to expose the smaller blood-vessels of the endometrium, and to so weaken their walls that they give way and hæmorrhage follows.

This menstrual flow is composed of blood from the vessels, with at least the débris of the degenerated and exfoliated epithelium. The flow, which lasts for days, subsides, the mucous membrane is renewed, and the same high state of anatomical completeness and functional capability is restored, when another menstruation takes place, and so this function is repeated over and over again, except when suspended during pregnancy or lactation, until the end of functional activity at forty-five years of age or thereabout.

During the period of functional activity of the sexual organs, from puberty to the menopause, menstruation is an evidence of health, and is also essential to health. It is an index of the state of the sexual system and also of the general health of mature women. Hence its derangements constitute most valuable evidence of the presence of disease, while its normal recurrence is an evidence of health. In practice it is best to study this function by its characteristics, rather than by theories regarding its cause or the reasons for its existence. It is on this account necessary to comprehend its natural history; therefore, I propose to give here a synopsis of the conditions of menstruation.

The laws which govern this function of menstruation, as given in our text-books, are so varied by climate, personal peculiarities, and the conditions of life, that a general average pertaining to these laws is about all that can be obtained, and this can be used to very little advantage in practice. Fortunately, there are certain rules. which apply to menstruation with great uniformity, and these should be clearly understood. The most important of these are the following:

1. Menstruation should begin at puberty-i. e., when the woman is maturely developed, no matter what the age may be. Increase of size may take place by growth after puberty, but all the organs of the body should be completely defined, so far as form and structure are concerned, before the function of menstruation is taken up.

2. It should recur at regular intervals; about every twenty-eight days is the average time. A regular periodicity is normal, but the duration of the periods often differs in different persons.

3. The discharge should always be fluid in consistence and sanguineous in color.

4. The flow should continue a definite length of time, the duration depending upon the habit of each case; at least there should not be any great deviation from this rule.

5. The quantity should be about the same each time.

There should be no deviation from the first rule. If the menses appear before development is complete, both in the sexual organs and the general system, it is an error which is either the result of disease or of the surroundings of the patient, and generally modifies unfavorably her future life unless it can be corrected. The same may be said regarding those who fail to menstruate when the development and growth of the body are completed. The other rules regarding the recurrence, duration, quantity, and character of the menstrual flow, may vary in different women, but they should be uniform and regular in each person. Whatever the habit may be that is established at puberty in a given case, that habit should be maintained through life. Some women menstruate systematically from puberty until after bearing a child, then they take up a different order of menstruation in regard to all or some of the characteristics of that function. That is normal, but it is the only well-marked change in habit which is the same in health.

Obedience to these laws of the menstrual function implies certain conditions that are necessary to the fulfillment of these laws. These may be briefly stated as follows:

1. Maturity of development of all the organs, both of the general and sexual systems, and a fair degree of health of all.

2. A sufficient and well-regulated supply of normal blood to the sexual organs.

3. Normal structure and functional activity of the nerves which preside over the action of the sexual organs.

4. Conditions of life favorable to general health and reproduction. This includes food, climate, society, and occupation.

Allusion has already been made to absence of the uterus and also to its rudimentary states in which the menses never appear, and because of these marked anatomical defects and absence of function nothing can be done by the gynecologist in the way of improve

ment.

There remain to be considered cases in which the conditions of menstruation are all present but in an imperfect degree, so that menstruation, although established, is performed imperfectly.

ILLUSTRATIVE CASES.

Uterus Unicornis; Imperfect Menstruation and the Results.-A woman, twenty-nine years of age, of healthy parents, above the average size, and well formed generally, had enjoyed excellent health until she was eighteen years of age. About that time her

mammary glands became well developed and she presented all the outward characteristics of woman physical and psychical. She then began to suffer at stated periods from backache, a sense of fullness in the pelvis, and slight leucorrhoea. In a day or two after these symptoms came on, and while they continued, she became heavy and sleepy, and had a feeling of fullness in the head and slight headache. These attacks lasted several days, when they passed off and again returned about every month. In the interval her health was good and she performed her duties as a domestic. Five months after the first time that these symptoms appeared, and while she was suffering from an attack, she had a slight menstrual flow, which lasted less than twenty-four hours, and appeared to alleviate her suffering. The next month her flow returned in the same way, but all her symptoms were increased. From this time on her menstrual flow returned regularly, but did not increase in duration or quantity. At each recurring menstrual period her suffering increased in severity until she was obliged to give up her duties at such times. On one occasion when she was trying to do her work while suffering, she was exposed to cold and was seized with an inflammation-pelvic peritonitis, no doubt-and was taken to the hospital, where she remained for three months. During that time she took morphine liberally. From this time her suffering during the menstrual period was very great, sufficiently so to keep her in bed, and to require large doses of morphine to make life tolerable. Another attack of pelvic peritonitis came, and again she was sent to the hospital for treatment. She recovered from the acute attack, but her suffering at her periods was far greater than ever before. Epileptiform convulsions came with her pelvic pains, and were repeated frequently until the menstrual period passed by. For several years her time was spent between her home and the hospital, and in occasional efforts to do the duties of a house-servant.

