Compliments of the Author. 
REPORT 
OF A 
CASE OF PREGNANCY IN THE RIGHT 
HORN OF A UTERUS BICOROTS, 
TREATED SUCCESSFULLY BY A 
MODIFIED CESAREAN OPERATION, TWELVE MONTHS AFTER 
THE DEATH OF THE-CHILD AT THE FULL TERM OF 
GESTATION: SO-CALLED “MISSED LABOR.” 
BY 
B. F. BAER, M.D., 
PROFESSOR OF GYNECOLOGY IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOR GRADUATES 
IN MEDICINE, FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY, MEMBER 
AND EX-PRESIDENT OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA, 
MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, THE COLLEGE 
OF PHYSICIANS OF PHILADELPHIA, THE PHILADELPHIA 
COUNTY MEDICAL SOCIETY, AND THE 
PENNSYLVANIA STATE MEDICAL 
SOCIETY. 
REPRINTED FROM THE 
TRANSACTIONS OF THK AMERICAN GYNECOLOGICAL SOCIETY, 
YOL. XIII. 1888. REPORT OF A CASE OF PREGNANCY IN THE 
RIGHT HORN OF A UTERUS BICORNIS,1 
Treated Successfully by a Modified Cesarean 
Operation, Twelve Months after the Death 
op the Child at the Full Term of Ges- 
tation: So-called “Missed Labor.” 
B. F. Baer, M.D., 
Philadelphia. 
The case whose history is here related is cue of unusual 
interest, and in some of its features probably unique. 
On June 11, 1885, I was consulted by Mrs. L. 0. She had 
been sent to me by Dr. G. D. Nutt, of Williamsport, Pa., who 
had diagnosticated extra-uterine pregnancy. She was then 
twenty-six years of age and had been married four years. She 
had one child a year after marriage, at the full term, after a 
normal labor. The child died when three months of age from 
cholera infantum. She then menstruated regularly until about 
September 1, 1883, after which time the catamenia were sup- 
pressed and she considered herself pregnant. In due time the 
morning nausea and vomiting, mammary signs, abdominal 
enlargement, quickening, and all of the other signs of normal 
pregnancy occurred in regular order. The abdomen continued 
to increase in size until she was as large as at full term, but the 
enlargement was greater on the right side than on the left. 
Foetal movements were active and strong, but did not impress 
the patient as unusual. She did not have the slightest hemor- 
rhagic discharge from the uterus, nor did she suffer any pain 
during the entire course of the gestation. She did not have a 2 
PREGNANCY IN A UTERUS BICORNIS. 
suspicion but that she was normally pregnant, and she antici- 
pated a normal labor as with the first pregnancy. During the 
first week of June, 1884, when she was about the full term, and 
hourly expecting to go into labor, she was attacked with sharp 
pain in the right side of the abdomen; she felt something give 
way, and the movements of the child, which had been unusually 
active, suddenly ceased. She became faint for a time, but soon 
rallied, and there was no further evidence of shock. Labor 
pains began almost simultaneously with these phenomena, and 
she sent for a physician, Dr. J. W. Sheets, of Northumberland, 
Pa., who kindly sent the following reply to a letter which I ad- 
dressed to him after the patient came under my care, and which 
I received on the day of the operation. 
“ My dear Doctor: Yours of the fourteenth instant received. 
On June 9, 1884, I was called to see Mrs. O. for the first time. 
She had been in the care of another physician of this place 
during what he and she supposed to be the later stages of natural 
pregnancy. For some reason the family became dissatisfied with 
him and sent for me. I found her losing a great deal of blood 
from the vagina, and suffering from pain in the region of the 
uterus. Examination revealed Avhat appeared to be a dilatable 
os, but rather of eight and a half months than full term. I 
ordered quiet and opium, and the next day found the patient 
easy but still losing blood. I now examined her more closely. 
