Chapter XL on Endometritis, page 166. In the present chapter we will take up the arrests of development, lacerations of the1 cervix, and diseases of the uterine ligaments.
DIAGNOSIS OF CONGENITAL ANOMALIES OF THE UTERUS
The uterus, which in the virgin measures three inches in length, two inches in breadth at the fundus, and nearly an inch in thickness,
is developed from the coalescence of the two Miillerian ducts in the embryo. This coalescence takes place from the eighth to the twelfth weeks of fetal life. The development should be com- plete, with the septum between the two ducts absorbed and the
197
198
CONGENITAL ANOMALIES OF THE UTERUS
uterus completely formed, by the twentieth week, and after this time the question is one of growth, and not of development. The period of growth extends to the twentieth year of life. Therefore, in seeking the cause of uterine anomalies we have to consider two factors — arrested development and arrested growth.
%■ Ostium aS^ominah
Ovary--- Epoophoron
xv
rfuJkrmrj Jucr^~ ----- tubal portion.
3iadder—
*"1
Ureter- -
Urethra-
Wolffian JJ duct
-f Mullen an duck
( Ufen'nC porttoq.
L ^fuller tar} ducts
J Vaginal portion
/ Urogenital £mu$.
Fig. 71. — The Development of the Tubes. Uterus and Vagina in the Fetus. The Vaginal Portions of the Miillerian Ducts Are Here Still Separate. (After J. Kollmann.)
I. Anomalies due to Arrest of Development
Absence of the Uterus. — Complete absence of the uterus, i.e., those cases in which there is present not even a knob of tissue at the upper end of the vagina to represent a uterus, is an affair only of non-viable fetal monstrosities or pseudo-hermaphrodites.
Rudimentary Uterus. — Rudimentary uterus, on the other hand,
ANOMALIES DUE TO ARREST OF DEVELOPMENT
199
is not so uncommon. A goodly number of cases have been re- ported in the literature and they generally appear under the caption of "absence of the uterus" because the diagnosis is so difficult during life. In these cases there is present, in the situation usually occupied by the uterus, a knob of connective tissue of variable
Fig. 72. — Uterus Bipartitus.
Fig. 73.— Uterus Didelphys.
Fig. 74. — Uterus Bicornis.
Fig.. 75. — Uterus Septus.
Fig. 76. — Uterus Unicornis.
Fig. 77. — Uterus Unicornis with Accessory Cornu.
size and there is partial or complete absence of the vagina. The tubes are absent and the ovaries may or may not be absent. If they are present the patient suffers from molimina. Patients with this abnormality of development are generally well-formed women with normal external genitals, breasts, hair, and voice, who consult
200 CONGENITAL ANOMALIES OF THE UTERUS
the physician because of the absence of menstruation. The case of a married woman reported by me,— "Congenital Absence of Uterus and Vagina " (Amer. Jour, of Med. Sci., March, 1897), came under observation because of the absence of a vagina.
The diagnosis is made by recto-abdominal examination with the patient under an anesthetic, — also by examination with a large sound in the bladder and the finger in the rectum. An absolute diagnosis can be made only by an abdominal section or by a post- mortem examination.
Uterus Bipartitus. — Uterus bipartitus consists of a poorly de- veloped cervix continuous with two rudimentary united cornua which are usually solid cords, but may be provided with, pervious canals as in the figure. The ovaries are generally present in an undeveloped state. Here only the lower part of Muller's ducts have succeeded in coalescing to form a cervix, failing to unite in their upper portions.
Uterus Didelphys. — This is rare. It consists of two separate uteri, each with one horn, and two separate vaginae. Sometimes the lower extremity of one vagina is occluded at some point above the vulva and may contain retained secretions. (See Congenital atresia of the vagina, Chapter XX., page 357.)
Uterus Bicornis. — Uterus bicornis is a relatively common condi- tion. In it Muller's ducts have united to form a cervix with two canals and two ora, but are ununited above, so that there are two long cornua representing a uterine body. Sometimes the union has progressed to a point a little higher up in the cervix and we have one external os and one cervical canal below, and two cer- vical canals above, or the condition known as Uterus bicornis uni- collis. (See Fig. 78.)
Uterus Septus. — Uterus septus is the coalescence of the ducts to form a uterus which appears to be normal externally but within, its cavity is divided longitudinally into two cavities by a persist- ence of the septum.
Uterus Unicornis. — Uterus unicornis results from the develop- ment of only one cornu, the other being entirely absent or rudi- mentary. The corresponding Fallopian tube is generally absent. If secretions accumulate in the rudimentary cornu, there being no outlet, a distended sac will be formed; but fortunately this is a rare happening. Pregnancy may occur in a rudimentary horn,
ANOMALIES DUE TO ARREST OF DEVELOPMENT
201
also in uterus didelphys, and, of course, in uterus septus. (See