Condition when First Examined.-Having obtained the above history from the patient, I observed that she still had all the evidence of fair general health, except that, from pain and the use of morphine, her nervous system was decidedly impaired.

Physical Signs.-The touch detected a very small cervix uteri which projected into the vagina only half an inch. The organs and tissues were fixed, and on the left side there was an irregular mass which felt like the products of a former pelvic peritonitis. On the right side the parts were less elastic than normal, and, owing to an exceedingly tense state of the abdominal muscles, the body of the uterus could not be felt, neither could the right ovary be positively

made out. From the negative signs, however, I was able to satisfy myself that the right ovary was not enlarged, nor was the body of the uterus as large as it ought to be. The speculum revealed nothing of value, but, in using the sound through it, I could pass that instrument into the cavity of the uterus. The canal of the cervix was an inch in length, and in its proper position as indicated by the sound. When the internal os was reached, the sound turned to the right and passed in that direction about an inch. This led me to suspect that the uterus was unicornis. To obtain further evidence, the speculum was removed, while the sound was left in the uterus. The patient was then placed upon the back, and, by the rectal and vaginal touch combined, the horn of the uterus above the vagina was reached. While making the combined touch, an assistant rocked the horn of the uterus with the sound, and I could then outline it with the fingers. It was about an inch in its transverse, and only a little more in its long diameter. The upper end, which represented the fundus, appeared to be slightly pointed in place of rounded, as is the fundus of the normal uterus.

Treatment. There was nothing in the case to give the slightest hope that she would derive benefit from any general treatment. The removal of the ovaries to stop the tendency to menstruation was the only indication apparent to my mind, and, owing to the old adhesions from the former pelvic peritonitis, the dangers of that operation were fully appreciated. The case was explained to the patient and the friends who brought her for my advice, and they were left to choose between the removal of the ovaries, or no further care on my part. The patient, after thinking of the dangers and the prospects, became very anxious for the operation. Her argument was that she was tired of life, and that all her friends were tired of caring for her, and, if there was one chance in a thousand of being relieved, she longed for that chance.

The operation was performed with great difficulty, owing to the adhesions. The right ovary was completely surrounded with inflammatory products, and was found with much trouble. The left ovary was adherent at several points that were easily broken up. There was no trace of the left horn of the uterus, nor of the left Fallopian tube. The right ovary was located within one inch of the upper end of the right horn of the uterus, and there was no well-defined Fallopian tube on that side.

Comments. This case certainly illustrates fully the great suffering that may arise from this degree of malformation. The presence of well-developed ovaries which excite a demand for menstruation,

associated with a uterus incapable of performing that function, is one of the most unfortunate conditions known to the gynecologist. It is evident, also, that the development of the one horn of the uterus sufficient to make a slight effort to menstruate only aggravated the difficulty. She would perhaps have been better had the uterus been absent altogether.

Incidentally, I may remark that the absence of the tubes in this case is evidence against those who claim that they have a leading influence in causing menstruation.

Rudimentary Uterus Bicornis; Entire Absence of Menstruation.When first examined, this lady was thirty years old, below the average size, but well formed, and presented, to outward appearances, all the characteristics of her sex. As a child she was rather small and delicate, but had good health. At the age of sixteen she passed through all the changes of form common to puberty, but never menstruated. When questioned regarding her health at that time, she remembered only that she occasionally had slight headache and indisposition, but whether these symptoms came periodically or not she did not know. At no time was her suffering sufficient to interrupt her school duties. She was married at eighteen, and, while she was affectionate and devoted as a wife, sexually she was perfectly negative. Without being very strong mentally or physically, she enjoyed good health, and only called upon me at the time she did because of some temporary irritation of the urethra which caused pain on urination. This gave me an opportunity to examine her pelvic organs. The external organs were normal, and the vagina also. The cervix uteri was not more than five eighths of an inch in diameter. The os externum was small but normal. In the location of the body of the uterus two small, oblong, bifurcated bodies were found continuous with the cervix. These bodies were about a quarter of an inch thick and about an inch long, as nearly as could be estimated by the bimanual examination. I regarded them as the rudimentary horns of the uterus, which were retroverted. Near the upper ends of the horns of the uterus, and a little outside of them, two other bodies were found which I presumed to be the ovaries. They were about half the size of a fully-developed ovary and of the usual form of that organ, except that they were not so flat from before backward, and appeared to be more dense than normal. It was evident that the development of the ovaries had progressed further than that of the uterus, because they were relatively much larger than the rudiments of the uterus. Owing to the fact that the patient was of small size, with non-resisting abdominal muscles and