5. Uterus Bicornis (Fig. 231).-When the Müllerian ducts remain more or less separated from one another in that part which forms the uterus, this organ appears with two more or less distinct horns at its upper end. There may be a complete partition going all the way down to the external os, so that there is a double cervix, or the cervix may be single, or the partition may be absorbed more or less high up between the two horns, until it is only represented by a ridge at the

Uterus Bicornis (Hunkemüller): ur, urethra cut off; iu, meatus urinarius; rag and rage, entrance to the double vagina, the anterior wall of which has been removed, showing the two vaginal portions of the two-horned uterus.

fundus inside, while the horns are only separated by a corresponding slight depression on the outside, so that both the external contour and the cavity have somewhat the shape of a heart on playing-cards.

6. Uterus septus, or bilocularis, is a uterus with a complete partition between the two halves, but with the normal shape of a uterus outside, a kind that is of much rarer occurrence than the corresponding bicornute variety.

If part of the septum has been absorbed, the uterus is called subseptus-i. e. partially partitioned.

In all forms of double uterus, be it horned or not, the vagina may be single or double (p. 332). The menstrual flow may come from one or both halves, and if from both, it may either come from both sides at the same time or alternately from each half.

Pregnancy may take place in either half or in both at once. Even if it is confined to one side, the other, as a rule, partakes in the pro

cess, forming a decidua, and producing muscular hyperplasia and hypertrophy.

The presence of a double uterus serves to explain many cases of superfetation, an occurrence that is impossible in a single uterus after the third month of gestation.

Childbirth takes in most cases a normal course, but complications are comparatively much more frequent than with a normal uterus. Diagnosis. The presence of a two-horned uterus may sometimes be felt by bimanual examination or from the rectum.

The condition of the septum in a double uterus is ascertained by simultaneous use of two sounds, one in either half of the uterus. If there is a communication between the two, the sounds may be brought in direct contact.

7. Atresia Uteri.-Just as we have seen above (pp. 326 and 328) that the hymen or the vagina may be closed, the uterine canal itself, although more rarely, may be the site of atresia. The mucous membrane of the vagina may cover the whole vaginal portion without forming any external os, or the cervix forms one uninterrupted muscular mass without bore. In such cases the vaginal portion may be well developed or totally absent. In a bicornate uterus one horn may be closed.

In regard to symptoms, prognosis, diagnosis, and treatment, we refer to what has been said above in treating of atresia of the hymen and the vagina (pp. 327-330). Wherever the genital canal is closed the symptoms due to retention, such as amenorrhea, pain, menstrual molimina, and the formation of a tumor, are the same. Here we will only mention a few special features belonging to atresia when it is situated in the uterus. The vagina can be explored to its full extent with the finger and the speculum. Above it the uterus forms a round elastic tumor, in the differentiation of which the examiner must especially think of pregnancy, fibroma, and hematocele.

In

a case of pregnancy the patient will, as a rule, have menstruated before being impregnated, and more or less of the well-known signs of pregnancy will be present. A fibroid forms a hard nodular tumor, and causes often menorrhagia. Hematocele appears suddenly and forms a broader mass, which pushes the uterus forward.

If the uterus is double, the atresia is found much more frequently on the right side. As a rule, the tumor will begin to form at the time of puberty and increase with every monthly period, as in atresia of the single uterus, but sometimes the development is slow and irregular. Blood may accumulate in the corresponding tube, which gives way before the stronger uterine wall is ruptured. The closed horn may become adherent to the anterior abdominal wall, and rupture take place through it. The hematometra may also rupture into.

the stomach or the intestine, which leads to septicemia and death. The least dangerous rupture is that through the partition into the pervious part of the uterus, in which way a permanent cure may be effected; but in other cases the opening closes again and a new accumulation takes place, which in consequence of the entrance of pyogenic bacilli becomes purulent (pyometra). This abscess may again open into the normal half of the uterus, from which the pus then flows out, or it may burst into the peritoneal cavity, causing septic peritonitis.

Exceptionally, the contents of the closed horn are only mucus (hydrometra). If a purulent collection becomes decomposed gases are formed in the cavity of the uterus, a condition called physo

metra.

Treatment. If the uterus is single, a puncture should be made through the cervix with a trocar and enlarged with a bistoury or a metrotome. After evacuation an iodoform-gauze drain should be left in the uterus, and after its removal a perforated intra-uterine glass stem should be inserted in order to keep the cervix open. Later, curetting of the endometrium and packing with iodoform gauze will combat endometritis and help to bring the distended and, as a rule, hypertrophied uterus back to a normal condition.

If the accumulation is found in one half of a double uterus it is still an advantage, if possible, to enter through the cervix, but often there is no choice and the tumor must be punctured at its lowest point in the vagina. Puncture alone, even repeated, rarely effects a cure, and it should, therefore, be followed by an incision, or even an excision, of a portion of the wall, so as to insure permanent communication with the open half of the genital canal. When the closed half has been punctured and evacuated it may be possible to dilate the open half by Vulliet's method (p. 156) and remove a part of the partition between the two halves of the uterus.

