The Division Of The Uterine Cavity

The Division Of The Uterine Cavity by a vertical septum into two loculi extends in rare cases into the external orifice, but more generally is united to the cavity of the uterus, or the septum does not even suffice to divide the uterine cavity: when this malformation approaches the normal character of the organ, we merely observe a ridge on the fundus and along the posterior wall of the uterus, representing a rudimentary septum. If the septum does not reach the external orifice, its lower free border is always thinner, pointed, and falciform. It probably always descends lower at the posterior than at the anterior surface of the uterus, and this becomes particularly apparent when it merely exists in a rudimentary state.

In the case of the uterus bicornis or bilocularis, the vagina is either single, or may in either be divided in all the forms and degrees described at p. 202. The most perfect fissure seen is that in which the septum of a uterus bicornis or bilocularis descends to the external orifice, divides the latter, and extends to the vagina; the septum may reach as far as the pudenda, and in the virginal state divide the hymen. In this case there is a separate vagina for each half of the uterus.

All these malformations of the uterus occur associated with various irregularities in other organs, as also in individuals that in other respects are well developed. In reference to conception, pregnancy, and parturition, connected with the uterus bicornis, bilocularis, and unicornis, we have to make the following remarks.

Firstly

Numerous well-authenticated observations prove that the anomalous conditions of the uterus which we have discussed, i. e. the uterus bicornis and bilocularis, with or without division of the vagina, and even the uterus unicornis, are capable of being impregnated. In the first we find repeated pregnancy occurring in either half, but there is a preponderance in favor of the right side. There are even cases on record of a twin pregnancy occurring in one, or of concurrent pregnancy in both halves; one foetus has been found less developed and smaller, and in solitary cases perhaps - though this is to be received with certain doubts - superfoetation had taken place. In the Viennese Museum we have even an example of pregnancy in a rudimentary uterine horn, which terminated fatally in the third month by rupture and sanguineous effusion into the peritoneal cavity. The case was formerly taken for impregnation of the Fallopian tube, until a further examination convinced me to the contrary. It is highly instructive, and doubtless the only case of the kind on record. We shall, therefore, devote a little further attention to it.

The true uterus is a uterus unicornis of the left side with a cervix, in which cicatrices that have been left by former births are visible; the left Fallopian tube issues from its apex, which is turned to the left side. A tolerably thick, roundish, flattened, and hollow cord, consisting of uterine parenchyma, is inserted into the convex right margin of this uterus, and communicates by a millet-sized opening just above the internal os uteri with the cavity of the latter. This cord is above two inches in length, and is dilated externally into a sac of the size of a duck's egg, from the termination of which the right tube with its ovary, and from the lower surface a round ligament proceed. This sac, the rudimental right half of the uterus, contained a female foetus of the third month enclosed in the normal membranes; it presented a transverse fissure, in the vicinity of the insertion of the umbilical cord, of almost two inches in length. All the membranes were ruptured. The left half of the uterus is twice as large as it would be in an unimpregnated state, its walls thick, and its innner surface, as well as that of the channel of its parenchymatous process, invested by a deciduous membrane, and the cervix blocked up with a plug of coagulable lymph.

The preparation was taken from a maid-servant twenty-four years of age, who had died suddenly after attacks of pain and spasm in the abdomen on the 24th of March, 1824, and was examined by order of the sanitary board. The body was delicately built and rather emaciated; four pounds of blood, which had been effused in consequence of the rupture of the pregnant rudimentary uterus and the foetal membranes, were found in the lower part of the abdomen.

The formation of which we are speaking, is the same as the transition form from the uterus bipartitus to the uterus bicornis described at p. 208, with the exception that in this case the parenchymatous cord that passes from the rudimentary to the developed half of the uterus is hollow, and contains a channel which establishes a communication between the two, whereas in the other case the cord is solid. By means of this channel impregnation of the rudimentary uterus was rendered possible; this pregnancy forms a species of transition from uterine to extra-uterine pregnancy, and particularly to pregnancy in the Fallopian tube.