She had the appearance of a healthy person in the last month of 
utero-gestation. The foetal heart sounds were strong and appar- 
ently natural—at least, I was satisfied such was the case at the 
time. The next day, the third from the time I first saw her, she 
was up and assisting her husband with some light duties in his 
bakery. I did not have an opportunity to examine her thoroughly 
after that. There seemed an unusual condition, but her freedom 
from all peculiar symptoms until what I considered near the full 
term of gestation, and the natural appearance externally, led me 
to advise her to await development for a short time. The second 
week the husband called to pay me, saying, ‘we move to- 
morrow.’ This was June 23. They moved to Towanda, Pa., 
and several months afterward I received a letter from a physi- 
cian attending her, in which he stated his conviction that Mrs. 
O. was the subject of an abdominal growth. I persisted in the 
presence of a foetus, and if not in the uterine cavity it must be 
otherwise, but I was sure of a foetus. I looked upon her case 
as one presenting very exceptional features. Nearly as I could 
ascertain, all through her pregnancy she presented no unusual B. F. BAER. 
3 
symptoms, and only within a short time of what seemed to be the 
full term did she present any, and they not remarkable. 
“ Very truly yours, 
(Signed.) “ J. W. Sheets.” 
The patient further stated that within a few days after the 
false labor in June the mammary glands became swollen and 
tense and milk was secreted ; but it soon disappeared and the 
glands returned to the non-pregnant condition. The abdominal 
tumor began to diminish in size. In the meantime she was in 
comparatively good health, and had removed (as stated by Dr. 
Sheets) to a distant town. In the first week of July, just one 
month from the commencement of the symptoms described 
above, labor-like pains and metrorrhagia again set in, and the 
physician who Avas now called thought she Avas in labor. 
He said that the child had probably died in June, and that 
“missed labor” had occurred, but that the contents of the 
uterus would noAAf be expelled. After two or three days, how- 
ever, the pains and hemorrhage subsided and the patient went 
about. 
The next month, and the next, “ hard labor pains ” oc- 
curred with the recurrence of the menses, and each time both 
the patient and her physician looked for the delivery of the 
product of the “ missed labor.” They Avere disappointed. 
But the tumor was becoming gradually smaller and more firm. 
At the fifth recurring menstrual period from the beginning of 
the trouble in June, labor pains were absent and she had a 
natural menstruation. It Avas at this time that her physician 
Avas so puzzled that he AArrote to Dr. Sheets his belief that Mrs. O. 
had an abdominal tumor (non-pregnant). After this the cata- 
menia occurred regularly, but the expulsive pains did not return. 
She Avas about, attending to her duties, but she gradually lost 
strength and flesh. A few Aveeks before she came under my care 
she Avas suddenly attacked, at midnight, by a sharp pain in the 
right hypogastric region, folloAved after a time by a fainting sen- 
sation and then cold (shock). She continued ill the remainder 
of the night and the forenoon of the next day, Avhen she felt 
better; but the symptoms returned the folloAving night, and 
every night subsequently, at about the same time, and continued 
as with the first attack. The pain also extended to the back and 4 
PREGNANCY IN A UTERUS BICORNIS. 
down the right groin and anterior portion of the thigh. The 
patient presented a considerably emaciated and pallid appear- 
ance. 
Inspection.—Patient in the dorsal position. The right side and 
centre of the abdomen were shown to be distended by a mass as 
large as the uterus at the seventh month of gestation. It was 
pyramidal in shape, larger above than below. The abdominal 
wall presented a dry, drawn, emaciated appearance. The iliac 
processes were very prominent. There was a wide, deep sulcus 
into which the hand could be laid between the left superior iliac 
spine and the tumor. A depression also existed between the 
right anterior iliac prominence and the tumor, but it was much 
smaller. The lower anterior surface extended downward and 
rested upon the right pubic ramus, apparently dipping into the 
pelvic cavity. 
Palpation.—The upper portion of the tumor was easily movable 
from side to side in the abdominal cavity, but the lower portion 
seemed to have a deep pelvic attachment. It was smooth on the 
surface and appeared to be entirely free from the abdominal wall. 
