But it must be conceded that for an exact examination into the condi tion of the womb it is necessary to have some skill and experience in gynecological examination& The chief danger is of confounding the condition with uterus unicor nis. For it would be the lateral implantation of the vaginal portion in the vault, the lateral position and the corresponding curvature of the uterus, the pointed fundus, and, not infrequently, the proof of the exist ence of a subsidiary cornu. On the other hand, a central and perpendi cular position, a round fundus, and the absence of any subsidiary horn would speak for the simple womb.
The treatment of hypoplasia uteri depends not only upon the grade of the abnormality, but also upon the condition of the ovaries and the general constitution.
When the patient is robust, the general health good, and no local dis turbances present, it will be best to avoid any action. If there are dys menorrhoic symptoms, and the menses are absent or scanty, the mode of treatment depends primarily upon the condition of the ovaries and the uterus. If the ovaries are not atrophied, and if the womb is not too backward, we may attempt to establish the menses by local irritants (leeches, scarification, hot-water injections, cold douches, sounds, intra uterine pessaries, electricity, etc.). But if the ovaries are rudimentary, and the uterus ketal, it will hardly be possible to accomplish anything iu this way; we can only deal with the symptoms. But if the dysmenorrhoic symptoms are very marked, and local treatment is useless, we may think of castration. Hegar has done so (as he has told me), though with but little effect, but Bruggisser has removed the enlarged ovaries in a uterus infantilis 1.2 inches long, belonging to an amenorrhoie girl of twenty-one years, with the best result.
When chlorosis occurs in connection with the malady, a roborant treatment and diet (suitable nourishment and drink, change of climate, tonics and iron) are in order; and often render the local tre-atment un necessary, which may be so disagreeable at the time of puberty. There is no doubt that when the abnormality is not very marked, the normal function of the uterus may be re-established in this way. In married women, where our main idea is often to overcome the sterility, the local treatment will be the chief thing. Nevertheless we must warn our readers against too extensive and long-continued local treatment of antemic and nervous persons.
Kussniaul, in his book upon deficiency of the uterus, questions whether the uterine wall may be thin and deficient at one part,—say the fundus,— while the rest of the organ is normal. He says he cannot decide this very important question, since lie has never met any such case. It is true that the older recorded cases, in which rupture of the uterus is said to have occurred in consequence of such an abnormality, are not quite sat isfactory; but experience, which shows that pregnancy and childbirth niay occur when the uterine walls are thin in toto, is not opposed to it.
As Laehapelle and Wiegand have claimed, it is not infrequently seen that in women who have borne many children in rapid succession, and whose abdominal walls are thin, the foetus seems to lie immediately under the abdominal walls, so plainly can they be seen and felt. It appears as if the walls of the womb cannot be thicker than a sheet of paper. But this appearance is due rather to the relaxation and softening than to the thin 11CS3 of the uterine walls. For these uteri do not seem to be smaller than
others post partuni; and it must have had the ordinary volume during pregnancy. The same thing occurs in the normal womb when examined with the sound. The consistency, and not the size of the walls, is the determining factor.
Nevertheless, abnormal thinness of the walls of the womb does exist, though not to the degree which the above-named authors would have it. For it is not very infrequent to find at the autopsies of women dead shortly after confinement, that the muscular structures are not distrib uted in the ordinary way. Instead of the walls gradually becoming thicker from the internal os to the fundus, or at all events remaining of the same size, the fundus is decidedly thinner than the parts around the es internum. And even more frequently we can recognize partial defects of the uterine walls in the living subject and during pregnancy. Not in frequently we find every thing normal, save that one or other cornu (if we may so designate the neighborhood of the tubal mouths in the normal womb) is swollen like a bladder. Here the walls are thin, and the child's parts can be more easily felt than elsewhere. When uterine contraction occurs, the defect can be still more plainly felt; the contracting organ drives the fluid into the thin cornu, which then becomes more cystic in appearance than ever. This deficient development is not infrequent; and attention once directed to it, is not infrequently found in pregnant women. It cannot be explained otherwise than as a local thinness; the rest of the organ is of normal consistency; and it is found in primiparw, in whom there is none of that loosening, etc., of tissue which is found after many successive pregnancies. Nor can it be due to a partial con traction of the circular muscles around the tubal mouths, as sometimes occurs after delivery; for there would have to be at that time a corre sponding depression, and the spasm would have to be a permanent one.
We cannot tell the cause of this defect. It is remarkable that it always affects the upper angles of the womb where the tubes and round ligaments are inserted; and it is not infrequently found together with a slight de pression of the fundus uteri. Both these facts show that the condition is connected with that of the uterus arcuatus. This partial thinning must be connected with the rudimentary formation of one cornu, as is the ease with the other double formations.
What the influence of the abnormality is upon pregnancy and child birth is not decided. I have had occasion in an exquisitely marked case not only to confirm its existence by internal examination, but to apprecia.te its serious consequences.
In a primipara twenty-eight years old, the uterus contracted firmly during the pains, while the right cornu became distended like a bladder the size of a man's fist. I was compelled to terminate the labor with for ceps. Hemorrhage then set in, and I had to introduce my hand into the womb to remove the placenta. Here I could feel the abnormal partial thinning, as if the organ had been ruptured. The placenta was partly implanted upon the thinned area. It required injection of liq. ferri ses quichlorati to stop the hemorrhage.
There is not the slightest doubt that the thinned spot could not close the mouths of the vessels on account of the deficiency in muscular tissue. And it is undoubtedly quite possible for such a spot to be the seat of rupture.