Paper 2- An Early Ovarian Pregnancy - Revision history

Z8600021 at 07:54, 30 July 2014

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	==Introduction==		==Introduction==

	The literature of ovarian pregnancy takes us as far back as 1614, when Mercer first suggested the possibility of its occurrence. There seems to have been a common belief that the ovum might ~~l)e im])lanted~~ and could for a certain time develop within the ovary. No demonstrative histological evidence was however forthcoming, and as data regarding tubal pregnancy, and the varieties it may assume, accumulated, it became increasingly doubtful whether the early records were not due to inaccurate diagnosis. This opinion was expressed by such authorities as Lawson Tait and BlandSutton. In 1899, however, a careful histological description of an early case was published by Catherine van Tussenbroek, by which she demonstrated beyond question that the ovum could be imbedded in the ovary. Since then her main conclusion has been confirmed by a immber of observers, and it is now universally admitted that such an implantation, remarkable ~~iis~~ it may seem, does occasionally occur.		The literature of ovarian pregnancy takes us as far back as 1614, when Mercer first suggested the possibility of its occurrence. There seems to have been a common belief that the ovum might be implanted and could for a certain time develop within the ovary. No demonstrative histological evidence was however forthcoming, and as data regarding tubal pregnancy, and the varieties it may assume, accumulated, it became increasingly doubtful whether the early records were not due to inaccurate diagnosis. This opinion was expressed by such authorities as Lawson Tait and BlandSutton. In 1899, however, a careful histological description of an early case was published by Catherine van Tussenbroek, by which she demonstrated beyond question that the ovum could be imbedded in the ovary. Since then her main conclusion has been confirmed by a immber of observers, and it is now universally admitted that such an implantation, remarkable is it may seem, does occasionally occur.


	The details of the process of imbedding in the substance of the ovary are not however fully known, nor completely understood. The desideratum is a still earlier chorionic! vesicle than any yet described ~~imj^anted~~ in the gland. Catherine van Tussenbroek considered that her case proved that the essence of ovarian pregnancy was imjJantation of the ovum in a Graafian follicle, but other cases since published do not all bear out this conclusion. The specimen which we have to describe shows that imbedding may occur outside the follicle, and it is especially valuable in respect that the stage of development reached ~~l)y~~ the chorionic vesicle, is earlier than in any of the cases hitherto recorded. It serves to reconcile the data of previous observers, its histological details throw light on some of the points still at issue, while comparison with the very early ovum described in the first paper helps to explain more clearly the nature of the processes involved.		The details of the process of imbedding in the substance of the ovary are not however fully known, nor completely understood. The desideratum is a still earlier chorionic vesicle than any yet described implanted in the gland. Catherine van Tussenbroek considered that her case proved that the essence of ovarian pregnancy was imjJantation of the ovum in a Graafian follicle, but other cases since published do not all bear out this conclusion. The specimen which we have to describe shows that imbedding may occur outside the follicle, and it is especially valuable in respect that the stage of development reached by the chorionic vesicle, is earlier than in any of the cases hitherto recorded. It serves to reconcile the data of previous observers, its histological details throw light on some of the points still at issue, while comparison with the very early ovum described in the first paper helps to explain more clearly the nature of the processes involved.


	Catherine v. Tussenbroek justly claims that her investigations furnish incontestible proof that the plasmodium, which covers the villi of an ovum imbedded in the ovary, just as it does those of an ovum imbedded in the uterine mucous membrane, cannot be a derivative under any circumstiinces of the uterine epithelium. The corollary however, that her specimen provides a proof of the foetal origin of the layer, is not fully warranted. Her case affords strong presumptive evidence that the pltismodium is foetal, but it carries us little further than the data on the subject accumulated by Peters. A combination of the data from the two cases described in the present memoir furnishes more decisive proof.		Catherine v. Tussenbroek justly claims that her investigations furnish incontestible proof that the plasmodium, which covers the villi of an ovum imbedded in the ovary, just as it does those of an ovum imbedded in the uterine mucous membrane, cannot be a derivative under any circumstiinces of the uterine epithelium. The corollary however, that her specimen provides a proof of the foetal origin of the layer, is not fully warranted. Her case affords strong presumptive evidence that the pltismodium is foetal, but it carries us little further than the data on the subject accumulated by Peters. A combination of the data from the two cases described in the present memoir furnishes more decisive proof.




