[Reprinted from the American Gynaecological and Obstetrical Journal 
for July, 1P95-] 
REPORT OF CASES, 
WITH PRESENTATION OF SPECIMENS* 
B. F. Baer, M. D., Philadelphia, Pa. 
A Rare Form of Arrest of Development of the Right Uterine Cornu, 
simulating Ovarian Hcematoma. 
This small specimen which I first present is one of exceeding in- 
terest to me because of its unusual and probably unique character. 
It is a mass of fibro-muscular tissue which resembles the uterus in 
color and consistence, although not in shape. In its center is a little 
cavity which is lined by a mucous membrane which resembles the 
endometrium, but it has no outlet. It had attached to its outer side 
the right ovary and a portion of the Fallopian tube. By its inner side 
it had a membranous attachment to the uterus proper. 
The patient was an unmarried girl of twenty years, in whom pu- 
berty occurred at the normal age, menstruation recurring without 
event until about two years ago, when she began to suffer pain in the 
right ovarian region at the menstrual epochs. At first the pain was 
not severe, but it gradually increased in severity until it became of 
such intense and excruciating character that the patient would writhe 
in agony, and, although the usual anodyne remedies, including mor- 
phine, would be administered in large doses, she would only obtain 
relief with the subsidence of the flow. As stated above, the pain was 
always felt most intensely in the right iliac region. These symptoms 
led me to suspect hsematoma of the right ovary, and physical exami- 
nation confirmed this view, for I found a tumor about the size of a 
hen’s egg occupying the position of the right ovary, except that it was 
located higher than the ovary usually is under these circumstances; 
and it was not tender upon pressure, nor was it fixed. The cervix 
uteri was infantile, the os small, and the uterus deflected to the left. 
* Read before the Philadelphia Obstetrical Society, May 2, 1895. 
Copyright, 1895, by J. D. Emmet, M. D. B. F. Baer, M. D. 
In accordance with my custom in the treatment of haematoma of the 
ovary, which gives rise to such serious symptoms, I advised its re- 
moval, which is, I believe, the only proper treatment for this condi- 
tion. This advice was gladly accepted, and I operated about six 
weeks ago. Under ether, I was a little uncertain as to the correctness 
of the diagnosis of haematoma, because the tumor appeared so firm 
and elastic, and was situated too high. Abdominal section was made, 
and the small tumor which 1 hold in my hand came into view. It had 
the color and consistence of uterine tissue, and the right ovary was 
found attached to the mass. Diagnosis of arrested development of 
the right horn of the uterus was made. The mass was removed, 
together with the right ovary, which you see attached, after ligation 
of its membranous attachment to the uterus. The left side, or uterus 
proper, being in an undeveloped condition, it was thought best to 
remove the left ovary also. The patient has made a good recovery. 
Section of the tumor showed it to contain a little cavity which is lined 
by an endometrium, and which contained a small quantity of men- 
strual fluid. This cavity had no outlet whatever. 
The explanation of the intense dysmenorrhoea from which the pa- 
tient suffered was evident; there was an effusion of blood into the 
cavity with each menstrual recurrence, but as there was no outlet, the 
pain resulted. 
In connection with this interesting case I wish to record the fol- 
lowing, which has never been reported : 
A Case of Double Uterus and Vagina, one Side of which was Patulous 
and the other closed, resulting in Tumor from Retention of Men- 
strual Fluid, while Menstruation was Normal from the Opposite Side, 
in a Girl Fourteen Years of Age. 
Instead of a specimen, I will present a diagram which represents 
the condition found in the following case : 
A. B. was sent to me several years ago. She was fourteen years of 
age, and had begun to menstruate eleven months before I saw her. At 
the second or third period after the menses first appeared she began 
to suffer intense pain with each recurrence, and soon after there was 
evident a swelling in the right iliac region and a smaller tumor or pro- 
trusion at the vaginal orifice. Finally the pain and distention became 
extreme ; soon after this I saw her. The history led me to suspect 
retention of the menses, but the presence of a regular monthly flow 
was at first puzzling. Physical examination, however, fully explained Report of Cases, with Presentation of Specimens. 
3 
the unusual phenomena. The right iliac region was found distended 
by a tense, globular, fluctuating mass as large as a cocoanut. On the 
upper border of this mass an elongated firm body, somewhat the shape 
of the uterus, could be distinctly outlined. Inspection of the vaginal 
orifice revealed a mass the size of an egg, which occupied a position 
on the left side of that orifice. It was purplish in color, and resem- 
bled the vaginal mucous membrane. Pushing this mass aside, the 
finger entered what appeared to be a normal vagina, except that it 
was flattened by pressure from the left side by a tense, fluctuating, 
elongated mass which was continuous with the tumor at the orifice. 
At the upper end of this canal a small cervix uteri was located. A 
sound was now carried along the finger and made to enter the uterine 
cavity. It curved over the summit of the iliac tumor and passed hori- 
zontally to the right, showing that the firm body referred to above 
was really the uterus or a part of it. The patient had a double uterus 
and a double vagina, and menstruated from both uteri, but atresia of 
one vagina existed; hence the retention on that side. I advised 
operation, and the patient entered my private hospital. 