It was firm, almost hard, and this fact, taken in connection with 
its smoothness and mobility, suggested uterine fibroid. Vaginal 
palpation showed that the uterus was elevated and placed some- 
what diagonally across the pelvis, the cervix pointing downward 
and to the right, the fundus upward and to the left, the organ 
being apparently suspended from the tumor to which it was 
loosely attached. The uterus was unusually small and could be 
moved to a limited degree independently of the tumor, as though 
it had a broad-ligament attachment. A broad, ligamentous 
attachment could almost certainly be made out by bi-manual 
palpation. The cervix and os were quite small; the sound gave 
a measurement of two inches and a half, and showed the uterine 
cavity to be small; the uterus was apparently more cylindrical 
than flat. The lower surface of the tumor could be felt very 
distinctly by the vaginal finger. It was smooth, globular, and 
semi-fluctuating. There was duiness on percussion over the 
tumor ; resonance on the lateral and upper borders. 
Diagnosis.—The question of diagnosis became a very interest- 
ing one. It was clear that some form of ectopic gestation had ex- 
isted. But it was also clear that it had not been of the ordinary B. F. BAER. 
5 
tubal variety of extra-uterine pregnancy, since the patient had 
not had any of the symptoms of rupture of the gestation sac, as 
pain, hemorrhage, discharge of decidua, shock, etc , which always 
attend that accident. The so-called abdominal gestation was also 
excluded for the same reason; for it is now a well-established 
belief that when this form of extra-uterine gestation exists, 
which is rare, it begins as a tubal pregnancy. The tube ruptures 
and the embryo escapes, either into the abdominal cavity, where 
it probably dies, or into the broad ligament, where it may go on 
developing. The symptoms of rupture of the tube ai*e, therefore, 
always present in these cases in a greater or less degree. Further, 
as the external covering is destroyed when the tube ruptures into 
the abdominal cavity, the chorion is without protection. Nature, 
therefore, imperfectly supplies this, if the product lives, by form- 
ing an adventitious inflammatory sac to which the chorion be- 
comes attached. The gestation under these circumstances is 
always attended with great suffering to the mother, if indeed she 
escapes with her life. And if full term is reached, the phenomena 
of labor do not occur and recur so perfectly as were here mani- 
fested. Again, when an inflammatory sac has been formed it is 
always closely adherent to the organs and tissues around it and 
to the uterus; therefore, the physical signs would be entirely 
different from those present in this case. There Avould not be 
the mobility of the womb, nor a non-inflammatory and apparently 
ligamentous attachment as was found here. 
In view of the history and physical signs related above, I 
concluded that some form of abnormal pregnancy had existed 
and that the tumor contained a dead child; but I was puz- 
zled as to the character of the sac. It could not have been 
tubal and reached term, as it did, without symptoms of rup- 
ture. It could not have been intraligamentous and reached 
term without having given rise to symptoms and physical 
signs, which were absent in this case. There was no doubt, 
however, as to the proper course of treatment. I advised 
laparotomy, and hoped, in view of the transverse mobility 
of the upper portion of the tumor, to be able to remove 
the sac entire, whatever its character might prove to be. 6 
PREGNANCY IN A UTERUS BICORNIS. 
The patient was very anxious to have the operation per- 
formed, and she entered my private hospital for that purpose. 
Operation.—On June 18th, assisted by Drs. J. Milton Miller, 
H. M. Christian, and J. D. Nutt, in the presence of Drs. J. F. 
Wilsony De Forest Willard, Latta, Day, and others, I proceeded 
to operate. 
An incision three inches and a half in length was made in the 
median line below the umbilicus, and the tumor at once exposed 
to view. It was entirely free from adhesions everywhere, except 
at its lower portion. It presented a smooth, nacreous, glistening 
appearance, and resembled so much, at first sight, a thick-walled 
ovarian cyst that I, for a moment, questioned the correctness of 
the diagnosis. On closer examination, however, it was found to 
be more vascular and deeper in color. An effort was next made 
to find a pedicle with the view of ligating it, but this could not 
be done as the tumor was found to have a broad base which 
dipped into the pelvic cavity and which appeared to be firmly 
adherent in that position. It was then deemed best to endeavor 
to reduce the size of the mass by evacuating the fluid contents of 
the tumor, and for this purpose I plunged the aspirator trocar 
into the sac. Its contents appeared to be almost solid, and noth- 
ing flowed through the canula. The instrument was now with- 
drawn, and at once pus began to flow from the puncture. An 
incision was then made into the sac, when pus flowed freely and 
continued until at least a quart was discharged. It was not fetid. 
