a tumour filling the pelvis is felt, and upon this there lies a small swelling. This is the uterus. In many cases the distended tubes are to be felt as sausage-shaped bodies close by. The examination must be made very carefully, as the tubes may be ruptured, and fatal peritonitis may

ensue.

In primary hæmato-metra the uterus is felt by the bimanual method of examination as a tense elastic tumour, the cervix is effaced, and there is no os uteri. In atresia at the internal os the cervix is present, but a round elastic tumour is felt in the position of the uterus, and the sound does not enter its cavity. The prognosis is bad unless skilled treatment be adopted, because the blood cysts may rupture. Most commonly the tubes burst, and as a rule the patient dies of peritonitis. Spontaneous cure only takes place when the obstruction itself yields, or a very premature menopause sets in.

The treatment is simple only in those cases where as yet no hæmato-salpinx sac has formed and the vagina is present; for the closing septum is then but thin. In these cases the septum should be split by a small incision, so that the collected blood may flow away slowly. A small incision is preferable, because it is possible for a hæmato-salpinx to have escaped palpation. When the outflow is more rapid, and especially if pressure from above be used, the tube sacs may be torn (owing to the downward displacement of their uterine ends) at their abdominal ends, which are more or less fixed by adhesions. In such a case the abdomen would nowadays be opened, and the tubes and ovaries removed. In the same cautious way one proceeds in opening hæmato-kolpos and hæmatometra, where, owing to the thickness of the obstructing membranes, difficulties arise. These difficulties can be overcome by working in the middle line between the bladder and the rectum after incising the outer skin, until the blood sac is reached.

For this purpose a catheter must be placed in the bladder, and the operator's left forefinger in the rectum.

With the finger or with a trocar the blood sac is opened and the canula is left in or a drainage tube is introduced. The decomposition of the retained fluid is prevented by applying antiseptic pads to the vulva, and by changing these frequently. The channel thus formed is best kept open by plastic covering of its surfaces. Even after a hæmatokolpos or a hæmatometra has been opened, immediate salpingotomy (the removal of the tubal sac by laparotomy) may be necessary in those cases when the tubes do not pour their blood into the uterus, or when the sausage-like sacs retain their size unchanged while the uterus diminishes, or when they suddenly disappear without at the same time any corresponding amount of blood being passed below, or when rupture has taken place with escape of blood into the peritoneal cavity. The prognosis of genital atresia with hæmato-salpinx can be much improved by salpingotomy, as the cases of Leopold, Kehrer, Czerny, and others prove, while Fuld's researches show the simple vaginal operation in cases similarly complicated to have a mortality of 70 per cent (39 deaths in 56 cases). Atresia of the internal os is treated by simply passing a sound or trocar through the obstruction.

Atresiæ, with Doubling of the Genital Canal.

These atresiæ receive special mention because their diagnosis is very difficult. The symptoms consist of pain, as previously described, but menstruation is present. On examination in case of doubling of the whole genital canal there is found an elastic swelling adjacent to the vagina and uterus, and adjacent to the uterus alone in case of doubling of the uterus (Fig. 58). The absence of the vaginal fornix on the side of the swelling and the semicircular shape of the os uteri, with its concavity directed towards the swelling, are very characteristic signs. The prognosis in these cases, when allowed to take their course, is not so grave as in the other forms, because rupture

takes place into the other half of the genital tract with greater ease. The treatment is much the same as in the more usual atresiæ. In case of hæmato-metra in a rudimentary horn of the uterus laparotomy is indicated. is only by laparotomy that the correct diagnosis can be established in many cases, for unless the inclination of the fundus uteri towards the other side leads the surgeon to diagnose a uterus unicornis, and in consequence of this to diagnose the tumour correctly, the presence of a pediculated swelling in the broad ligament (such as is the

FIG. 58.-Schematic coronal section of hæmato-metra and hæmato-kolpos laterales dextræ (after Breisky). c.u.d, right uterine horn; c.u.s, left uterine horn; o.e, external os; c.i, internal os of the dilated cervix of the right side; v.e, blind saclike rudiment of the right vagina protruding into the open left vagina, v.s; p.v, vaginal portion of left cervix; h, Hymen.

characteristic formation in these cases) would lead him to think rather of an ovarian tumour. Four successful cases (Schröder, Leopold, Kehrer, Czerny) prove that laparotomy is indicated in cases of hæmato-metra in rudimentary uterine cornua with hæmato-salpinx, while of 10 similar cases operated upon from the vagina only one survived (90 per cent mortality). In laparotomy it is best to leave the sound appendages behind. If castration is performed, we do not usually require to perforate the hæmato-metra.

DISEASES OF THE UTERUS.

Malformation and Defective Development of the Uterus.

1. Complete Absence or Rudimentary Formation of the Uterus.

(a) With Absence of the Ovaries. -Patients so affected when viable are cretins without distinctive sexual characters.

(b) With Presence of the Ovaries. Patients so affected are of normal female habit and inclination. In rare instances severe pain (menstrual molimina) comes on periodically, produced by the ripening of the ova. In these cases the vagina may be entirely absent. The urethra and the rectum are sometimes utilised in coitus.

Such patients are of great concern to the practitioner whom they consult for amenorrhoea, impossibility of coitus, sterility, and for dysmenorrhoea. For making a diagnosis the bimanual examination by rectum and abdomen is necessary, because the vagina is wanting. If necessary this may be done under anesthesia. In a case of rudimentary uterus one feels a band running length or crosswise, or a T-shaped body, the legs of which represent the ununited remnants of the uterine horns. Near these one may often feel the ovaries.

Treatment.

Since such patients are often married, the making of a passage with the knife between the bladder and the rectum has been undertaken, and by

laying gauze in it, or by turning flaps of skin from without into it, attempts have been made to keep it open in order to permit of coitus. Sterility cannot, of course, be cured. Should the menstrual molimen be excessively painful, castration is indicated.

2. Congenital Atrophy of the Uterus.

In this condition the uterus has its normal shape, that is to say, the cervix is not longer than the body, but the uterus, as a whole, is smaller than normal, and its walls are very thin. This congenital hypoplasia is commonly found, according to Virchow, in those severe forms of chlorosis which are associated with congenital smallness of the heart and aorta. This is a malformation just as much as uterus rudimentarius. If there is any development of the ovaries the menstrual molimen, with scanty but distinct menstruation, takes place. The symptoms which cause the patient to consult a surgeon are amenorrhoea, or scant and infrequent menstrual molimina, and in married women, sterility.

An exact diagnosis of the state is made by measuring the uterus with the sound, when a length of 51⁄2 cm. (2·0 inches roughly) or less is found.

3. The Foetal or Infantile Uterus.

This is characterised by its smallness, but differs from congenital atrophy in the abnormal length and thickness of the cervix in comparison with the thin-walled body. These points are easily made out bimanually. The possessor of such a uterus often presents a very childish bearing. The hair of the mons veneris and of the axilla is wanting, the vulva and vagina are narrow, the breasts badly developed, and menstruation is absent as a result of defective development of the ovaries. It is this last sign which causes the patient to seek advice. Differences