were regular every thirty-two days, lasting five days. During this time there were no menstrual cramps, but frequently she

had a sense of fullness and bearing down in left ovarian region. For the past two years these discomforts have increased in frequency and severity, and have gradually grown so bad at menstrual periods as to necessitate her remaining in bed the first and second days. Eighteen months ago she noticed an intermittent, bloody, vaginal discharge, possessing an offensive odor. The discharge gradually increased in amount and constancy until during the last six months there has been a continuous show, becoming excessive at the menstrual period. The headache, together with backache, and those symptoms referrable to the lower zone of the left abdomen have grown worse with the increasing metorrhagia. With the conditions growing more severe, a chain of nervous symptoms, sleeplessness and hysterical manifestations have come on. The odor of the discharge has been so foul as to make her presence objectionable to those around her and life almost a distaste to herself. The odor is much like the putrid discharge from a puerperal patient, being even more fetid.

Gynecological examination:-Vulva shows a foul smelling bloody discharge, otherwise normal. The vagina normal except for a bulging area to the left and anterior to the cervix. The cervix high in vagina, and found posterior to the right, otherwise apparently normal. Above the cervix and to the left is a bulging in the vaginouterine fornix. This mass fluctuates and cannot be separated from the cervix. In the medium line and inclined to the left is felt the uterus slightly larger than normal. The tube and a cystic ovary can be made out distinctly on the left. The tube cannot be detected coming from the right cornu, which seems rounded and not angular. In the right side is felt a tubular body, freely movable, with smooth surfaces and apparently attached to the body of the uterus near the cervix. The right ovary can be detected somewhat enlarged in about its normal position.

Operation September 9, 1902. In the lithotomy position the vagina was exposed. The cervix uteri brought down to the vulva with tenacula forceps. With a bistoury the mass to the left of the cervix was incised. From this incision about a teacupful of gelatinous, bloody fluid escaped. This escaped slowly and possessed the odor of decomposed blood. The cavity was irrigated, and by a small, dull uterine curette explored and evacuated. The cavity was continuous with the cavity of the uterus, but I was unable to find any connection between this cavity and the cervical canal, although I am convinced one

existed. Through a media abdominal incision the pelvic viscera were inspected. The body taken to be the uterus and emptied by vaginal incision is found to have but one tube and ovary attached. The smaller body apparently attached to the cervix is another uterus of diminutive size, and having one tube and ovary which comes off of the right side. The left ovary attached to the larger body is the size of a goose egg, adherent, and contained several cysts. Its corresponding tube was larger than normal, but free from adhesions. The right ovary, attached to the lesser uterus, is the size of a hen's eggfree, and contains several small cysts. The right tube is short and smaller than normal. The cervices of the two uteri seemed to unite at the peritoneal juncture to form one cervix. Just below this location both uteri were amputated, and with their respective ovary and tube removed. While the external surfaces of the cervices were united into one, the point at which the amputation was made had two distinct canals, one continuous with the cervical canal into the vagina, the other continuous into the incision.

The recovery was uninterrupted except for a stitch abscess. She reports May 1st, 1903, that she feels perfectly well with the exception of the hot flushes which occasionally annoy her.

Congenital absence of the vagina may be due either to an obliteration of a segment of the Müllerian ducts, or to an imperfect division of the cloaca. Defective formation of the Müllerian ducts, failing to provide a vagina, is likely to have rudimentary uterus and ovaries. In the case here reported, these organs had attained their full size. The reverse condition is reported by Antonio Bustello-Livola1. He observed the absence of the uterus, tubes and ovaries with a fully developed vagina in a prostitute.

The periodic pains having the cyclic time of menstruation must have been ovarian and due to ovulation. Both ovaries had undergone hypertrophic changes and cystic degeneration. There was no evidence of true or vicarious menstruation, but the presence of an apparently functionally normal uterus and ovaries encouraged me to hope to succeed in bringing about normal menstruation and establish a vagina. Emmett advised this effort. Thomas3 advised efforts to be made to establish a vagina (a) when there was retained menstrual fluid; (b) a uterus can be distinctly discovered and the patient suffering from absence of menstruation; (c) if the necessity for sexual intercourse be imperative.

Had I known of the uterine atresia I could not have hoped for a favorable result, but there was no way by which I could well determine that. After puncture of the cervix, in which there was no canal, the sound entered the uterine tissue with comparative ease, so much so that I mistook it for the uterine cavity. After inspecting the uterus through a section of its body, and studying the course of the patient, I am fully convinced that the remedy for her relief rested in the removal of the ovaries, and the fibroid change in the uterus is of itself sufficient, I feel, to justify its removal.

Dr. John G. Clark1 reports a case of bicornate uterus, one horn of which was filled with pus and having a downward saculation, which pressed upon the lateral wall of the vagina. Dr. Clark's case and that of my own have very analogous conditions with this differencethat in his case the retained menses had become infected. A strange coincidence in these two cases is that, rare as it is, both cases seen were referred by Dr Harvey. The first case Dr. Harvey saw at Latimer, Pa., and referred to Dr. Clark, January, 1901. The other case he first observed a little more than a year later. The case which was operated on by Dr. Clark and reported by him, the infected cornu was amputated and removed, leaving the normal cornu. Dr. Harvey tells me that he has just heard from this patient, and that she has given birth to one well-developed child and has since miscarried at three months.

In my own case, although it was not demonstrated, the evidence favors the fact that there was some opening present between the uterine cavity distended with blood and the free cervical canal of the right uterine cavity, and that this opening was not sufficiently large to give free drainage. This was evident by the discharges through the vagina being of the same material as was the retained menses in the distended uterine cavity.

The question of removing both of these uterine bodies, or only the distended one, was considered while the abdomen was opened, but in view of the fact of both ovaries being markedly cystic, it seemed advisable to me to take both out at this operation.

I cannot conceive of any drugs, or any, but operative remedies, giving any benefit in either of these conditions, and I am fully convinced that radical operation was the only remedy in one case and to have been the preferred treatment in the other.