I have also many times examined another woman twenty-eight years old, married several years. She is of medium size, female habitus; breasts, external genitals and vagina normal. Uterus 1.6 inches long only, walls very thin, ovaries imperceptible. Has only had a few weak faint signs of menses; yet the sexual impulse is very strongly developed indeed. She has a vaginal blenorrlacea, and has been concerned in scandalous actions, has broken her marital vows, and hats surrendered herself to the most var ious sexual excesses.
Sterility in the higher grades of the anomaly always occurs with amenorrho3a, but the condition of the ovaries is certainly as much re sponsible for that as the state of the uterus. Even in the more fully developed womb conception is the exception. If it does occur, abortion is very liable to happen; the danger of rupture of the uterus is a theo retical, but hardly a practical conclusion.
The symptoms of hypoplasia will vary in accordance with the malady that causes it. This is especially the case in chlorosis. In the less marked forms of course they will be less severe.
There is a good deal of evidence to show that the lesser forms of hy poplasia are capable of cure; that after long stasis the growth of the uterus can begin again, and the organ attain a normal size.
Thus we see not infrequently that chlorotic girls with poorly developed uteri, after years of suffering and amenorrhcea, may go on to menstruate and conceive. But we must deny that well-marked forms, like uterus fcetalis and infantalis, where the ovaries also are frequently atrophied, can recover. The reported cases where in a short space of time such uteri have increased an inch or more in size are certainly erroneous an their measurements. Here the frequent anteflexion of the uterus plays& part; and the pathological thickening of the walls consequent upon lengthy local treatment may also have its effect.
Nor must we forget that a hypoplastic uterus may become impregnated, and thus attain the normal shape and size. This is seen in Pfau's case: A girl had an occluded vagina with an imperfectly developed uterus. When seventeen years old the tendinous hymen was split, and the mulated menstrual blood evacuated Three months later menstmation began with very severe pain; and in spite of all treatment continued with almost unbearable severity until her twentieth year, when she married. Coitus was very painful, and she was examined. The external genitals were normal, the smooth vagina before mentioned one and a half inches long. Instead of the portio vaginalis was a warty elevation the size of a bean, in which was a small opening into which the sound could hardly be passed half an inch. Examination per anum showed that the entire
womb was deficiently developed, it being barely one and three quarter inches long. There was thus little chance of her becoming pregnant. During the next two years menstruation, though yet painful, became more abundant, but the cervix did. not change. Nevertheless the sudden ceention of the menses looked like a pregnancy, and on October 13th, 1F44, three years after marriage, symptoms of labor set in. The head could be felt at the pelvic entrance, but the os could not be found. After four days Pfau was about to cut, but he found that he could bore his finger through the tendinous moss-like tissue which occluded the cervix. Delivery was completed through the cervix. The child lived. Four months later the menses reappeared, and were painless. The vagina was now of normal size, the portio one quarter inch long, forming a slit.
The diagnosis of the affection is not difficult, at all events in the well marked forms. Amenorrhcea or scanty menstruation directs our atten tion to the internal genitals. Occasionally also we see atrophy of the ex ternal genitals, small-sized vagina, small cervix and os, all of which point to defective development of the rest of the genital tract. But I must remark that the condition of the cervix, which has not quite properly been designated uterus parvicollis and acollis, occurs also with the normal womb; and that the normal cervix of the normal uterus may for various reasons disappear in the vaginal vault. By bi-manual examination (per vaginam or per rectum) the practised hand can decide upon the size and shape of the womb, especially when the external conditions, relaxation of the abdominal walls, etc., are favorable. But the sound must be intro duced to make a positive diagnosis. This is often difficult on account of the small size of the cervical cavity. Hypoplasia is present if the uterine cavity is less than two inches long. But we must not forget that the body of the womb is often anteflexed, and the sound may penetrate only to the internal os. It is well, therefore, to again make a bi-manual ex amination, leaving the sound in situ. The womb may be pressed forwards, or backwards against the rectum, and so felt. Even if the sound pusses 2.2 to 2.4 inches in, hypoplasia may be present, and the walls may be thin and membranous. The distinctness with which we can feel the head of the sound, will give us information upon that point. By bi manual examination we would also appreciate the extreme flatness of the organ, when its walls are very thin.