	==History of the Case==		==History of the Case==


	The patient was 27 years of age, had been married for two years, and had one child born eleven months before the present occurrence. During lactation, and subsequently, menstruation was regularly repeated. On November 20th, 1903, she became unwell for the last time, and as menstruation did not recur in December she believed that pregnancy had supervened. On January 1st, 1904, she made complaint of pain in the back and lower part of the abdomen. This recurred at intervals during the succeeding ~~da)^s~~, and was associated with abdominal tenderness and inclination to faint. On the night of January 8th she had a more severe attack of pain, and on January 9th was seen by Dr. Munro Kerr, who made a diagnosis of extra-uterine pregnancy with the tube probably as yet unruptured. For certain reasons the operation was postponed till January 13th, when the symptoms pointed to rupture having taken place. When the abdomen was opened two or three pints of blood were found in the cavity. On drawing up the right appendages Dr. Kerr was surprised to find that the Fallopian tube was to all appearance normal, but projecting from the free margin of the ovary he observed a haemorrhagic ratuss about the size of a walnut, which he diagnosed as an ovarian pregnancy. The tube and ovary were removed in the usual way, and the patient made an uneventful recovery. The uterus at the time of operation was ~~considerabl)''~~ enlarged, soft and globular, and the presence of an intrauterine pregnancy was suspected. This surmise proved correct, ~~tJie~~ pregnancy went on to term, and on August 19th, 1904, she was delivered of a full-time child.		The patient was 27 years of age, had been married for two years, and had one child born eleven months before the present occurrence. During lactation, and subsequently, menstruation was regularly repeated. On November 20th, 1903, she became unwell for the last time, and as menstruation did not recur in December she believed that pregnancy had supervened. On January 1st, 1904, she made complaint of pain in the back and lower part of the abdomen. This recurred at intervals during the succeeding days, and was associated with abdominal tenderness and inclination to faint. On the night of January 8th she had a more severe attack of pain, and on January 9th was seen by Dr. Munro Kerr, who made a diagnosis of extra-uterine pregnancy with the tube probably as yet unruptured. For certain reasons the operation was postponed till January 13th, when the symptoms pointed to rupture having taken place. When the abdomen was opened two or three pints of blood were found in the cavity. On drawing up the right appendages Dr. Kerr was surprised to find that the Fallopian tube was to all appearance normal, but projecting from the free margin of the ovary he observed a haemorrhagic ratuss about the size of a walnut, which he diagnosed as an ovarian pregnancy. The tube and ovary were removed in the usual way, and the patient made an uneventful recovery. The uterus at the time of operation was considerably enlarged, soft and globular, and the presence of an intrauterine pregnancy was suspected. This surmise proved correct, the pregnancy went on to term, and on August 19th, 1904, she was delivered of a full-time child.


	The simultaneous occurrence of an intra-uterine and ovnrian i)regnancy is of considerable interest. It will be noticed that labour supervened 8 day's prior to the day anticipated by the ordinary obstetric tables, and the cessation of menstruation had probably relation to the uterine gestation. If 28 days be counted from the 20th of November we reach the 18th of ~~Dectcmber~~ as the day from which the duration of pregnancy is calculated according to ~~Ilis~~' rule. The first ~~s)''mptoms~~ of the extra-uterine pregnancy set in on January 1st, and the final rupture came on January 8th. If we assume that fertilization of both ova took place as the result of the same insemination, the age of the ovarian pregnancy may be anything between 14 and 22 days according to His' convention. The stage of development of the chorionic vesicle and embr)^onic rudiment })oints to the age as being (still according to the convention) from 12 to 15 days, so that we must assume that growth and differentiation ceased on the occurrence of rupture of the implantation sac and commencement of haemorrhage from the ovary on January 1st. if this were not the case we must conclude, either that the ovarian ovum was fertilized later than the uterine, or that development was retarded owing to the site of implantation.		The simultaneous occurrence of an intra-uterine and ovnrian i)regnancy is of considerable interest. It will be noticed that labour supervened 8 day's prior to the day anticipated by the ordinary obstetric tables, and the cessation of menstruation had probably relation to the uterine gestation. If 28 days be counted from the 20th of November we reach the 18th of December as the day from which the duration of pregnancy is calculated according to His' rule. The first symptoms of the extra-uterine pregnancy set in on January 1st, and the final rupture came on January 8th. If we assume that fertilization of both ova took place as the result of the same insemination, the age of the ovarian pregnancy may be anything between 14 and 22 days according to His' convention. The stage of development of the chorionic vesicle and embr)^onic rudiment })oints to the age as being (still according to the convention) from 12 to 15 days, so that we must assume that growth and differentiation ceased on the occurrence of rupture of the implantation sac and commencement of haemorrhage from the ovary on January 1st. if this were not the case we must conclude, either that the ovarian ovum was fertilized later than the uterine, or that development was retarded owing to the site of implantation.

