one and the same thing, nor are they always simultaneous. After their teens is time enough for women to marry. Nor can we refrain from referring to some of the etiological factors of female diseases which date even earlier than puberty, as: "neglect of out-door exercise and physical development, overwork of brain and excessive development of nervous system, improprieties of dress," mentioned by Thomas in the second chapter of his book on "Diseases of Women." These excesses should be corrected by the doctor before they have produced their results. Let us suppose that our new patient has arrived at the ninth calendar month of her pregnancy and that she has heretofore had no untoward symptoms for which she has had to call in the doctor. Suppose, also, that she engages her attendant and he goes at once to see her. Most men, we believe, would recognize and treat anemia, constipation, etc., if they existed; but the essential points to be learned by vaginal and abdominal palpation would very likely be overlooked. Equally unlikely would any treatment against possible complications be undertaken. A small amount of albumin is found in the urine. This occurs frequently and gives rise to no uneasiness. There is, however, some connection between albuminuria and eclampsia, whereas eclampsia occurs only once in five hundred' gravidæ and albumin is found in the urine of one in twenty-five, convulsions occur once in twenty (20) women eliminating this morbid product. Albumin has been noticed before attacks of cerebral and pulmonary apoplexy, acute mania, paraplegia, and affections of the eye and ear; while the hyperemia of the kidney constituting "puerperal nephritis," of which albuminuria is significant, will degenerate into serious disease unless we stop it. Further, Barnes' states that, "as a general proposition, convulsions and albuminuria increase the disposition to and severity of the diseases to which the puerpera is liable." It does not seem to me, therefore, that continuous albumin in the urine. should be viewed with tranquillity, it being often the first prodrome of one of the most fatal diseases that mother and child are exposed to. The preparation of the perineum for labor usually receives 1 Lusk, "Obs.," p. 526. 2 Fordyce Barker in AM. JOUR. OF OBST., July, "78. 866 Obst. (Med. and Surg.)," p. 287. but little if any attention. Yet there have been from time to time various methods of treatment and drugs brought forward as having a relaxing effect upon it. This is surely a much to be desired end, and experimentation should not cease until something has been found to answer the purpose. In the examination of the abdomen, the first thing to be decided is whether pregnancy exists at all. Rarely we may save a woman a month of suffering by assuring her that she has no labor to expect. An extrauterine pregnancy might possibly have gone so far without discovery. The presence of tumors, of injury from previous labors, of malpositions of uterus, of multiple pregnancy, and the size, condition, and position of the. fetus will be discovered. By the vagina we find injuries, from previous labors or diseases, which may need repairing. Tumors and malformations. may be present. The measurement of the pelvis is of great importance. Twelve deviations from the normal are recognized.' In all of these, the mechanism of labor is modified to a greater or less extent according to the degree of deformity. I do not think that there should be any discrimination in favor of either the multipara or the primipara in our practice. Both should receive equal care, except, of course, the pelvic measurements need not be taken twice in a known case. This branch of medicine clearly presents a wide field for the practice of prophylaxis, and while it is generally conceded that, though child-bed mortality is less than in former years, it is still too large, we would urge that one of the most potent ways of reducing the rate is by the proper preparatory treatment for the tremendous strain of labor. 'King's "Manual of Obs." 51 REPORT OF TWO CASES OF CCCLUSION OF THE VAGINA; ONE FROM TRAUMATISM, THE OTHER CONGENITAL. BY E. CROSS, Little Rock, Ark. I PROPOSE to report these two cases very briefly, giving only such points as are of interest, without going into details. CASE I.-Mary L.,.a bright mulatto, three years previous to coming under my care had been delivered of twins. She informed me that instruments were used, and that she was in labor three or four days. The children were still-born. She made a tardy recovery, though she did not know she was injured until an attempted approach of her husband revealed the fact that the vagina was closed. I found her general health impaired; she was exceeding nervous; her bowels were tympanitic, and she suffered at each monthly period to such an extent as to require the free use of opiates, besides being confined to her bed from six to ten days. This suffering had during the last few months become almost unbearable, and rendered her unfit for any work. An examination revealed a complete occlusion of the mouth of the vagina by dense cicatricial tissue. To what extent this occluding tissue extended it was impossible to determine, as it was so firm as not to yield to pressure. The diagnosis formed from the history and symptoms was that of occlusion of vagina with retained menstrual fluid for over two years, as since the birth of the twins there had been no appearance of menstruation. With the assistance of Dr. Watkins, she being placed under an anesthetic, the tissues closing the vagina were divided, proving to be about one-half inch in thickness, very firm, and closely pressed together. Quite a quantity of dark fluid was at once released; the parts were washed out with an antiseptic solution; a tampon or dilator introduced into the vaginal opening, and in a few weeks the patient was discharged. After this I lost sight of her until a few weeks since, when she called at my office to say she was again pregnant, and to engage my services. She expressed great fear that she might again suffer as at the first confinement. CASE II.