THE TWO-CHAMBERED UTERUS.
As in the uterus bi cornis, the dividing membrane may involve the entire genital tract, from the fundus to the hymeneal ring. If it extends to the external os, we have a uterus bilocularis septus sine completus; if only to the internal 08, we have a uterus bilocularis unicorn& If it does not extend even so far, we have a uterus bilocularis unicorporeus.
Naturally, there occur all manner of transition forms between uterus bilocularis and uterus bicornis, and the varying forms may be reckoned now in one category, and now in the other. Thus the uterus arcuatus, with a more marked partition, would belong here, and not to the uterus bicornis.
The external form of the bilocular womb is rarely perfect. Both sides are seldom equally developed; and Blob claims that we frequently see a long band running up and down, but especially marked upon the poste rior surface of the womb. The organ is regularly increased in its trans verse diameter, though it is usually of normal size, as a whole.
Internally, the dividing wall may end crescentically, or it may be continued lower down as a fold or beam. It may be perforated in various places. In fact the uterus bilocularis is the transition form between du plexity of the uterus, and those less-marked congenital anomalies of the genital canal, which are met with in the vagina as unimportant membranes and cords.
Atresias of one, usually somewhat atrophied half, may also occur, though more rarely than in uterus bicornis.
The anomaly originates in the same period as does that of uterus bi corn's, but somewhat later. The MtIllerian ducts coalesce, but the par tition wall disappears only partially, or not at all. The cauae .of the faulty development is probably the same as in uterus bicornis. Perhaps the above-mentioned fold upon the anterior and posterior wall has some thing to do with it, but we will say more about this when we consider uterus didelphys.
The physiological processes are the same as in uterus bicornis. One case exists, reported by W. B. D. Blackwood, in which menstruation occurred alternately from one and the other cavity: Tbe patient, twenty-two years old, complained of pains in the left hypochondrium, which became quite severe at every other period. Ex amination showed a hymen with two openings, two completely divided vaginal and ut,erine cavities, and a single corpus. In twelve consecutive menstrual epochs he observed that hemorrhage occurred alternately from one or the other uterine cavity. The dysmenorrhoic symptoms of the left ovary were specially well marked when hemorrhage occurred from that side. Only twice did the flow come twice in succession from the left cavity.
Here alai the imperforate half may become distended with blood, mucus or pus, and the same results ensue as in the case of the bicorned womb. The same may be said about cohabitation and conception. If pregnancy occurs, the non-gravid half of course participates in the gen eral hypertrophy, and it becomes almost as large us the pregnant half. The cavity also is lined with a decidua.
The pregnancy is rarely interrupted, and the fcetns, save in miscar riages and the transition forms to uterus bicornis unicorporeus, is verti cal, and with the head presenting. The pregnant portion is not displaced, nor does the non-gravid part interfere. Only the partition wall itself
may give rise to trouble; it may be necessary to tear it in extracting the ftetus. Very profuse hemorrhages may occur if the placenta is partially seated upon the poorly muscular and thinned partition wall.
Twin pregnancies have hardly been noticed in this form of anomaly. Tile puerperal period has naturally not so good a prognosis as is the ease with the simple uterus.
While we have many cases of gravidity in rudimentary cornua recorded, we search in vain for examples of pregnancy in the imperforate half of a uterus duplex. For the closed half menstruates, and cases of hemato metre lateralis are not uncommon. Perhaps gravidity does occur in the occluded loculus, but is misunderstood. This may be explicable as fol lows: The tumor of an imperforate half of the uterus bilocularis and bicornis displaces the os of the patent half, and so does the advancing head in labor. Such latter cases would then closely resemble the frequently described cases of atresia of the simple pregnant uterus. Many such eases of apparent occlusion of a simple os externum, in which instruments had to be used to open a passage, may have been instances of this anomaly.
The diagnosis of the anomaly presents many difficulties. The ex ternal shape of the organ will hardly give us any clue, though the partial or complete dnplexity of the vagina may excite in us the suspicion that the same malformation occurs higher up. When once the cervix is di lated, and the membranes are felt in it, and bi-manual examination Flows that the body of the organ is single, it could only be confounded with the uterus biforis, of which more as we proceed.
The diagnosis may be confirmed by introducing two sounds into the fundus, and getting no feeling of metallic friction when we endeavor to rub their points together. • In gravidity the unimpregnated half lies closely applied to the gravid womb, and cannot be diagnosticated. In most cases, when the vagina is empty, the anomaly can only be recognized at birth, when the hand is introduced into the uterine cavity.
The treatment also is entirely the same as in uterus bicornis, save that it is simpler, in that a series of disturbances which are common in the two homed uterus cannot occur. Obliquity of the uterus and abnormal posi tion of the head is not usually seen. It. is rarely necessary to turn, since the broadening is not great enough to cause a. transverse position, and the rudimentary half offers no hindrance to delivery. Only the septum can be in the way, and may necessit,ate interference; and the placenta may be partly implanted on it, and so give rise to hemorrhage. But the usual measures for atony of the uterus will suffice.
The splitting of the uterine septum is the only process which might involve auy special action. C. Ruge has recently done it on a woman who had been twice pregnant, and miscarried both times. He supposed that the one loculus was not large enough for the fcetus at the latter end of pregnancy. The woman carried the third child to term. Unfortunately this operation can bo done in the two-chambered uterus, but not in other forms of duplexity.