The congenital atresia3 of the uterus also belong in this place. This defect very rarely remains unnoticed until an examination is made for detecting a cause of sterility; if so, there is amenorrhcea and generally a dwarfed uteru& More frequently there might be found a small retention tumor, which was slowly produced by a collection of mucus and pus due to the closure of the os uteri. As a rule, however, the menstrual blood collects in larger quantities after puberty has been reached. Here again atonstance is not sought for sterility, the patients not being married, but on account of the existing hematometra. It is only after the uterus is emptied that the opening newly made by opemtion may become the sub ject of medical treatment for sterility. It is true that with a simple atre sia of the os externum the opening might be easily maintained, so that not only the menstrual blood can flow out, but also the sperma can enter through it; but it is a different matter when the atresia also embraces a portion of the cervix and of the fornix of the vagina, i.e., where a utero raginal atresia had existed. Here, too, there is not merely a simple open ing, but there 'is a canal of greater or less extent, which always shows a tendency to rapid diminution of its lumen, or even to complete closure. Under these circumstances sterility may be the result. What a difficult tank it is to keep the canal open, I have lately experienced in a case where m spite of extensive dilatations, excision and union of the uterine and vaginal mucous membmnes by suture, so as to cover up the walls of the canal, nevertheless a narrowing again took place. Here a removal of the sterility would render the hope much more likely as to permanent main tenance of the canal.
The generative processes may also be essentially impaired by an im perfect development of the uterus. This may show itself in various de gr e es. In a number of cases the form even in adults is an almost fcetal one; the uterus is in that stage of development which corresponds to the end of embryonal life, having remained stationary through childhood, and also at puberty. The cervix uteri forms the main part of the organ; the small, thin body is more like an appendage of it, and is often ante flexed. The palmai plicata3 extend almost to the fundus. The entire organ is too small. This condition, often called infantile uterus, I should like to designate as uterus fcetalis. Another form consists in this, that the uterus, while normal in form, is abnormally small in all its dimen sions. The cavity is short, the walls very thin, the vaginal portion small. This is the form that has been called uterus pubescene (Puech), hypo plasia of the uterus (Virchow); most generally, however, it is known as congenital atrophy of the uterus. From its small size I should be inclined to call it uterus infantilis, were it not that the uterus of infancy had a fcetal form. In these two forms which together may be combined under the name of hypoplasia of the uterus, conception is in the majority of cases excluded, disiregarding other causes, for the reaaon that probably the ovaries also are in the fcetal stage of development, and the follicles, if present, do not rupture, for which reason such individuals often suffer from amenorrhcea. As a rule, the disturbances connected with it (affections of the heart, severe chlorosis, a weak, imperfec development of the body) are such that a marriage is not concluded. In rarer cases such individuals are healthy and well developed but sterile. With the imperfect statements furnished by authors apon the condition of the ovaries it is difficult to decide whether the uterus is unfit for the reception and development of the ovum, or whether it is the fcetal condition of the ovary that renders conception impossible from the start.
These uteri, that rarely enough come under medical observation, are of great interest, inasmuch as they do not occur as a class by themselves, but in my opinion gradually merge into the normal form and size of the organ of parturition. For there certainly occur not a few eases of chlo rosis and sterility, in which the uterus is certainly not of normal size, but on the other hand cannot be designated as foetal or infantile. These are cases where the uterus, besides being small, also shows slight anteflexion, that is easily corrected by the sound—cases which certainly have assisted in the assumption that anteflexion was the normal position of the uterus. Here Schultze is certainly right in saying that in these cases the flexion is not the cause of sterility; the imperfect development of the uterus, and probably of all the genital organs, is the cause of this defect; it then of course resists all mechanical treatment. If these cases are classed with uterus infantilis, then the latter is indeed not a rare occurrence. This also explains the difference among observers as to the frequency of this anomaly; for instance, while Chrobak restricts the idea of uterus infantilis in narrow limits, and therefore among 100 cases of sterility discovers but one imperfectly developed uterus, Beigel says that among 155 sterile women he found the infantile uterus 4 times, and Kisch even found it 16 times among 200 cases of sterility. Certainly the hypoplasia3 of the uterus, and still more the transitions to the normal womb, represent not an inconsidemble number of sterile women, especially of those who have married early. It has already been mentioned that the uterus does not reach its full development before the twentieth year, before which time its development is still imperfect. It was also said at the same place that in this not quite perfect condition of the internal genitals concep tion may follow later, but also that by cohabitations the foundation may be laid for lasting sterility. (See ante, Influence of Age.) Malformations of the Vaginal Portion.—Next to the malformations of the uterus we have a deformity of the vaginal portion, which in the doctrine of sterility plays an important part; this is the so-ealled conical elongation of it. It consists in this, that the vaginal portion is not merely elongated, but it also tapers off into a point. The external os is almost always very small and of a roundish shape, the cavity of the cervix is as a nde, in a condition of catarrh. This fault is rarely acquired; it can cer tainly not, as Grfinewaldt would have it, be considered the consequence of a disease of the walls of the uterus, for although endornetritis may occur in connection with it, chronic metritis does so very rarely. The very fact that most women with conical vaginal portions have never borne children, speaks decidedly against Griinewaldt's explanation, inasmuch as the so-called chronic metritis is rather mre in nulliparre. (See Chronic Metritis.) This form of the vaginal portion is rather to be regarded as a congenital malformation. Its frequency has been greatly over-estimated. Even if the transition forms between it and the normal vaginal portion are included, we can not get such high figures as are given by Marion Sims, who in 218 cases found.this abnormality not less than 116 times. Kisch was able to find it only 8 times in 200 sterile women. If the chief weight be attached to the elongation and not to the narrowness of the os, this figure is certainly not too low an estimate.