—Mrs. V., aged 17 years, was sent to our Infirmary from Texas. She was a well-developed blonde, had been married four months; said that until within six months of her marriage she had enjoyed uninterrupted health, when she began to suffer once a month, though she had never had any external appearance of menstruation. After her marriage it was discovered that there was no entrance to the vagina. She had been examined by 66 several physicians, some telling her husband that she was of no sex," others that there was "absence of the womb," and that nothing could be done for her. Considering herself incurable, and much depressed, she came under my care. A most careful examination with a sound in the bladder and finger in the rectum revealed the uterus in normal position and of normal size. She was assured that it was possible to relieve her of this congenital occlusion of the vagina, the dangers of the operation being plainly stated to her, as well as the possibility of failure, she still urged it, willing to take all the chances "to be made a woman," as she said. Assisted by Drs. Watkins and Scott, the operation was undertaken after placing her fully under an anesthetic, the external organs of generation appearing perfectly normal; a deep incision with a scalpel was made at the ostium vaginæ, then slowly, with finger-nail and blunt instrument, the parts were torn and separated until the os uteri was revealed; the hemorrhage was considerable, being controlled by the use of compression and hot sponges. A glass dilator was placed in the new-made vaginal tract, and the patient put to bed, having been given a full opiate. The dilator was ordered to be removed, and the parts syringed twice a day with an antiseptic wash of the temperature of the body. Through the negligence of the nurse, who yielded to the entreaties of the patient, the dilator failed to be introduced one night, and so great was the contraction that a second operation was required, and a large glass tube introduced, which was worn night and day for five weeks. Then the patient left for Texas with the dilator in place (she being taught to remove and replace it), with orders that it should be worn for the next six months. At no time after this operation did the temperature exceed 102°, even then a rise followed the rigor which was induced by the shock. It is now twelve months since the operation, and I learn by letter that the patient is in good health, menstruating regularly, and is in every way a satisfactory wife. The operation for congenital absence of vagina is one which gives the gynecologist as much, if not more trouble and uneasiness than any that falls under his care. As the tissues are divided in making the new tract, there are no landmarks to guide him; carefully he must feel his way without compass or chart, and where a slip of the knife or a tear of the parts may at any time cause serious trouble. A SUCCESSFUL CASE OF HYSTERECTOMY FOR AN BY A. B. ATHERTON, M.D., Toronto, Can. MRS. B., æt. 35. First seen by me in December, 1884, when I obtained the following history: Catamenia began at 13, always regular, but rather free from the first. Was married at 25. For some months previous to that event the flow used to last from ten to fifteen days, and was accompanied with clots, sometimes as large as an egg. After marriage an increased loss took place, and a hard lump, which had been noticed previously in the hypogastrium, became considerably enlarged. The late Dr. Hodder was then consulted, and from what he said it was inferred that he considered her pregnant. From this time until August, 1883, menorrhagia continued, lasting often from two to three weeks at a time. At the latter date, the whole of the left lower limb began to swell, and in a day or two she was obliged to take to her bed. After two or three weeks, swelling commenced to subside, and in about two months the leg had returned to nearly its normal size. During this attack, she was at one time so ill that the attending physician gave up all hope of her recovery. For a period of three months after this attack, the menses were entirely absent, and with the exception of a flow which lasted four weeks, during June, 1884, they have been quite scanty up to the present time. The abdominal enlargement has gradually increased from the first, until now she measures fifty-one inches around the umbilicus. At various times since 1874 she has consulted medical men of eminence, but no one advised the removal of the tumor. Five years ago she was tapped by one of these gentlemen in two different places, but only blood was got. At the present time, the edematous abdominal walls reach down to her knees, the tumor having a tendency apparently to grow forwards and hang down over the thighs. The epigastric region is comparatively free from it. Both legs are considerably swollen, especially the left one. Patient looks pale and emaciated, and her face is drawn down, and expressive of suffering. The superficial abdominal veins are much enlarged. Tumor has a soft and almost fluctuating feel over its upper two-thirds, but below it seems more firm and hard. Per vaginam, cervix uteri is found occupying a lower plane than usual. Vaginal walls are apparently swollen, so as not to |