DOUBLE UTERUS AND VAGINA WITH A NEW BLOODLESS OPERATION FOR THE CORRECTION OF THE DEFORMITY* BY A. E. RocKEY, M.D. OF PORTLAND, OREGON Two cases of this malformation have come under my personal observation. Beyond the vague statement by several text-book authors that it is fairly common, my library contains no statistics of its relative frequency. The index of the first sixty volumes of the ANNALS OF SURGERY makes no mention of it. In Ashhurst's System of Surgery, in the gynmecological section, written more than thirty years ago, by Theophilus Parvin, of Philadelphia, there is a rather comprehensive paragraph with eight quotations from the literature. Since that time but little has been added, except an illustration of a case in Kelly's Operative Gynaecology, published in I898, Fig. i, and one by Dr. J. M. Fisher in Volume V of Keen's Surgery. One modern encyclopaedic work treats the subject, including operative method, in a five-line paragraph. If the condition is fairly common, it must be that at the present time it is not considered of sufficient importance to gain any prominent notice. Embryologically this malformation is an arrest of development rather than a redundancy, as the duplicity of parts would suggest. The uterus and vagina are developed from the fusion of the Muellerian ducts, which occurs between the tenth and twelfth week of fetal life. Nor- mally the intervening septum is absorbed, and a single cavity and canal results. Arrest of development in this fusion causes uterus bicornis, septus, or subseptus, which may occur either with or without the per- sistence of a partial or complete septum in the vagina. When the vaginal septum is obliterated within the hymen, or when one vaginal canal remains rudimentary, the condition may be undiscovered until a bicornate uterus is found during the performance of an abdominal operation. When it is complete it may not be found until labor occurs, or, if the vaginae are rather small, may be discovered after marriage. The operative procedures mentioned in the literature are limited to the division of the vaginal septum. Excision with scissors and suture of bleeding points is the method suggested, though Parvin also mentions * Read before the North Pacific Surgical Association, Spokane, Decem- ber 17, 1915. 615 A. E. ROCKEY the elastic ligature, and galvanocautery loop. I find no suggestion for the removal of the uterine septum. Of the two cases that I have observed, one was in a woman forty years of age. The vaginal septum had been excised after marriage, years before, and was evident only as a slight ridge, and an interruption of the normal vaginal rugae in the middle line. There was a double cervix with a complete septum in the uterus. She had never conceived. The case which I wish to report in-detail was referred to me by Dr. A. Tilzer: Patient was married at the age of nineteen and a half years, in April, I906. Seven weeks later she consulted Dr. Tilzer, who FIG. 2.-Showing forceps placed on septum, and the septum divided between the forceps with scissors. discovered that she had a double vagina and double uterus. On May I5, I9o6, the operation, which I will describe below, was performed. In November, I9o8, she was delivered of a normal girl baby; also in July, I9IO, of a normal girl baby; on April 24, 19I2, a girl baby, breech presentation; on September 9, 19I3, a boy. The children were all normal, and living. The following operative procedure was adopted in this case. Under ether anaesthesia a long straight broad ligament clamp was placed on the posterior part of the vaginal septum, and another on the anterior part (Fig. 2). The ends of both extended to the vaults of the vagine. They were firmly clamped, and the septum divided between them with scissors. Two long, straight, right angle retractors were introduced through this incision between 616 FIG. I.-Double vagina and double cervix, with a blade of a bivalve speculum introduced into each side so as to show both cervices and the septum in the middle. (From Kelly's Operative Gynaecology, t. 241, vol. i.) DOUBLE UTERUS AND VAGINA the clamps and the now enlarged vagina, permitting a good view of the double'cervix. Exploration by two uterine sounds demon- strated the presence of a complete septum in the uterus. The FIG. 3.-Showing one blade of forceps on each side of double uterus, preparatory to destroying the septum by pressure necrosis of the clamp. 9'? FIG. 4.-Side view of forceps on divided vaginal septum and central clamp fastened to uterine septum. cervices were separately dilated with a small uterine dilator. This permitted the introduction across the septum of the blades of a full length curved clamp forceps (Fig. 4). This was then firmly 617 A. E. ROCKEY locked into place, compressing the septum (Fig. 3). The handle of this forceps was supported by a folded strip of gauze placed under it in the vagina, and over the perineum, to avoid pressure injury by its weight. In bed the handles of all three forceps were further supported by pads. They were allowed to remain in place for thirty-six hours, and were then removed. The compressed septum soon sloughed out, and healed completely, leaving a single uterus and vagina, that were normal in appearance. The simultaneous examination of the cavities with two sounds during the performance of this operation is important. The existence of a possible bicornate uterus with a wide low divergence of the bodies should be predetermined. In such a case it might be advisable, after introducing the separate blades of the long curved clamp into the cavities (Fig. 4), to raise the table to the Trendelenburg position, and close the clamp very slowly to avoid any possible injury by catching the intestine between the approximated uterine bodies. In uterus septus, or when, as is usually the case, only the upper part of the body externally is bicornate, no such possibility exists. By this method the fusion of the two vaginal canals and the two uterine cavities, by forceps pressure, is accomplished with facility and without any bleeding. 618.