Since the vagina usually participates in the higher grades of internal genital Aefects, and, a canal for the reception of the male organ is not present, a substitute for it is generally found by energetic and persistent cohabitation. Either the vaginal rudiment becomes in time stretched into a very fair receptacle for the penis, or the organ wanders into the urethra, and dilates it so that a finger can readily be passed into the blad der, and, remarkable to state, without always causing insufficiency of the sphincter vesicre. Cohabitation per anum and masturbation per ure tliram have been observed. We have not anatomical data sufficient to decide the important question whether sexual feeling can be present when the ovaries are entirely absent, or at least no Graafian follicles are devel oped. There can of course be no question of conception in any case.
It is not difficult to diagnose between a normal uterus and atrophy of the organ, but it is not easy to decide whether the organ is entirely absent or is present in a rudimentary form. We can, however, do better than former investigators, since we have in hi-manual examination and aniestliesia two powerful aids in diagnosis.
The examination is usually begun by an attempt to decide the cause of the amenorrhcea or sterility by digital exploration. Absence or rudi mentary formation of the vagina can be ascertained in this way, but the finger may make the same error loci as does the penis, and enter the urethra. We must proceed as with virgins in whom vaginal examination cannot be made; we must explore the rectum. We can frequently, by bi-mannal examination conducted in this way, res,ch an ex.act decision as to the shape and relations of the uterus. If bladder and rectum are empty, the pelvic contents may be pushed against the anterior pelvic wall, and easily palpated; and thus we can at once decide as to the presence or absence of the normal uterus. If now we introduce a catheter into the bladder, we can feel the entire instrument, while the presence of a normal uterus would prevent all but its lower segment being felt. If no other compli cations are present, this simple method v:ill suffice to decide as to the presence or absence of a normal uterus.
It is more difficult to decide whether or not a rudimentary organ is present. Bi-manual examination under chloroform will give us a fairly good picture of the pelvic contents. If the uterine remains form sharply circumscribed masses in the broad ligaments, the differential diagnosis is easy. Thickened parts will be felt between the catheter and the finger, or in its neighborhood hard bands or masses will be felt. But these masses may be tubes or ovaries, as well as uterus. Whether it be uterine cornu or tube cannot be so easily told even at a post-mortem examina tion; and in the living subject the round ligament can not be certainly recognized, and the same is true of an unthickened and undilated tube We will not go far wrong in regarding any thick median mass as a latend uterine rudiment. If there are two bodies on the same side, one of them is probably the ovary; the more elongated and median one being the womb, and the more external and rounded one the ovary. The peculiar unevenness, the great motility and sensibility of the organ, will also dis tinguish this latter. The presence of molimina will support our diag nosis. In difficult cases it may be necessary to palpate the posterior blad
der wall after dilating the urethra; and this is rendered the more easy by the urethral dilatation which is generally present, and the fact that the rudimentary bodies are attached to the vesical wall.
If complications are present, a certain diagnosis will be less easy; es pecially when the rudimentary structures have undergone further change, perhaps have become blood tumors. Of this we will have more to say later.
I will record a typical case of the kind which 'have recently had the opportunity to examine thoroughly.
Anna Barbara, of H., received in the gynecological clinic Feb. 20, 1882.
Anamnesis.— Twenty-two years old, well in childhood, has suffered from weakness and headaches since her fourth year. Has never men struated, but since six months has had every three to four weeks cramps and backache for four to five days. Well in tho intervals. Married one and one half years. Seeks assistance for the pains.
Status Prcesen8.—Strong, thoroughly feminine looking person of medium size. Breasts developed, pelvis female. External genitals nor mal, hairy, urethra not changed. Hymen present and normal. Vagina closed just behind it, but the end of the blind sa.c can be protruded one inch with the finger. No trace of internal genitals.
Internal Examination under Chloroforin.—Rectum normal; the catheter can be easily felt through the anterior wall in the median line; at each side of this there can be plainly felt two elongated, rodlike, fairly well-marked firm bodies ith inch long, and ith inch broad. They ap proach one another without coalescing. To the right, about inch from the external edge of the body, is an oval mass feeling just like an ovary; and to the left can be felt a similar smaller body.
Unfortunately no information could be obtained concerning sexual inclinations. The vulva did not show signs of frequent cohabitation, 114 urethra and hymen were intact. The menstrual molimina pointed to functionating ovaries.
The case might be called one of uterus rudimentarius bipartitus, per haps even bicornis.
There is of course no treatment, save perhaps for the trouble caused by the menstrual naolimina in these cases. If these latter are very marked, castration may be thought of.
Thus Tauffer had a patient twenty-five years old, who bad a rudimen tary uterus and a vaginal atresia, but her ovaries were normal; and the trouble was so great that an operation was sought for, and successfully done. Peaslee, Langenbeck, Savage, and L. Kleinwachter report simi lar cases.
Still more radical measures, such as extirpation of the rudimentary uterus, may be necessary, as G. Leopold's case shows us.
The patient was twenty-eight years old, married, had vaginal atresia and defect of the uterus, and suffered from severe menstrual troublea and other nervous symptoms. Besides this there was found in the left in guinal region a hen's egg-sized tumor, se pposed to be a prolapsed ovary. It was decided to remove the ovary. But when the hernial sac was opened, it was found that the tunior consisted of the left rudimentary and hollow uterine cornu, from the apex of which a tube proceeded up to a well-formed ovary. Both cornu and ovary were removed, and a per fect cure ensued.