I next introduced my finger and found a child filling the sac. The 
incision in the wall of the tumor was now increased to about three 
inches in length when several fingers were introduced. The child 
was fixed in the lower jJortion of the sac by its breech, which pre- 
sented at the superior strait, with the back to the right side. The 
head was in the upper portion of the sac, the entire foetal ellipse 
being sharply flexed upon its anterior plane. I endeavored to make 
version and deliver by the feet, but the foetal mass was so fixed 
that it could not be moved without undue force. While making 
this manipulation the hands and arms escaped from the incision 
and I then endeavored to deliver by traction upon the head, 
which partly collapsed, the parietal bones slipping off. When 
the head was delivered, it was discovered that the breech and B. F. BAER. 
7 
back were firmly adherent to the lower and outer surface of the 
cyst wall. They were finally separated and the child removed, 
a portion of the skin and superficial fascia remaining attached to 
the gestation sac. It was necessary to clamp many bleeding ves- 
sels in the cyst wall. 
The cyst cavity was now cleansed of blood and debris. The 
umbilical cord was attached to the posterior and right side of 
the pelvis, below the superior strait, where its atrophied vessels 
branched off in different directions. I could not find a placenta, 
but the cord was firmly attached. The placenta was doubtless 
likewise atrophied. 
I now again passed my hand over the external surface of the 
collapsed gestation sac with the view of possibly being able to 
remove it, but it was found certainly to have a broad base which 
dipped into the pelvis, apparently spreading out in the direction 
of the uterus; the latter organ being loosely connected with the 
tumor. In addition it seemed to be firmly attached to the deep 
pelvic vessels. I determined, therefore, that it would not be safe 
to attempt its removal. The sac undoubtedly contained mus- 
cular tissue. Examining now carefully, the left ovary and tube 
were located to the left and deep in the pelvis; the right ovary 
and tube were not found. As I could not remove it, I decided 
that it would be safer to stitch the cyst wall to the abdominal 
incision. This was done by first passing the needle through the 
cyst wall and then through the abdominal wall, thereby coaptat- 
ing the incised edges of the sac and, at the same time, bringing its 
outer or peritoneal covering in contact with the peritoneal sur- 
face of the abdominal wall. The cord was brought out at the 
lower angle of the incision and a drainage tube placed alongside 
of it. The wound was dressed with salicylated cotton, supported 
by adhesive plaster and a flannel binder, and the patient returned 
to bed one hour and fifteen minutes after the operation was com- 
menced. The child was a full-term male and weighed, in this 
macerated condition, seven pounds. 
There was not the slightest evidence of shock during the opera- 
tion, and but little hemorrhage. When the patient was returned 
to bed her pulse was 104 and temperature normal. She soon 
recovered from the ether and asked about the result of the opera- 
tion. During the next twenty-four hours she complained of 8 
PREGNANCY IN A UTERUS BICORNIS. 
considerable pain, for which hypodermic injections of morphia 
were administered. 
There is very little to record regarding the temperature and 
pulse in the after-history of the patient. She was practically 
convalescent from the beginning. Her temperature did not rise 
above 100°, and her pulse was never more than 112, usually 
about 100, until about the tenth day, when both temperature and 
pulse were normal. Her bowels were moved on the fifth day 
and she was permitted to take solid food in small quantity from 
that time on. The drainage tube was watched with considerable 
solicitude as was also the healing of the wound, and it is sufficient 
to state that the latter did not differ in any particular from the 
healing of the ordinary abdominal incision, as union occurred by 
first intention. 
At 7 P. M. on the evening of the day of operation, about a 
tablespoonful of sweet, bloody serum had been discharged from 
the tube. 
