Compliments of the 
A UTHOR. 
TYPICAL 
UTERUS-BlCORNIS: 
Living Seven Months Child Expelled From Left 
Horn.—Laparotomy for Parovarian Cyst.— 
Uterus-Bicornis Then Discovered. 
RECOVERY. 
GEORGE WILEY BROOME, M.D, 
ST. LOUIS, MO. 
Reprint from The Weekly Medical Review, April 25, 1891. UNIQUE CASE OF UTERUS - BICORN IS. 
BY (IKORfiK WILEY BROOME, M.D., ST. LOUIS. 
]Read before the St. Louis Medical Society, April 18,1891.] 
Pregnancy in the Left Horn.—At the end of the Twelfth 
Week from Date of Conception, Alarming Haemorrhage 
< per Vaginam set in.—Tumor apparent at the Left 
Hypogastrium.—Extra-Uterine Pregnancy strongly sus- 
pected.—Expectant Treatment.—Three and a half Months 
thereafter a Living Child was Born.—Four and a half 
Months following, Laparotomy Performed for Well De- 
fined Swelling in the Left Ovarian Region.—Cyst, Size of 
Tamarind Orange, Enucleated from the Parovarium; 
Uterus Bicornis discovered.—Patient leaves Hospital 
Apparently Well on the Seventeenth Day..—Probable 
Pregnancy Twenty Days Later. 
Conservatism vs. Laparotomy.—Summary of Reports 
of Operations ani> Results in Similarly 
Obscure Cases. 
In the month of July last I received a message to 
visit Mrs. S., whose interesting case is the subject of 
this communication. The members of the household 
present were in great trepidation over a sudden 
and profuse haemorrhage from the patient, per vaginam. 
This was her first pregnancy. Physical proportions and 
constitutional health excellent. German parentage. Mar- 2 
ried but a little over a year, at the age of fifteen 
years. The husband at the time was absent in a distant 
State, and this circumstance only tended to intensify 
the excitement of the occasion. The mattress and bed 
clothing beneath the patient were saturated 
with blood. The heart’s action was rather feeble; 
Fig. 1. 
there were no abdominal pains. Haemorrhage had ceased. 
The os was rather soft but not yielding or dilated. A 
tumor was plainly visible in the left side. Area of dul- 
ness, extent of which as nearly as I can outline it, is 
shown by the accompanying zinc etching. (Fig. 1.) 
My mind was strongly impressed with the belief, 3 
that I had to deal with an ectopic pregnancy. It 
was true there had been haemorrhage per vaginara, 
Avhich seemed now to be completely arrested; yet here 
was a tumor, following immediately upon the sudden 
flooding and the tumor appeared, so 
far as the natural anatomical landmarks indicated, to 
be outside of the uterus, and in a direction parallel 
with Poupart’s ligament. Dulness was absent in the 
median line. 
I sat by the patient’s bed-side, perhaps an hour; and 
as her condition improved during this period of time, 1 
determined to treat the case expectantly. The sequel 
proves the wisdom of this course. 
I was not again called to see this patient until October 
20, being about three months after the visit to which 
the above has reference. The tumor, in the left side, 
had increased considerably in size. Its upper portion 
had reached the level of the umbilicus. The os was 
soft and now dilated. The patient complained of 
frequently recurring paius in the abdomen. No haem- 
orrhage. She stated she had been confined to bed for 
four days, suffering much in consequence of the uneas- 
iness in the region of the tumor, and to such a degree 
as to deprive her of rest and sleep. 
After the lapse of about three hours, during which 
time she was given chloroform, by inhalation, at inter- 
vals, a living child, weighing three and a half pounds, 
was expelled through the natural passages. There was 
no unusual flooding. 
Besides the deformity of its legs and feet, 
the child was very small and puny. After thirty- 
two hours it expired. The cut, Fig. 2, fairly illustrates 
the positions of the feet and legs at the time of its birth. 