The vaginal septum was divided with scissors from the orifice to 
the os uteri. A large quantity—fully a pint—of a tarlike semi-fluid 
escaped. A pin-hole os uteri was now discovered. A free incision 
was made from this point outward, when at least a quart more of the 
same fluid escaped. Thorough irrigation of the uterine cavity was 
made and then the uterine septum was divided to the fundus. This 
completed the operation. The after-treatment consisted of a daily 
antiseptic irrigation. The patient made an easy recovery, and has re- 
mained in good health since. 
A Case of Ovarian Tumor in tvhich Rupture had occurred followed by 
Chronic Peritonitis. 
The large specimen which I here exhibit is one of peculiar inter- 
est, because it shows that although the question of early operation in 
ovarian cystoma has been urged so often that the profession and the 
laity should both be familiar with the fact that early interference is 
necessary for the highest operative success, we still too often meet 
with cases which, like this one, narrowly escape death as a result of 
delay. 
The patient, Mrs. L., aged forty-seven, five children, five years 
ago consulted the late Dr. Goodell, who made a diagnosis of ovarian 
tumor and advised its removal, but she declined operation. 4 
B. F. Baer, M. D. 
Shortly afterward there were symptoms of rupture of the cyst, 
followed by profuse diarrhoea and micturition, with decrease in the 
size of the tumor. 
She then had great tenderness of the abdomen with tympanites 
and other evidences of peritonitis. She recovered, and seemed better 
for a time, the tumor remaining of the diminished size ; but, as usual, 
the cyst began again to refill. Its growth was slow, however, until 
about six months ago ; after that date the increase in size was rapid, 
and the patient became so ill from exhaustion and emaciation, and 
from the dyspnoea resulting from pressure on the diaphragm, that suc- 
cessful operation was now considered almost beyond reach. Under 
these circumstances I was requested to see the patient. I found her 
even worse than described, but I decided to operate. For this pur- 
pose she was removed with difficulty to this city, where the operation 
was performed on April 17, 1895. An incision through the linea alba 
revealed the bladder drawn up as far as the umbilicus and spread out 
over the tumor. But I was on the outlook for it, having, several 
years ago, cut into-the bladder in a similar case. (I think Dr. Noble, 
as well as some other invited guests, was present at that operation. 
It was the first time that I had been so unfortunate as to wound the 
bladder. My incision extended at least two inches through the wall 
of the viscus. I immediately closed it with several silk sutures. No 
trouble ensued, for the patient made an uninterrupted lecovery. I 
have wounded the bladder once or twice since, no bad result occurring 
in either case.) But to return to the case in hand : After learning 
that the bladder was adherent to the tumor, I carried my incision 
farther up, and came upon the growth just below the umbilicus. The 
tumor was found to be ovarian, with the thick walls which you see, 
and it was closely adherent to everything with which it came in con- 
tact. The mass was friable, and in manipulating to separate adhe- 
sions, rupture occurred. The cyst contained great quantities of 
cheesy material, as well as a semi-fluid substance. In addition there 
was a large quantity of fluid in the abdominal cavity. Finally, the 
tumor was separated from its firm intestinal adhesions and the pedicle 
reached, the latter being situated low down under the bladder, where 
it was found to be attached, through the Fallopian tube and broad 
ligament, to an enlarged and fibrous uterus. Ligation of the pedicle 
was made, and thorough irrigation continued until the peritoneal cav- 
ity was entirely freed from tumor contents. Examination now 
showed the uterus to be the size of a large cocoanut, but the patient 
was in such a low condition that further operative measures could not Report of Cases, with Presentation of Specimens. 
5 
be considered. After placing a glass drainage-tube in the peritoneal 
cavity, the patient was returned to bed more dead than alive. Under 
careful and continued stimulation she finally rallied, and has recov- 
ered, much to the surprise of every one who saw her before or at the 
time of the operation. 
This case emphatically teaches the folly of the delay which places 
the patient, to say nothing of the surgeon, in so hazardous a position 
and upon a trial so great. 
The patient fortunately recovered, but if she had died it is proba- 
ble that the fatal result would have been attributed to the operation, 
whereas the operation would have had nothing to do with the death. 
I am so firmly convinced of the advisability of early operation that 
where a tumor, of whatever character, is found to exist I always advise 
its removal, even though the patient does not then appear to be suffer- 
ing from its presence. 
The next specimen is from 
A Case of Intraligamentary P'ihrocystic Tumor of the Utents. Hyste- 
rectomy, in which Unusual Difficulties were Encountered. 
Mrs. L. G., aged thirty-three years ; married two and a half years; 
sterile. 
Puberty occurred at the normal age. She had always had dys- 
menorrhoea, so that she was obliged to go to bed the first day of the 
flow. Six or eight months ago she was awakened in the night by a 
violent craraplike pain in the right ovarian region, and in placing a 
hand upon the abdomen she felt a “ knob ” in the right iliac region. 