June 19 (twenty-four hours after the operation). The notes 
state that the patient passed a good night, and that she felt better 
than at any time for weeks. The pain and backache are gone 
and she feels strong. She is bright and cheerful. No blood 
and very little serum from the drainage tube. 
20th. Passed a good night; slept well. Passed flatus. No 
discharge from the tube. No tenderness on pressure anywhere. 
In the afternoon of this date it is noted that the entire dressing 
was changed for the purpose of examining more carefully as to 
the condition of the cord and also to learn whether there might 
be any difficulty along the line of the incision. There was not 
the slightest odor and no more staining of the cotton than after 
an ordinary laparotomy. The cord was undergoing further 
atrophy, but was still attached. About a drachm of serous fluid 
was drawn from the bottom of the drainage tube. A little car- 
bolized water was introduced from the sponge, but returned 
unstained. The wound was covered with iodoform and the 
dressing replaced. Patient seems bright and well. 
22d. Drew a quantity of fluid from the bottom of the sac. It 
is thicker and lighter in color than yesterday. 
2Jf.th. Patient felt bright and well. Sutures were all removed 
except three or four immediately around the drainage tube. B. F. BAER. 
9 
Union seemed to be perfect, and there was not the slightest sign 
of pus or odor. 
26th. The glass drainage tube was removed and a small rubber 
tube substituted. Removed the remainder of the sutures ; union 
perfect and solid Cord separated about an inch from the open- 
ing. There has not been the slightest tenderness on pressure or 
tympanites since the operation. 
27th. There was a slight discharge of healthy pus when the 
patient occupied the lateral position ; ordered to remain in that 
position as much as possible. 
28th. Dressed wound; very little pus, and that perfectly 
sweet. The incision had closed around the orifice of the tube 
track and the patient seemed not quite so well; a little feverish. 
I therefore passed a probe and found that the track extended 
deeply into the pelvis, but there was no further discharge. A 
small plug of lint was introduced and left in the orifice. 
29th. Temperature normal; pulse 94. Removed a few drops 
of healthy pus. 
From this date there was quite a free discharge of a sero- 
purulent, but perfectly sweet fluid, which continued in diminish- 
ing amount. 
July S. At this date there was considerable odor present for 
the first time since the operation. Irrigation with carbolized 
solution. In the evening of this date, temperature 100°; pulse 
90. The abdomen a little tympanitic; no pain or tenderness. 
Vaginal examination made; first since the operation. The 
uterus was found a little to the left, as it was prior to the opera- 
tion and perfectly mobile. There was no induration, and I 
could scarcely distinguish the remains of the sac. But I did not 
examine very thoroughly for it. 
Jfth. During the night the tube became clogged. Tempera- 
ture and pulse a little higher than yesterday. Temperature 
99f°, pulse 100. Slight diarrhoea and evidence of digestive dis- 
turbance. 
6th. Very little discharge from the tube. Sat up for the first 
time and felt strong and well. Did not want to return to bed. 
16th. She went home (two hundred miles) on the twenty-eighth 
day after the operation. 10 
PREGNANCY IN A UTERUS BICORNIS. 
The patient has remained well; yet, although three and a 
half years have now elapsed, there is still a small fistulous 
opening at the lower end of the incision. At each recurring 
menstrual period there was, for more than two years, a dis- 
charge of blood through the fistula, menstruation at the same 
time occurring in the natural manner from the womb. No 
pain or inconvenience was felt from this discharge of blood; 
on the contrary the patient was always relieved; and it was 
determined by the patient as well as her physician that the 
discharge from the fistula was of the ordinary menstrual char- 
acter. It would continue during the period and disappear as 
the flow disappeared from the natural channel. 
The following letter, dated December 8, 1888, will explain 
the patient’s present condition : 
“Dear Dr.: Mrs. O. says you wish to know how she is at the 
present time. There is still a fistulous opening, and although 
her menses do not now come that way, there is still a watery 
substance discharged. Her general health is first class. There 
is an abdominal hernia in the line of the incision. 
