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THE treatment of congenital absence of the vagina appears to have exercised the patience and skill of gynaecologists for many years. A glance at the literature shows that there is no settled opinion as to the correct management of the condition, while there are some definitely opposed to its surgical treatment by any existing method. Three procedures have been used by those who are surgically inclined : ( a ) Free gvafts. Heppner,' Abbe,' Flynn,' Kirschner and Wagner,'"' Monod aRd Iselin.' Here free skin grafts, usually in multiple small pieces, are applied to the walls of the cavity made between the rectum and the bladder and maintained there by some form of flexible or rigid mould for 7 to 10 days. At the end of that time the mould is removed and the calibre of the cavity maintained as far as possible by intermittent dilatation. In the words of Monod and Iselin this must be begun early, repeated frequently and prolonged indefinitely. Judging from reported cases the results are indifferent and appear to run parallel with the efficacy of the subsequent dilatation. ( h ) Pediculated paps. Gravesfi first advocated the use of two full thickness pediculated flaps turned up from the thighs and inserted into a pre-formed vaginal cavity. Frank and Geist' modified this as an application of the Gillies tubed pedicle with better results. They stated that the only methods which can compare with it are the Baldwin,8 Mori,' and Schubert'O operations.

This is a report of a case of successful childbearing following an operation for the construction of an artificial vagina in a patient who presented the following anomalies: Agenesia of the vagina, left tube and ovary, left round ligament, left infundibulopelvic and left uterosacral ligaments, together with agenesia of left kidney and the presence of an abdominal ninth rib on the left side. In this case the Graves' operation for the construction of an artificial vagina was eminently successful, although a modification in the technique has been suggested. The patient is now pregnant for the second time. It is very important in the aftercare of patients operated upon for vaginal agenesis to stretch the artificial vagina twice weekly for six months. If they are married they should have coitus twice weekly during this time. The tendency to contraction of the artificial vagina, however, is over at the end of six months.

There is general agreement that the use of a free split-thickness skin graft as popularized by McIndoe and by Counseller is the most acceptable procedure. We have adopted certain modifications which appear to improve the results by reducing postoperative infection, increasing the percentage of graft take to essentially 100 per cent, increasing patient comfort, and improving the cosmetic result of the donor site. These modifications involve (1) the use of both buttocks as donor sites, (2) preparation of the graft over a proctoscope, using xeroform-impregnated gauze packing for the first 7 days, and (3) use of a flexible Ethafoam mold for the postoperative care. Proper selection of the time for operation and the appropriate psychological preparation of the patient are the primary keys to success. Twenty-one cases treated during the last 8 years are presented and discussed.