Z8600021 at 07:45, 30 July 2014

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Description of Sections

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	Remains of an embryo were found within the collapsed chorion, but in so damaged a stat<3 that it was not considered worth while to give the time necessary for reconstruction. There is a thick abdominal stalk containing vessels full of nucleated red corpuscles, the yolk-sac is much folded, but shows the development of vessels in its walls. The germinal disc is cut very obliquely, and the presence of a primitive streak or neurenteric pitseage could not be detemiiuecl. Its geueral cliaracters indicate however that the cmhiyo cauiiot liavc been further advanced than Graf V. Spec's embryo " Gle," aud it is probably even younger.		Remains of an embryo were found within the collapsed chorion, but in so damaged a stat<3 that it was not considered worth while to give the time necessary for reconstruction. There is a thick abdominal stalk containing vessels full of nucleated red corpuscles, the yolk-sac is much folded, but shows the development of vessels in its walls. The germinal disc is cut very obliquely, and the presence of a primitive streak or neurenteric pitseage could not be detemiiuecl. Its geueral cliaracters indicate however that the cmhiyo cauiiot liavc been further advanced than Graf V. Spec's embryo " Gle," aud it is probably even younger.






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	~~FIRUHK~~ XI~~, TlUNH~~		===Figure XI===


			===Figure XII===

	OL-oupj tliu mouth and centre nf cur[>UB liitenm.		OL-oupj tliu mouth and centre nf cur[>UB liitenm.
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	The sections corresponding to Figures xi and XII show that the sides of the blood clot are clothed for a distance of about 1 cm. from its base		The sections corresponding to Figures xi and XII show that the sides of the blood clot are clothed for a distance of about 1 cm. from its base by a layer of ovarian stroma more or leas infiltrated with hlood. This lamelhi of ovarian tissue end-s di.stally in a free edge, leaving an interval between its lips of about 2 cm., in which the blond riot is exposed on the surface of the ovary. It is apparent from a study of the sections that considerable haemorrhage had taken plaee shortly liefore the operation, and that the blood had more ex Unisi vel v infiltrated the intervening between a layer of necrotic tissue immediately applied to the villi, and the more healthy, living ovarian tissue forming the outer lamella of the wall of the cavity. A large coagulum was thus formed round the chorionic vesicle, and the whole constituted practically a ** fleshy mole,'* which would dc>ul)tles8 in a short time have been extruded from the ovary into the l)crit()neal cavity.


	~~DESCRIPTION OF SECTIONS "~~
	by a layer of ovarian stroma more or leas infiltrated with hlood. This lamelhi of ovarian tissue end-s di.stally in a free edge, leaving an interval between its lips of about 2 cm., in which the blond riot is exposed on the





	\



	surface of the ovary. It is apparent from a study of the sections that considerable haemorrhage had taken plaee shortly liefore the operation,


	and that the blood had more ex Unisi vel v infiltrated the i


	: intervening


	~~78 OVARIAN PREGNANCY~~
	between a layer of necrotic tissue immediately applied to the villi, and the more healthy, living ovarian tissue forming the outer lamella of the wall of the cavity. A large coagulum was thus formed round the chorionic vesicle, and the whole constituted practically a ** fleshy mole,'* which would dc>ul)tles8 in a short time have been extruded from the ovary into the l)crit()neal cavity.


