As to the real causes, we are by no means entirely clear. Where the rest of the body is normal, the causes must be purely local; perhaps nu tritive disturbances play here a role similar to their part in the causation of deformities of the womb. V. Recklinghausen's case shows that inflam matory action in the neighborhood of the uterus may cause it to remain stationary at a very low stage of development. He found a uterus fcetalis which was bound down by pseudo-membranous adhesions to the posterior vesical wall, and thus hindered in its development.
In other cases the absence or rudimentary formation of the ovaries may exist, and the absence of the sexual influence of these organs rnay pre vent uterine growth.
In the case of dwarfs, the hypoplasia of the uterus may be a part of the general defective growth, or it may be dependent upon deficient de velopment of the ovaries. I have repeatedly exhibited to the clinic in recent years an individual of this kind forty years-old. She only began to menstruate at twenty-three; and the function was weak and irregular, often remaining absent for years. Anmmic symptoms, heart normal. Yagina narrow and smooth; os a little groove; uterus 2.4 inches long, but membranous, movable to all sides. Ovaries very small and smooth, the left somewhat irregular.
Cretinism also causes the affection, which is then not uncommonly found in connection with a child's pelvis. Scrofula and rickets also may cause it, but the frequency with which women who have most marked malformation from the latter disease, do conceive and bear children, would speak against the latter cause.
Certain nervous diseases, epilepsy and hysteria, are spoken of as causes, but perhaps the connection is accidental or the nervous affections are consecutive.
But chlorosis plays an important part in connection with hyperplasia uteri. While we formerly believed that the deficient genital develop ment was primary, and caused the chlorosis, we are now inclining to Virchow's opinion, that it is the chlorosis that hinders the genitals devel oping into the full virginal form. Especially is this the case when the chlorosis is dependent upon congenital smallness of the heart, and con genital narrowness of the great arteries (aorta). But, as E. Friinckel has proven, there very certainly are cases where the uterus fcetalis has origi nated in cases that were effective during embryonal or early child life, while chlorosis only appeared later at puberty. And in other cases, after
the anomaly has lessened, and the walls of the uterus have become stronger, the antemic symptoms have improved; so that we must regard hypoplasia uteri as an occasional cause of chlorosis.
But in most cases it is quite impossible to decide which is the primary, and which the secondary affection. As a rule an examination is only made after the chlorosis has existed for some time, and we find ourselves unable to decide whether the hypoplasia uteri is cause or effect. Nor is the defective uterine development always so great that a conscientious and skilled observer can venture to decide that it is the etiological moment of the malady. It needs be said, of course, that chlorosis occurs with entirely normal uteri.
Hypoplasia uteri may also be found with early tuberculosis.
As to the symptomatology. If the individual is otherwise well devel oped, and the anomaly is confined to the uterus, or the uterus and ova ries, the symptoms will only appear at puberty. Menstruation does not oc cur; and even in later life, complete amenorrhcea without any other trouble is not uncommon. But there are usually moliminal symptoms; mucus flows from the genitals, accompanied with periodical abdominal pains or true dysmenorrhoic troubles. Or there may be cyclic congestions or dis turbances of other organs, abdominal pains, vomiting, diarrhcea, palpita tion, pains in head and loins, etc. Vicarious hemorrhages from nose, lung, rectum, etc., have also, though rarely been observed. Yet cases have been recorded in which there was a true menstruation, though it was scanty and irregular. If the uterus approaches the normal standard the menses will be scanty, and dysmenorrhoic symptoms will be present. In very rare instances there is an abundant monthly flow.
The sexual impulse is absent or very weak, but not always so.
Thus I treated a woman forty years old, and who had been married for several years, for a profuse vaginal blenorrhcea. She was very strongly built, markedly female in habitus; yet her uterus was only 1.8 inches long, and her ovaries were imperceptible. She had never menstruated, and sexual desire was very weak indeed.