Secondly

In reference to the course of pregnancy and of parturition in uterine formations that are capable of being impregnated, Meckel concludes, from a review of the cases that had been published in his time, that of the comparatively small number of cases of fissured uterus the majority died during or after birth; this ratio is increased by the consideration that in the great majority of these cases the malformations occurred in monstrosities, children, and virgins. Since Meckel, Carus has directed particular attention to the unfortunate issue of these cases. Numerous cases may now be opposed to the ancient and modern observations of the above description, but it appears that the unfavorable ratio pointed out by Meckel still holds good with regard to the uterus bicornis and bilocularis.

Various circumstances conspire to induce great distress or rupture of the womb, even during the early periods of pregnancy (Canestrini, Dionis), to give rise to abortion, flooding, difficult and slow parturition, with consequent exhaustion and predisposition in the uterus to puerperal disease. They become apparent on examining the fissured organ, and we find them to be the following.

a. The absence of the necessary dimensions in the uterine half that undertakes the functions of the entire organ during pregnancy, and the development of which is only provided for by one set of vessels. This applies with additional force to a rudimentary uterine half, as in the case just detailed; in reference to its termination in rupture also, it is allied to extra-uterine pregnancy, and especially to pregnancy in the Fallopian tubes.

b. The obstacle opposed to the uniform development of the impregnated uterine half by the unimpregnated half. It appears that the latter, after the formation of a more or less complete decidua, keeps pace in its development with the impregnated half up to a certain point only, and then remaining stationary, forms an impediment to the uniform growth of that half. This observation is particularly applicable to the bilocular womb, with a complete septum, as the latter being common to both cavities, remains undeveloped on the side of the unimpregnatecl portion; it applies less to the true uterus bicornis, the two sides of which are independent of one another.

c. The nearer the uterine malformation approaches the uterus bicornis, the more the two halves of the organ diverge from the axis of the body and the pelvis. In the bilocular uterus, the uterine halves are tolerably parallel to the axis of the body; in the uterus bicornis they form an acute, or even almost a right angle with the latter. The impregnated half of the uterus certainly shows this deviation; but in the uterus bicornis it appears to diminish, whereas in the uterus bilocularis it seems to increase. The axis of the impregnated uterine half is therefore certain to meet with the vaginal axis in an obtuse angle; consequently, during the act of parturition, the direction of the uterine force and of the expulsion of the foetus will cross the axis of the pelvis, and fall upon the pelvic parietes that lie opposite to the vertex of the pregnant half of the womb. The direction of the impregnated half and of its force, will also be influenced by the unimpregnated half, which during the act of parturition rests upon the pelvis, and especially on the linea innominata of the corresponding side.

d. The fundus uteri and its expulsive power is of particular importance in the act of parturition. The uterus bilocularis has only one half of this part of the organ, and in the uterus bicornis it is totally deficient.

e. Carus considers the impediment to the discharge of the superfluous amount of blood from the uterus to be the cause of the fatal issue which commonly follows birth in the case of fissured uterus. In the normal uterus the return of the blood accumulated in the pregnant womb is effected by means of two sets of vessels; whereas in the fissured uterus, each half of which is supplied by separate vessels, one-half of the venous channels only can carry off the blood. Consequently, although the single uterine horn becomes almost as much developed as the undivided uterus, an unfavorable relation is established, from one set of vessels only being charged with the entire quantity of blood that has to be returned. Besides the above arrests of development, we find, not so much in new-born infants as in the later periods of life, an imperfect development of the uterus occurring in reference to its size, its tissue, and especially to its vascular system; the organ remains small and retains the foetal or infantine character.

Excess of development, except in the shape of precocity, does not occur; the cases on record of plurality of the uterus are to be viewed as cases of fissure.