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	~~'*' OVARIAN PREGNANCY~~
	&'>nnti it.-H-i: wirain me -MiiTu^ri!!!' D:tl:»-ii- j^-r l^ a •nmUiv thin; blastficvst fia^i.- :t^Lf. :if?:rrr ::> c^L^iur-r riir- '.r 'iitr Fujrf;u^ Tiabr. in. the uterine •'ravitv. It: t«>w heii.-iv-H; ^j x I'erne '.'Vim wi^oltl have •ione. It artai-kni th- wall ''t 'he :'-[/>l»- ir.il .m-e-Mrrii ii^lf in the vas<^alar "»>in«^'-tive ri>.Tie in:m.riiL;i::riv ■s'lTii"!: :h.r ^iisnlrr. ThL s?\|ueii<?e of event.' U iti»li«-;ice«i ^'V riie i.ir^- 'Lze '>r :ii»r 'r»=^Lk: in rh»r wall «>f thtr •M>rpnis Ititenm. whirh L* o'L-i'i- ribiy L;Lr'^»rr "iLia irh.ir tV»aiii in the wall of a Dormal fn>r^»a* lateam .i f-rjr x^t-k- rifror rie e>rap«e of the ovum from the fi>IIi«:le. an»i aL^> ny the nam^j^eii ^Lssue La the l:f< '.'f the opening. The tibrinoa^ an«l f<irtially neii-rjci-: maA* in the m'^ath of the c>rpU5 liiteum wti: tak^ therefore to •:T»rrv-^t'«'CL'L r«» ihe ti'r.rin e»>ne in the aperture • »f •=^ntr:in«'-»^ in th»^ rtrlv atrrine •'^."^In. '-r :ar lir^r ••i-.titrit-ial tiss^ue known as Reirhert's ^''^,v. Having: l»l^<e4 it^/.f \ii rbi-.- trArr.'W- K\iil of 5tn>ma between th" corpus lat^^ura and the -urta«>\ th^- further t2T»>wth of the ovum has resoltotl in the exten:?ive «:l--tru:ri-ii t..f th»r '.'vary whieh is now visible. We have seen iii the fct {»aper that the ovum tends to pn^iuce in the fir=it instance an im{»lantatit>n 'avity •»{ transversely elon^ratel shape. Here there st.-ems likewise to have lieen greater extension of the destructive rhanf'es in a lateral direction, in'l th*.- ovarian stn^ma had vielded rdaee to		&'>nnti it.-H-i: wirain me -MiiTu^ri!!!' D:tl:»-ii- j^-r l^ a •nmUiv thin; blastficvst fia^i.- :t^Lf. :if?:rrr ::> c^L^iur-r riir- '.r 'iitr Fujrf;u^ Tiabr. in. the uterine •'ravitv. It: t«>w heii.-iv-H; ^j x I'erne '.'Vim wi^oltl have •ione. It artai-kni th- wall ''t 'he :'-[/>l»- ir.il .m-e-Mrrii ii^lf in the vas<^alar "»>in«^'-tive ri>.Tie in:m.riiL;i::riv ■s'lTii"!: :h.r ^iisnlrr. ThL s?\|ueii<?e of event.' U iti»li«-;ice«i ^'V riie i.ir^- 'Lze '>r :ii»r 'r»=^Lk: in rh»r wall «>f thtr •M>rpnis Ititenm. whirh L* o'L-i'i- ribiy L;Lr'^»rr "iLia irh.ir tV»aiii in the wall of a Dormal fn>r^»a* lateam .i f-rjr x^t-k- rifror rie e>rap«e of the ovum from the fi>IIi«:le. an»i aL^> ny the nam^j^eii ^Lssue La the l:f< '.'f the opening. The tibrinoa^ an«l f<irtially neii-rjci-: maA* in the m'^ath of the c>rpU5 liiteum wti: tak^ therefore to •:T»rrv-^t'«'CL'L r«» ihe ti'r.rin e»>ne in the aperture • »f •=^ntr:in«'-»^ in th»^ rtrlv atrrine •'^."^In. '-r :ar lir^r ••i-.titrit-ial tiss^ue known as Reirhert's ^''^,v. Having: l»l^<e4 it^/.f \ii rbi-.- trArr.'W- K\iil of 5tn>ma between th" corpus lat^^ura and the -urta«>\ th^- further t2T»>wth of the ovum has resoltotl in the exten:?ive «:l--tru:ri-ii t..f th»r '.'vary whieh is now visible. We have seen iii the fct {»aper that the ovum tends to pn^iuce in the fir=it instance an im{»lantatit>n 'avity •»{ transversely elon^ratel shape. Here there st.-ems likewise to have lieen greater extension of the destructive rhanf'es in a lateral direction, in'l th*.- ovarian stn^ma had vielded rdaee to
	f^ mm.		f^ mm.