“Yours very truly, 
(Signed.) “J. D, Nutt.” 
At the time this patient came under my care I did not know 
of a single recorded case of pregnancy, which had reached term, 
in one horn of a uterus bicornis, and was not aware that any 
such existed. It was at that time the general belief among 
observers that the cases which had been described by the older 
writers as “ missed-labor ” (Oldham) were really examples of 
extra-uterine gestation; probably of the secondary abdominal 
variety. But the history and physical signs of this case 
removed it from that category, and I was therefore greatly 
perplexed as to the true character of the gestation. It was 
mainly for this reason that I did not at once report the case. 
More than a year after the operation and while I was still 
looking among the literature on extra-uterine pregnancy for a 
similar case, I happened upon the very interesting and in- B. F. BAER. 
11 
structive paper by the late Dr. Angus Macdonald, entitled, 
“ Deport of a case of pregnancy in the left horn of a bifurcated 
uterus,” etc., which had been published in the Edinburgh 
Medical Journal for April, 1885. It now at once became 
clear to me that my case was of similar character. 
In addition to his own case, Macdonald gives a brief 
account of two others, one by Litzmau, of Berlin, the other 
by Salin, of Stockholm, and refers to one by Sanger. There 
also had been at that time a fourth case recorded, that of 
Wiener {Archiv f. Gyndk., Bd. xxvi., heft 2, Greig Smith), 
but it had escaped Macdonald’s notice. These fives cases, with 
my own, the sixth, include all the recorded operations, so far as 
I have been able to learn, for this rare condition; mine being 
the only one in America. It is worthy of note that they all 
occurred within a period of five years, and that each operator 
was unaware of the work of the others; and furthermore, that 
in not one of the cases was the condition fully understood. 
Macdonald, indeed, thought he was operating for fibroid 
tumor of the uterus, and did not discover his error until he 
was severing the pedicle, when a limb of the child escaped. 
In Litzman’s case, the first (February 14, 1880), “ The 
diagnosis was retention of a mature putrid foetus inside the 
uterus.” The Porro-Muller operation was performed, but 
the patient died on the third day, from previously exist- 
ing septicaemia, when the true condition was learned at the 
autopsy. The left horn with its corresponding tube and 
ovary was found within the pelvic cavity; the right had been 
removed with the gestation sac. It was therefore the right 
horn of a uterus bicornis which had been impregnated. 
Salin was the second operator (June 17, 1880), but he did 
not, I believe, fully report his case until 1885 (Hygiea, 1885 ; 
translated by J. G. Tapper, M.D., Elgin, Illinois., Annals 
of Gynecology, Boston, September, 1888). He says, in speak- 
ing of the difficulty of diagnosis in his case, the symptoms of 
which had been much like mine: 12 
PREGNANCY IN A UTERUS BICORNIS. 
“We had naturally, first of all, to suspect an extra-uterine 
pregnancy. Against this diagnosis were many convincing cir- 
cumstances. The patient’s general condition was very good. 
She had certainly lost in weight, yet still was quite plump, and 
could, without great suffering, remain about, a very great con- 
trast to what many suffer in extra-uterine pregnancy. The foetal 
tumor in an extra-uterine gravidity generally appears unsym- 
metrical in form, although these irregularities are difficult to out- 
line with certainty; as nothing but the abdominal walls and the 
thin foetal sac cover the foetus, it is usually very easy to palpate. 
In this instance the tumor was perfectly symmetrical and round. 
