The septum may be entirely overlooked; and it is often only when operative procedures, as turning or detachment of the placenta, have to be undertaken, that it is noticed.
Although I know no reported case of the kind, the non-gravid cornu might be driven down, and would then be with difficulty distinguishable from a rudimentary cornu.
During the uterine contractions, and for some days after labor, the peculiar shape of the uterus arcuatus can be distinctly appreciated. But it fades out as the organ gets smaller.
We are less in the dark as to the etiology of this condition than of the other anomalies which we have been considering. It occurs from only partial fusion of the middle portion.of the Milllerian ducts as they lie side by side. This union, as we have seen, begins below, and ext,ends upwards. The varying parts left ununited, go out to develop separately as if each were a uterus unicornis. But the septum also does not always disappear, and the lower parts, though outwardly single, may still be really double. Nor do the separated parts develop equally always. All this occurs in the first two epochs of uterine development.
And here we approach an explanation of the real cause that hinders normal growth. The vesico-rectal ligament above inentioned has not yet been referred to any embryonal structure in the regular order of de velopment, but it occurs so frequently with marked division of the uterus, that it must stand in some causal relation to the abnormality. (See Uterus Didelphys, page 2:35.) Treatment is neither necessary nor possible for the deformity itself. If the septum vaginte interfere with cohabitation, it should be divided or removed. Only when atresia has set in in one half, and blood or mucus has collected, do we need to interfere actively. The chances are that the tumor will get larger; and to avoid the dangers of a considerable collec tion of fluid, an early opening is necessary. This is best done at the most dependent point of the tumor, in the vagina, save when exceptional thin ning at some other part, as the cervix, shows that that is the preferable place. In no other gynecological operation of similar small importance in itself is so much caution necessary. Abdominal pressure must be avoided; the puncture must be simple, and the outflow slow. The dangers are indeed great, and a whole series of deaths have already occurred after opening an imperforate cornu of a uterus bicornis. Simple puncture, however, is merely palliative; the orifice soon closes, and the fluid reaccumulates. Olshausen only has succeeded in curing a case by two punctures; the woman in question had three normal children afterwards. We must en deavor to secure a permanent communication between the sac and the genital canal.
Even puncture above needs much care, since masses of blood or mucus may easily remain behind, undergo septic decomposition, and lead t,o pyometra. A. S. Galabin has observed an exquisite ca,se of this kind:
A blood-tumor the size of the womb at the fourth month was incised in a fifteen year old girl. Peritonitis and septic endometritis followed, to which the patient succumbed upon the twelfth day after the operation.
The sac must be incised after evacuation, or, better, a portion of tissue must be excised from its wall, and, if possible, the mucoea united over its edges. The sac must then be well washed out or drained. If pyo metra forms after puncture, we must have recourse to incision as above.
Extirpation of the tumor by laparotomy is not justifiable so long as it can be reached per vias naturales.
John Homans has cured a hematometra in a uterus bicornis, where the tumor projected into the pelvis, by supra-vaginal amputation.
The most serious complication, the tubal sac filled with blood and mucus, and which may not be connected with the uterine cornu, and evacuated by its puncture, is best regarded as a noli me tangere. If rup ture threatens, or if there are recurrent neighboring inflammations, operation is inevitable. Puncture can best be done from the cavity of the formerly closed cotnu, or from the vagina; and measures must be taken to maintain the passage open. The results have not been bad. Rectal puncture is not so good, nor is puncture through the abdominal wall, since these tumors are small, and rarely reach it. Salpingotomy may be done in extreme cases; the operation is as justifiable as ovariotomy, or uterine extirpation. Adhesions are frequent; and stitching the sac to the abdominal wound, with subsequent incision, may be necessary.
What we have said above in regard to castration in cases of blood ac cumulations in rudimentary cornua is true also for atresias of the uterus bicornis. (See Tubal Diseases and Gynatresias.) As to the treatment of obstetric cases, the head may sometimes be impeded by the ligamentum vesico-rectalis. Sometimes the mere correct ing of the obliquity of the pregnant cornu, or placing the patient upon the side corresponding to the non-preguant half, will suffice; if it does not, podalic version and extraction must be done. The non-distended cornu may be forced down; the treatment is then the same as that of a rudimentary cornu under like circumstances. If the vaginal walls or bands hi the vagina or cervix are in the way of the advancing he,ad, they must be pushed to one side, or divided. If hematometra lateralis is pres ent, the sac must be early decreased in size, so as to leave room for the passage of the head.
When there have been twins, one has been born after the other, and no trouble has ensued. There is danger of postpartum hemorrhage, however, on account of deficient uterine development and the possible location of the placenta upon the septum.