	the crrowing ~~blastrMV^t~~ rather than ~~thu «oq»us~~ luteum : this is probaldy rlue to the nature of this tis-ue. What the l>lasto*;yst re^^uires is a vascular connective tissue, ami this it must have foun»l more reailily in the stroma of the gland.		the crrowing blastocyst rather than the corpus luteum : this is probaldy rlue to the nature of this tis-ue. What the l>lasto*;yst re^^uires is a vascular connective tissue, ami this it must have foun»l more reailily in the stroma of the gland.




	==DISCUSSION OF DATA==		==DISCUSSION OF DATA==

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DISCUSSION OF DATA

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	I.— Case of C. van Tussenbroek.		===I. Case of C. van Tussenbroek===


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	L


	~~>-»~~


	~~OVARIAN' PREGNAXCY~~


	~~— im.~~


	rne fi>^r.ia :ij=»'tii^. UtT- "iie vi»l jC riii: >it£y 'irvers^t <•> diac the		rne fi>^r.ia :ij=»'tii^. UtT- "iie vi»l jC riii: >it£y 'irvers^t <•> diac the
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			===II., III. Cases of Kelly and M'Ilroy, and of Hendes de Leon and Holleman===
	ir, III ~~Cftief~~ of Kelly and ~~HUroy~~, and of Hendes de Leon and ~~Hollfnnan.~~


	In the .H\|;f:eirnenH dert/:riU^d l;y thcv* authors there was no formed ('it\\f\iA Ifiteum, fiiJt lutein eelln were found in th»- wall of the implantation iiiy\\y. In the fjr.Ht mentionfid eane the lutr-in tissue was sep;irated from the villi by a thin layer of fibrous tissue, and the conditions of irnphinUition w^-re pnictifjdly identical with those in van Tussenbrceka r;iw, liut the corpiiH luteum hml apparently been distended and spread out over the mass of blood enclosing the remains of the chorionic vesicle. The difference is accounted for by the much larger size of the mass of clot and tissue enclosed in the implantation sac.		In the specimens described by these authors there was no formed ('it\\f\iA Ifiteum, fiiJt lutein eelln were found in th»- wall of the implantation iiiy\\y. In the fjr.Ht mentionfid eane the lutr-in tissue was sep;irated from the villi by a thin layer of fibrous tissue, and the conditions of irnphinUition w^-re pnictifjdly identical with those in van Tussenbrceka r;iw, liut the corpiiH luteum hml apparently been distended and spread out over the mass of blood enclosing the remains of the chorionic vesicle. The difference is accounted for by the much larger size of the mass of clot and tissue enclosed in the implantation sac.



			===IV. Case of Thompson===
	~~IV—~~ Case of Thompson.


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	v.— The Case of Hewetson and Jordan-Lloyd.		===V. The Case of Hewetson and Jordan-Lloyd===


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			===VI. The Case of Franz===

	VI.— The Case of Franz.


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	~~DISCUSSION 85~~
	In addition to the above six, a number of other cases have been published with detail insufficient for the purposes of our present comparison, but it may be noted tliat in some instances the absence of a corpus luteum has been recorded, while one or two observers state that they were unable to find any lutein tissue round the gestation sac.		In addition to the above six, a number of other cases have been published with detail insufficient for the purposes of our present comparison, but it may be noted tliat in some instances the absence of a corpus luteum has been recorded, while one or two observers state that they were unable to find any lutein tissue round the gestation sac.