Not a trace of the child, or any unevenness, could be detected 
in any part Instead of the uterus being enlarged, 
as in extra-uterine gestation, it was here comparable to a normal 
virgin uterus. It was not closely applied to the tumor, but was 
distant and freely movable, by the side of which the hand could 
discover a pediculated structure passing from the uterus to the 
tumor. The decidua had passed away. Against the supposition 
of a new formation stand prominent before all else the patient’s 
own feelings. It is undoubtedly true that women, during the 
period of active growth of abdominal tumors, frequently deceive 
themselves by suspecting pregnancy, and thus call forth these 
ordinary complex symptoms. The patient so clearly described 
her condition, in such a trustworthy manner, that we were com- 
pelled to give them credence; and added to this was the testimony 
of the husband, who informed us that he had distinctly felt foetal 
movements, which confirmed her statements. Without these 
facts the enlargement of the mammas, with secretion of milk on 
pressure, as well as the appearance of fresh, red colored striae 
upon the belly, which do not generally appear without pregnancy, 
all spoke strongly. We were thus in doubt and could not estab- 
lish a correct diagnosis, but our suspicions inclined mostly toward 
an extra-uterine pregnancy The ordinary abdominal 
incision was made. During the time we were inspecting the 
tumor there oozed out through an opening, the size of a pinhole, 
in the wall of the tumor, a dirty-yellow fluid. Supposing the 
contents of the tumor to be of the same nature, a large ovarian 
trocar was introduced, but no fluid flowed out. On withdrawing 
the trocar a foetal part presented itself. The opening in the wall B. F. BAER. 
13 
of the tumor was then enlarged both in an inward and downward 
direction. . . . . We afterward endeavored to bring the 
tumor outside of the abdomen, which was very easily accom- 
plished. To our astonishment we then found a ligamentum latum, 
with a normal tube and ovary, springing from the right side of 
the tumor. We had, therefore, to deal with a double uterus, of 
which one-half was gravid, while the other, as we had previously 
determined by examination, was of normal size. Both were 
united by means of a short, broad, yet not particularly thick, 
peduncle.” 
The pedicle in this case was treated after Schroder’s method 
of dealing with the pedicle in hysterectomy, and dropped. 
The patient recovered. He continues : 
“ The placenta was completely adherent upon the inside of the 
sac, and from the walls the membrane hung in necrotic folds. 
Tube and ovary were both normal Our supposition 
was consequently incorrect. It was certainly a case of gestation, 
but not extra-uterine, as supposed, but intra-uterine.” 
I have quoted thus at length from Salin’s record to show 
the close resemblance which his case sustained to my 
own. It is almost identical, except in the method of operat- 
ing. The same, with slight qualification, may be said of 
the others. Unlike the other operators, I failed to remove 
the gestation sac, although, as stated, I had hoped, in view of 
the transverse mobility of the upper portion of the tumor, to 
be able to do so. As soon as the abdomen had been opened 
an elfort was made to find a pedicle, but the broad base of the 
tumor dipped deeply into the pelvis, where it was firmly 
fixed. A further attempt was made to remove the sac after it 
had been emptied, but it did not seem safe to continue the 
effort, since it was in such close contact with the deep pelvic 
vessels. Then the deep pelvic attachment of the placenta and 
cord led me finally to decide in favor of finishing the opera- 
tion as described. 
Although I did not at the time of the operation exactly 14 
PREGNANCY IN A UTERUS BICORNIS. 
understand the character of the sac, I fully realized that it was 
an unfortunate circumstance which compelled me to leave it; 
but I do not think I could have done otherwise had I known 
its true character. Removal of the gestation sac, where it is 
possible, greatly simplifies the operation and doubtless renders 
the recovery of the patient more certain and her subsequent 
condition safer. The recovery of my patient, however, could 
not have been more rapid, nor her general health better since 
the operation. True, she has had the annoyance of a perma- 
nent fistula, but this must be looked upon as a safety valve, 
since it gives exit to the menstrual and other discharges from 
this, now otherwise closed, uterine horn. 
I further regarded it as unfortunate that I felt compelled 
to stitch this rather thick-walled sac to the abdominal incision, 
but believe that it was the best that could have been done in 
the case. Even had I fully known the character of the 
tissue with which I was dealing, it would not have been 
proper to close the incision in this imperfectly developed 
uterine horn, as after the regular Caesarean operation, since 
there was now no opening from its cavity into the cervical 
canal. 
It is probable that the hernia which now exists in the line 
of the incision has resulted from a failure of that perfect 
adjustment of the peritoneal surfaces which is necessary to its 
firm union. The peritoneal surfaces on either side of the 
incision were not coaptated at all, the one with the other, but 
each side was first brought in close relation and contact with 
the peritoneal surface of the cyst wall. 
