The diagnosis is vasier when the vagina is single, and there are two cervices either separate or fused together. If two sounds are introduced, their points will diverge to left and right. Bi-manual rectal examination will now show the same state of affairs as in uterus unicomis, with the exception that it is found on both sides. We can through rectum or vaginal vault appreciate the course and direction of the two sounds. We will consider the possibility of confounding the condition with the uterus biforis, when we come to this latter affection.
If the cervix is simple, and childbirth has occurred, the lower border of the partition may be recognized by digital examination, or artificial dilatation may be effected. If the cervix is closed, the diagnosis may be made by the sound and rectal examination. Here also, as in the uterus unicornis, the one cornu may be mistaken for a fibromyoma if a sound cannot be passed into it, but the difference of consistency and shape should suffice to distinguish it. Mistakes are, however, possible; and very recently I supposed a second cornu to be a secondary cancer, in a case in which I had removed the carcinomatous cervix.
Much more difficult is the diagnosis when one cornu is imperforate and is distended into a tumor by blood, mucus or pus. The sac pushes the open half of the uterus to one side, and forces down the dilated cer vix and the corresponding part of the vaginal vault. The lower the atresia, the deeper down will the tumor reach. Examination will un doubtedly reveal a tumor above the symphysis, although its cystic nature can only be ascertained when it is of large size. Bi-manual examination will show that the upper part of the vagina is filled with an elastic or dis tinctly fluctuating tumor. The lateral position of this tumor is alone sufficient to discountenance the idea of hematometra of the simple uterus; and the history of regular menstruation will also exclude it. One side of. the vault is filled with the tumor; but at the other side the examining finger can be passed up, and here a cervix is discovered. Thus there must be a tumor filled with fluid alongside the uterus. The cervical canal which we have found is stretched and displaced, the ex ternal cat is crescentic, and lies around the lower end of the tumor. If the uterine sound is now introduced, it passes into the uterine cavity, and can be felt outside the tumor. The change of the cervix, however, ma only occur when a tumor is present which involves the walls of the cervix; and we can thus exclude all like tumors which lie without the utenis, such as ovarian and parovarian tumors, exudations and extravasa tions in the broad ligaments, retro- or ante-uterine hematoceles, etc. Fibromyomata of the cervical wall alone CaU8C a similar condition; and here the history and the consistence of the tumor will prevent a mistake.
There is little information to be obtained from external examination.
When the tumor reaches a certain size it applies itself to the non-dilated eornu, so that the angle between the two horns cannot te felt. Here ag,ain the sound will be of value. Puncture of the sac may be necessary before we can decide upon the nature of the tumor.
It is not difficult to decide whether the tumor contains blood, mucus, or pua. If a young person has menstruated regularly, and a tumor as above described has rapidly grown, it points to hematometra lateralis. If the individual, however, is amenorrhoic, if the tumor developes slowly and is but small, hydrometra is probably present. If after puncture the tumor reappears with great tenderness and the symptoms of peritonitis, the symptoms point to pyometra. This latter diagnosis is rendered cer tain when pressure upon the tumor causes pus to exude from the vagina or from the cervix. Of course, a purulent change may occur in the con tents of a hematometra or a hydrometra.
As to the recognition of the uterus bicornis during gravidity, the im portant diagnostic point of the septum can with difficulty be recognized, and the results of vaginal examination, at the beginning at all events, do not differ much from those of the normal uterus. At the beginning of pregnancy external examination will reveal the enlargement of both cor ium.
Later on the obliquity and pointed shape of the uterus may be of value, but, as we saw in the case of uterus unicornis, the first char acteristic may occur with the normal uterus, and the second is soon lost as the organ increases in size. As a rule the lesser are more easily recog nized than the more serionii gra,des of the anomaly. If the division of the uterus is well marked, the non-gravid half hypertrophies, but does not dilate; it is displaced by the gravid half, and sinks downwards and back wards into the pelvis, especially when it is placed upon the left side. If there is little external evidence of division, it soon becomes lost as gra vidity goes on. But when the uterine partition is very incomplete, anti the fcetus occupies the entire cavity, the cornua are distinctly perceptible, as pointed or round prominences with a depression between them; and we can often demonstrate the presence of the ketus in one half, while the other half is distended with liquor amnii only. The lesser grade of the anomaly,—uterus arcuatus--can be specially frequently diagnosed; and a little friction of the org-an will cause such a contraction as to render its outlines distinctly visible. (See Hypoplasia Uteri.) Only when in uterus bicornis septus both cavities become gravid and enlarge, can this latter form of the abnormality be easily recognized, since the furrow at the fundus and the anterior surface of the uterus can be distinctly recognized. The demonstration of the round ligaments is often important in the diagnosis; they go outwards from the apices of the cornua.