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	Lastly, ovarian pregnancy finally excludes the theory that the uterine epithelium can have any part in the formation of the j)lasmodium. The fact that neither the membrana granulosa nor the lutein tissue has any part in the formation of the investment of the villi in an ovum imbedded in the ovary, limits the possibilities of a maternal origin of the layer of syncytium to the connective tissue. The wholesale destruction of tissue in the ovary and the characters of the early stages of an ovum imbedded in the uterus quite put out of court any theory which has as its basis the idea of an interlocking of foetal and maternal tissue, and with it the derivation of the plasmodial layer from maternal endothelium. The fact that the tissue round the chorionic vesicle in the ovary is everywhere clearly recognisable as necrotic connective tissue, while it is strong presumptive evidence in favour of the wholly embryonic origin of the plasmodium, cannot be admitted as a decisive proof of that contention. When we consider, however, the nature of the processes involved in the implantation of the blastocyst, more especially in the early stage revealed by our uterine ovum, it may safely be affirmed that, if further proof were needed, the results of our investigations establish beyond all doubt that the phusmodium is in the human subject a product of the foetal ectoderm.		Lastly, ovarian pregnancy finally excludes the theory that the uterine epithelium can have any part in the formation of the j)lasmodium. The fact that neither the membrana granulosa nor the lutein tissue has any part in the formation of the investment of the villi in an ovum imbedded in the ovary, limits the possibilities of a maternal origin of the layer of syncytium to the connective tissue. The wholesale destruction of tissue in the ovary and the characters of the early stages of an ovum imbedded in the uterus quite put out of court any theory which has as its basis the idea of an interlocking of foetal and maternal tissue, and with it the derivation of the plasmodial layer from maternal endothelium. The fact that the tissue round the chorionic vesicle in the ovary is everywhere clearly recognisable as necrotic connective tissue, while it is strong presumptive evidence in favour of the wholly embryonic origin of the plasmodium, cannot be admitted as a decisive proof of that contention. When we consider, however, the nature of the processes involved in the implantation of the blastocyst, more especially in the early stage revealed by our uterine ovum, it may safely be affirmed that, if further proof were needed, the results of our investigations establish beyond all doubt that the phusmodium is in the human subject a product of the foetal ectoderm.




	==LITERATURE CITED IN THE TEXT==		==LITERATURE CITED IN THE TEXT==

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Description of Specimen

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	==Description of Specimen==		==Description of Specimen==


	~~7.3~~


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	~~,'Pmri^.~~		===Figure IX===




	a.f.. (iruMaii folliulc tillul with I'Inwl,		a.f.. (iruMaii folliulc tillul with I'Inwl,
	<;orpus luteum and vesicle une(p'nlly. the greater portion of each remaining in the lateral .segment to the left iti the fignri'. A eomi)lete series of -sections through the whole ovary heing, in the ein-umsranecs, imj>o.ssible, a slice of about 8 mm. thick was titkcn from t)ie outer portion, including the greater part of the corpus luteum and a complete section of the chorionic vesicle. Tliis block of tis.sue was cimvcrtefl into a complete series of sections 8 niicTons thick, and .-Jtained in various \va3's. A second l>ortion of tissue was then taken out from al)Ove the corims luteum to eomi)]ete the .section of tliat stru<'tun' in this plane, and to establish its relation to the rest of the ovary and the blood clot in which the vesicle la5^ From a careful study of the sections from the first block, and adjustment to them of the sections from the second, an accurate picture was obtained of the relations of the corpus luteum, the unaltered part of the ovary, and the vesicle to one another in the longitudinal plane (Figure x). The gland was then cut at right angles to this plane, and two supplementary slices (one from the lateral and one from the mesial half) through corpus luteum and chorionic vesicle were removed and sectioned. By this means a complete picture of the relations of parts in the transverse plane was obtained (Figures xi and xii).		<;orpus luteum and vesicle une(p'nlly. the greater portion of each remaining in the lateral .segment to the left iti the fignri'. A eomi)lete series of -sections through the whole ovary heing, in the ein-umsranecs, imj>o.ssible, a slice of about 8 mm. thick was titkcn from t)ie outer portion, including the greater part of the corpus luteum and a complete section of the chorionic vesicle. Tliis block of tis.sue was cimvcrtefl into a complete series of sections 8 niicTons thick, and .-Jtained in various \va3's. A second l>ortion of tissue was then taken out from al)Ove the corims luteum to eomi)]ete the .section of tliat stru<'tun' in this plane, and to establish its relation to the rest of the ovary and the blood clot in which the vesicle la5^ From a careful study of the sections from the first block, and adjustment to them of the sections from the second, an accurate picture was obtained of the relations of the corpus luteum, the unaltered part of the ovary, and the vesicle to one another in the longitudinal plane (Figure x). The gland was then cut at right angles to this plane, and two supplementary slices (one from the lateral and one from the mesial half) through corpus luteum and chorionic vesicle were removed and sectioned. By this means a complete picture of the relations of parts in the transverse plane was obtained (Figures xi and xii).