The course and termination of pregnancy in the rudi- 
mentary horn of a bicornate uterus are probably the same, in 
nearly all cases, as in the ordinary tubal form of extra-uterine 
gestation, viz., rupture of the sack during the early months of 
pregnancy. The time of rupture, however, usually is not 
as early as where it is of purely tubal character, nor the 
symptoms of extra-uterine pregnancy so marked as in the 
ordinary tubal variety. The signs are more likely to be those B. F. BAER. 
15 
of normal pregnancy, and the danger therefore masked ; the 
symptoms of rupture being the first evidence of the existence 
of an abnormality in the gestation. This view is supported by 
the result of KussmauPs investigations. “ Kussmaul has sub- 
jected this form of gestation to minute critical and anatomical 
analysis, and proves that it has often been mistaken for tubal 
gestation The thirteen cases collected by him 
all terminated by rupture of the fruit-sac and death. The 
period of rupture varied from the fourth to the sixth month, 
the greater number bursting in the fifth month.” (Barnes’ 
Diseases of Women, second edition, pages 328 and 329.) The 
cases forming the subject of KussmauPs analysis were mostly 
collected from records covering a period of two hundred years, 
the first one being taken from Diouis (1681). 
In a few cases the gestation proceeds to full term, when 
fruitless efforts at expulsion of the product supervene, and the 
child dies. These efforts may now result in rupture of the 
sac and the death of the patient. This is probably the usual 
termination, but in rare instances the sac is strong enough to 
withstand the strain of the false labor. Formerly the con- 
dition was then unfortunately regarded as one of “ missed- 
labor,” and the patient “ left to nature.” The retained 
product now soon began to undergo disintegration and de- 
composition and to ulcerate its way out, in most instances 
destroying the patient by septic absorption during the process. 
It is true that there are, here and there, scattered through the 
literature of many centuries, a few cases recorded where such 
changes have taken place in the retained product as to render 
it inert, the patient enjoying good health throughout the 
remainder of her life. A few have also recovered after the 
product has undergone decomposition and been discharged by 
various channels, through the abdominal wall, bowel, etc. 
Strange to say, until recently, the few instances of recovery 
had been permitted to establish the practice of non-interfer- 
ence in these cases. “ Missed-labor,” that is, the retention of a 16 
PREGNANCY IN A UTERUS BICORNIS. 
matured foetus within a normal uterine cavity far beyond the 
full term of normal gestation, probably never occurs. The 
term was unfortunate and the definition misleading. I fully 
agree with Macdonald in his view of the question, as expressed 
in the paper referred to above. He says : “It is, doubtless, 
difficult to understand how such a phenomenon could arise. 
It is quite foreign to the experience of obstetricians in dealing 
with difficult and laborious cases to find that the uterine pains 
should come and go, and the uterus quietly subside again into 
inactivity without further immediate results. The all but 
universal experience is, that either the uterus ruptures itself, 
or, becoming inflamed, the patient dies of exhaustion along 
with her unborn child.” 
The only question which is worthy of consideration regard- 
ing the treatment of these cases is : When should the proper 
operation for their relief (laparotomy) be performed? To 
which the answer should be prompt in forthcoming: As 
soon as the abnormal condition is recognized, unless this 
should happily occur before the death of the child and before 
it is viable, in which case an effort should be made to save 
its life also, by waiting, if possible, until near the full terra. 
But if symptoms of rupture of the sac, or of death of the 
embryo or foetus supervene ; or if the condition of the patient 
should be otherwise one of gravity, as a result of the ectopic 
pregnancy, valuable time should not be lost in the considera- 
tion of less radical remedies. The laws of physiology and 
pathology teach, and experience has now abundantly proved, 
that the patient is safe only ofter the product of an extra- 
uterine gestation has been entirely removed by laparotomy. 
This applies with greater emphasis, if possible, where the 
pregnancy exists in the rudimentary horn of a bicornate 
uterus.