If the swelling cannot be reached from the vagina, laparotomy should be performed and the affected horn or the whole uterus removed as for a fibroid.

If blood has collected in the Fallopian tube, and there is no communication with the uterine cavity, it is best to let it alone, as it may perhaps be reabsorbed. If the tubal sac grows, it may be punctured from the uterus or the vagina, and in the latter place treated with injection and drainage. Laparotomy and removal of the distended tube may be tried, but it is liable to prove difficult or impossible on account of adhesions.

C. Arrest of Development during the Second Half of Intra-uterine Life.-1. Fetal and Infantile Uterus.-Some adult women have a womb that in size and configuration corresponds to that of a fetus toward the end of pregnancy or that of a young child. Sometimes

it is only an inch and a half deep; in other cases it has the size of a virgin uterus, but is characterized by the preponderance of the neck over the body and the thinness of the walls of the latter. The folds of the mucous membrane may either be confined to the cervix or extend more or less up into the cavity of the body.

The fetal uterus may at the same time be two-horned (p. 390), as the result of a double arrest of development. The other organs may be normal, but often the condition is combined with other abnormalities, especially of the ovaries.

2. The pubescent, or congenitally atrophic, uterus is one that is characterized by its small weight, which does not exceed one ounce, but the cervix and body have about the same length.

Etiology.-Besides simple arrest of development from unknown causes, exudative perimetric inflammation, chlorosis, and tuberculosis may cause the deficient development of the uterus.

Symptoms.-Menstruation is, as a rule, absent or scanty. Often the patient suffers from dysmenorrhea, and sometimes vicarious menstruation (p. 241) takes place. All sorts of disorders in organs outside the pelvis (pp. 247-249) may occur with, or instead of, the menstrual flow.

Sexual appetite may be unimpaired, but as a rule women with too small a uterus are sterile, or if they conceive they are apt to abort. Prognosis.-The prognosis, especially in regard to sterility, should be guarded, but a late development of the uterus, leading to conception and childbirth, has been observed.

Diagnosis. The condition can, as a rule, be made out by palpation, especially through the rectum, and the use of the sound.

Treatment. If tuberculosis or chlorosis be present, the practitioner should carefully abstain from any local treatment that is likely to bring on the courses: the patient being anemic, her condition will only become worse by losing blood. In such cases a general tonic treatment is indicated (pp. 224-226).

If the patient is in good health, and sterility the chief complaint, galvanic treatment with the negative pole in the uterus and faradization have often good effect.

If she suffers from dysmenorrhea, vicarious menstruation, and dysmenorrheic disorders outside of the pelvis, she should be treated according to the rules laid down above (pp. 241, 243, 244, 249) in discussing those conditions, especially with tonics, a strengthening regimen, sedatives, electricity, and the uterine sound.

3. Uterus Parvicollis and Acollis.-Sometimes the body of the uterus is well developed, but the cervix is too small, or the vaginal portion is absent. In other cases the body is likewise too small, but the hypoplasia is most pronounced in the neck. These deformities have more pathological than clinical interest.

4. Anteflexion of the uterus is often congenital, and simply a continuation of the shape of the uterus found in the fetus and young children. This condition will be considered together with other displacements of the uterus.

D. Irregular Development.-1. Obliquity.-The uterus may be congenitally bent to one side (lateroflexion), the two Müllerian ducts that formed it not having kept pace with one another. Or a similar condition may be produced by fetal peritonitis and cicatricial shrinkage of one of the broad ligaments.

A normally shaped uterus may be tilted to one side (lateroversion), especially when there is a beginning ovarian hernia.

2. Malposition.-In consequence of an uneven development of the broad ligaments the uterus may be placed not in, but to one side of, the median line of the pelvis, lateroposition.

A similar irregular development of the parts situated in front of and behind the uterus leads to anteposition, when the uterus is situated too near the symphysis, or retroposition, when it is drawn too near to the sacrum.

3. Hernia Uteri.-The uterus has been found in a congenital inguinal hernia. In such cases the ovary descends first through the inguinal canal, just as the testicle descends, or rather is drawn, into the scrotum. The uterus has also been found in a crural hernia. Such hernia are exceedingly rare. The patient may become impregnated and the fetus develop in the hernia, whence it has to be removed by Cesarian section. If the condition comes under observation earlier and gives trouble, hysterectomy might be performed.

4. Elongated Cervix and Stenosis of the Cervical Canal are often found as a congenital irregularity, but will be treated of together with the same conditions when acquired later in life, in a subsequent chapter. (See Hypertrophy of Uterus).

CHAPTER II.

INJURIES.

A. Injuries of the Body.-On account of its position in the depth of the pelvic cavity the unimpregnated uterus is little exposed to injuries, but when during pregnancy it rises up from the pelvis and rests gainst the abdominal wall it is so much more frequently the seat of traumatic lesions, such as goring with a bull's horn, kicks with heavy boots, stab-wounds, or shot-wounds.'

An interesting case of the last kind was reported by Dr. George A. B. Hays, of Plaqueminos, La., in Gaillard's Med. Jour., Nov., 1879, p. 402, et, seq.