From that time on there was an increase in the size of the mass, and 
shortly afterward she noticed another mass about the size of a goose 
egg in the left iliac region. She consulted a physician, for the first 
time for this trouble, in May, 1894. Tumor was recognized, and the 
patient placed upon ergot without benefit. After this she had re- 
peated attacks of violent uterine tenesmus, lasting five or six hours, 
and only subsiding after the free use of opiates. The attacks of pain 
were attended with profuse metrorrhagia. The pain and hseraorrhage 
caused another physician, whom she next consulted, to think that the 
tumor was an intra-uterine fibroid, which could be removed by way of 
the cervical canal, and for that purpose, on September Bth, she was 
etherized and the cervix dilated, when it was determined that the 
tumor was intramural. Nothing further was done. 
On October 16th the patient was placed in my charge. She had 6 
B. F. Baer, M. D. 
then been bleeding continuously for almost a month, and was gener- 
ally in a very low condition. She had lost considerable flesh, and 
was cachectic in appearance. Examination revealed a tumor occu- 
pying the entire pelvis, especially on the right side, and extending 
into the abdomen. It was immovably fixed and very firm, but ob- 
scurely fluctuating. The cervix was carried far up behind the sym- 
physis pubis, so that it was almost entirely out of reach. The left 
iliac region was occupied by an irregular mass, which was determined 
to be the uterus, as it appeared to be almost one with the tumor. 
Diagnosis.—Intraligamentary tumor of the uterus or ovary. The 
patient entered a private room at the Polyclinic Hospital, and was 
placed upon preparatory treatment, which was continued about a week. 
Operation October 23, 1894. Abdominal section exposed the 
tumor. It was found to be entirely subperitoneal within the folds 
of the broad ligament, which were widely separated and carried up- 
ward into the abdominal cavity. The right Fallopian tube and ovary 
were spread out over the surface of the tumor. The uterus was com- 
paratively small, and was located on the left side of the tumor. The 
mass looked very vascular, and the operation for its removal appeared 
formidable. I first placed a ligature, after the method which I have 
introduced for supravaginal hysterectomy, upon the left broad liga- 
ment. Severing the latter, I next ligated the left uterine artery. 
After careful examination of the relation of the cervix to the tumor, I 
determined to pursue a different method from that which 1 usually 
follow. I immediately amputated the cervix, and came upon the 
uterine artery of the right side and then ligated it, thus controlling 
all arterial haemorrhage. But the real operation only now began— 
that of enucleation of the tumor from its very deep and intimate pel- 
vic connections. Many veins were severed in this manipulation and 
haemorrhage was free, but with pressure forceps and packing with 
balls of sterilized gauze as I proceeded, I was enabled to soon tear 
the tumor from its capsule. This was rendered more easy because 
the tumor was found to contain some liquid in its interstices evacuat- 
ing, which reduced its size somewhat. Finally the mass was removed 
leaving an immense vascular cavity in the pelvis. This cavity was 
made up of the widely separated folds of the right broad ligament 
and the pelvic peritonaeum, which had been lifted up by the growth of 
the tumor. The packing was next removed, when it was found that 
the haemorrhage had about ceased. The peritonaeum was now folded 
and stitched over the tumor cavity, and the abdominal cavity then 
closed without irrigation or drainage. Report of Cases, with Presentation of Specimens. 
7 
This is the sort of case in which gauze packing is sometimes placed 
and allowed to remain for the purpose of checking haemorrhage and 
to serve as a drainage apparatus. I was only once guilty of leaving 
gauze in the pelvis for this purpose, and that once was sufficient. I 
never found it necessary for the purpose of controlling haemorrhage, 
and certainly it is not necessary for drainage. Haemorrhage can and 
should always be controlled without such a clumsy procedure. When 
drainage is necessary it should be done thoroughly with the glass 
tube, but I so seldom find it necessary that it is quite unusual for me 
to place a drainage-tube. I am constantly closing wounds without 
gauze packing or drainage in cases of this character and in pus cases, 
and my patients are better for it, lam sure. Of course I am always 
careful to remove all pathological products, leaving only healthy 
tissues. 
The method pursued in this case is one which I have followed in 
several other instances of broad-ligament fibroids—that is, ligating 
one side and then amputating the cervix, and afterward ligating the 
vessels on the other side before proceeding to the enucleation of the 
tumor. 
The second case that I operated upon by the supravaginal 
method was one of somewhat similar character to the one just related. 
It was a fifty-pound fibrocystic tumor, in which several electro- 
punctures had been made, rendering the contents of the tumor puru- 
lent in character. I was somewhat frightened by the large size of the 
venous channels upon and around the tumor mass. There was con- 
siderable bleeding during the operation, and for haemostasis I packed 
into the wound balls of sterilized gauze, which were removed before 
closing the abdominal incision. This operation was so formidable in 
character from haemorrhage and the shock to the patient that it was 
thought by all present that she would certainly die on the table ; but 
she rallied and recovered. I closed without gauze packing, but made 
great compression by strapping a large roll of gauze on the external 
surface of the lower abdomen immediatelv over the tumor cavity. I 
believe this woman would have died if I had left this packing within 
the pelvis, for the additional healing processes would have been a far 
greater drain upon the vital forces.