The patient had regained much of her former physi- 4 
cal weight and strength, when, during the early part of 
the month of February, she consulted me for dysmenor- 
Fig. 2. 
rhoea and almost constant pain in the left side, which 
increased in severity at each recurring menstrual period. 5 
Upon examination a well defined swelling was found in 
the left ovarian region. After observing the case for about 
thirty days, on March 1st, I performed laparotomy, and 
removed a small cyst from the parovarium; and at the 
same time discovered the uterus to be bicornate; which 
is well illustrated by the accompanying zinc etching. 
(Fig. 3.) 
The round body, outlined by the shading underneath 
the left tube, represents the cyst which I removed. 
Dr. A. C. Robinson, of this city, was present, and 
made a very careful examination of the uterus through 
the abdominal incision. 
The patient returned home on the eighteenth day, 
having made a rapid recovery. During convalescence 
she menstruated, and without the slightest pain. With- 
in the next twenty days, after leaving the hospital, her 
husband reported that his wife was probably again 
pregnant. 
The specially instructive features of the case are: 1st, 
the phenomena presented at my first visit, as given 
above; and 2d, the solution of the problem, that one 
horn of a typical bicornate uterus is capable of expell- 
ing a living child. 
Oases similar to the above are narrated by men of 
large experience, and possessed of great sagacity and 
wise judgment. The principles of manipulation and 
treatment pursued by them, considered in connection 
with the final results, are on record, for adoption, mod- 
ification or rejection by those to whom the responsibil- 
ity of their like maybe committed. 
By a diligent search I have failed to find a like case 
on record. The element of “expulsion” renders it al- 
together unique; pertaining to which there is no litera- 
ture and, consequently, no rule for guidance; but the 6 
happy results of the course pursued demonstrates that 
that was the only one authorized, and must, therefore, 
become the precedent in all like cases in future. 
Greig Smith, in his excellent treatise on “Abdominal 
Surgery,” does not record a single case, and in the other 
now celebrated English work, which has helped so much 
to dignify gynaecological practice above the mere use 
of a sponge tent and a pledget of cotton, Mr. Tail 
speaks of but two cases, which present any resemblance 
whatever to the one just reported; and both of these 
described by him were published originally by Sir James 
Y. Simpson, some twenty-five years ago. Death, in both 
instances, was the result of the pregnancy in the left 
uterine horn. In one case the horn ruptured and the foetus 
escaped into the cavity of the peritoneum;in the other the 
foetus was retained in the left horn after the full period of 
utero-gestation, at which time severe labor set in and 
upon examination the os was found low down in the 
vagina. There was an enlargement of the abdomen ex- 
tending a little to the left side, and nearly of the same 
size and shape as a uterus containing a foetus at the 
full period of utero-gestation. The foetal heart was 
easily heard, and the motions of the child were strong. 
The pains were very severe and complicated with con- 
vulsions for a whole day, in spite of a free use of chloro 
form, which only modified them. The pains continued 
for several days, and then the patient began to go about 
as usual, to the astonishment of her friends and neigh- 
bors. The enlargement of the abdomen became grad- 
ually less, so that at the time of her death (which took 
place six months after the date of the supposed labor) 
it was not more than one third of its size when 
first seen. The organs, including the empty uterus and 
appendages, were carefully removed at a post-mortem 7 
examination. The most prominent peculiarity 
found was a large irregular ovoid sac measuring 
about twenty-seven inches in its greatest circumference. 
The sac contaiued a male foetus apparently about the 
full time, attached by a funis, one foot in length to a 
shriveled placenta, which in turn, was connected to the 
inner surface of the sac. 
In these two cases conservatism was perhaps not the 
best course to pursue. On the other hand the more ac- 
tive measures have been adopted in several cases of 
pregnancy in bicornate uteri, although the real condi- 
tion was not known, in either case, until disclosed by the 
operation. 
Munde reports an exceedingly instructive case in 
which a laparotomy was made for a suspected extra- 
uterine pregnancy. The woman had had one child sev- 
eral months before she placed herself under his care at 
the Mt. Sinai Hospital, in May, 1889. She had last 
menstruated four months before entering the hospital. 