	==Description of Sections==		==Description of Sections==

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History of the Case

← Older revision		Revision as of 14:05, 29 March 2014
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	The simultaneous ~~o(!Currencc~~ of an intra-uterine and ovnrian i)regnancy is of considerable interest. It will be noticed that labour supervened 8 ~~da5~~'s prior to the day anticipated by the ordinary obstetric tables, and the cessation of menstruation had probably relation to the uterine gestation. If 28 days be counted from the 20th of November we reach the 18th of Dectcmber as the day from which the duration of pregnancy is calculated according to Ilis' rule. The first s)''mptoms of the extra-uterine pregnancy set in on January 1st, and the final rupture came on January 8th. If we assume that fertilization of both ova took place as the result of the same insemination, the age of the ovarian pregnancy may be anything between 14 and 22 days according to His' convention. The stage of development of the chorionic vesicle and embr)^onic rudiment })oints to the age as being (still according to the convention) from 12 to 15 days, so that we must assume that growth and differentiation ceased on the occurrence of rupture of the implantation sac and commencement of haemorrhage from the ovary on January 1st. if this were not the case we must conclude, either that the ovarian ovum was fertilized later than the uterine, or that development was retarded owing to the site of implantation.		The simultaneous occurrence of an intra-uterine and ovnrian i)regnancy is of considerable interest. It will be noticed that labour supervened 8 day's prior to the day anticipated by the ordinary obstetric tables, and the cessation of menstruation had probably relation to the uterine gestation. If 28 days be counted from the 20th of November we reach the 18th of Dectcmber as the day from which the duration of pregnancy is calculated according to Ilis' rule. The first s)''mptoms of the extra-uterine pregnancy set in on January 1st, and the final rupture came on January 8th. If we assume that fertilization of both ova took place as the result of the same insemination, the age of the ovarian pregnancy may be anything between 14 and 22 days according to His' convention. The stage of development of the chorionic vesicle and embr)^onic rudiment })oints to the age as being (still according to the convention) from 12 to 15 days, so that we must assume that growth and differentiation ceased on the occurrence of rupture of the implantation sac and commencement of haemorrhage from the ovary on January 1st. if this were not the case we must conclude, either that the ovarian ovum was fertilized later than the uterine, or that development was retarded owing to the site of implantation.


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			--[[User:Z8600021\|Mark Hill]] ([[User talk:Z8600021\|talk]]) 14:05, 29 March 2014 (EST) Text is missing from the following section of the scanned book.
	i


	NAKRD-KYt-: nESCUUTIDX OF THK		NAKRD-KYt-: nESCUUTIDX OF THK
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	The posterior portion of the gland, cori'espondi ma.'^s mentioned above, was directly continuous sharply delimited from it by change of eohmr. Wl the mass appeared to consist of blood clot, tlio a cousidcrable portion of its cinmmference, was infiltrated ovarian stroma. The blood clot was thu from a rent in the surface of the gland, and rather of the clot was a small fissure betwceu the lipa of \ of villi which proved tx) be one end of a young cho		The posterior portion of the gland, cori'espondi ma.'^s mentioned above, was directly continuous sharply delimited from it by change of eohmr. Wl the mass appeared to consist of blood clot, tlio a cousidcrable portion of its cinmmference, was infiltrated ovarian stroma. The blood clot was thu from a rent in the surface of the gland, and rather of the clot was a small fissure betwceu the lipa of \ of villi which proved tx) be one end of a young cho
	Figure ix is a drawing of the glanrl .split open, c		Figure ix is a drawing of the glanrl .split open, c

	==Description of Specimen==		==Description of Specimen==

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