The usual signs of pregnancy were present. A tumor of 
the size of two fists extended over toward the right side. 
A small mass could be felt projecting from the left side 
of the tumor, which he took to be the fundns of the 
uterus. He felt so sure of this that he introduced a 
sound into it, which entered barely three inches to the 
left. The mass on the right was elastic, but had not 
the feel of the pregnant uterus, and did not contract un- 
der examination. The woman had had a bloody dis- 
charge at intervals, and pieces of membrane were said 
to have been passed. She had had much pain in the tumor 
on the right side for at least a month, and so severe 
that she was induced to consult a physician. In the light 
of these conditions, Munde unhesitatingly diagnosed it a 
case of tubal pregnancy. Fearing rupture, he at once 8 
obtained the consent of the patient and,her friends to 
an operation, and did laparotomy two days after he first 
saw her. 
He was much surprised, on passing his hand into the 
abdominal cavity, to find that the peculiar irregularity 
of the tumor had disappeared, and that nothing could 
be felt except what seemed to be the normal pregnant 
uterus. He was rather nonplused; but the sound 
being passed again by his assistant, it went to the left side 
to the same depth it had entered before. He was 
now convinced he had an interstitial pregnancy 
to deal with, which condition he thought was 
quite as dangerous as the tubal pregnancy he had ex- 
pected to find. He therefore decided to remove the 
amniotic fluid by aspiration, draw the uterus out of the 
abdominal cavity, open it, remove the ovum, and sew the 
horn of the uterus to the abdominal wound. At the 
first attempt at aspiration he struck the placenta (as 
the specimen afterward proved). Two more aspirations 
were made,and about one-half the amniotic fluid was 
removed. Not to prolong the operation, he 
lifted the uterus out of the abdominal cavity, when it 
was observed to be apparently normal in outline. 
The sound being passed again it went to the right to 
the very point where he had aspirated. Then the as- 
sistant, who passed the sound, said that he felt the sep- 
tum of a two-horned uterus; and that is what the deform- 
ity proved to be. 
The uterus was returned, the abdominal cavity closed, 
and, as expected, the patient miscarried that night. 
The specimen showed a large blood clot at the surface 
of the placenta where he had aspirated. The tempera- 
ture did not rise above the normal, and the woman made 
a rapid recovery. Subsequent examination with two 9 
sounds confirmed the presence of the uterine septum, 
The cervix was lacerated on the left side, which 
shows that the previous pregnancy was on that side; 
this fact, in conjunction with the more or less constant 
pain in the pregnant right horn (which in a normally 
developed uterus would scarcely be present), led him to 
believe that the right horn was in a state of rudimentary 
development and would soon have burst. 
He did not see how he could have made the diagnosis 
in the case unless he had accidentally passed the sound 
into the dilated pregnant right horn. He therefore con- 
cluded that the diagnosis of tubal pregnancy could not 
be made with as much certainty as is supposed. For- 
tunately this oase turned out well, except that the foetus 
was lost. 
VanderVeer has collected and recorded, including his 
own, sixty-eight cases, in all, of “Concealed Pregnancy,” 
in each of which the result of the laparotony revealed 
an error in diagnosis. Five of the cases, including the 
one just referred to, were found to be pregnancy in 
bicornate uteri. In one case the diagnosis before the 
operation was fibro-myxoma of the uterus; in two the 
operations were simply exploratory, and in the other 
case the diagnosis was extra-uterine pregnancy. In two 
cases the pregnancy had occurred in the right horn of the 
bicornated uteri; one was interstitial and the other in 
one horn, the particular side not stated. Four of the 
women recovered. Whether or not pregnancy again 
occurred in either of these cases is not a matter of 
record, but their subsequent history, if known, would be 
exceedingly interesting. It is my intention to keep care- 
ful record of the progress of the case reported, and at 
some future time give it publication. 
Fig. ;->.