OVARIAN PREGNANCY. 263 



relation with the onset of menstruation. Nor does it seem unlikely that the hy- 

 peremia accompanying the return of menstruation on June 25, if such it really 

 was, may have been partly responsible for the onset of a sufficiently large and per- 

 sistent hemorrhage to cause the slight rupture indicated by the symptoms on 

 July 7. It must also be remembered in this connection that cases of ovarian 

 pregnancy have been reported in which menstruation was uninterrupted. But 

 in the case of Chiene (1913), for example, the death of the conceptus may have 

 occurred so early that the succeeding period was not inhibited, and the same thing 

 may have been true in the case of Lea (1910). 



Since the material from the curettage, done at the time of operation, showed 

 the presence of a normal endometrium, the uterine decidua associated with this 

 pregnancy must have been shed some time previously. Such a conclusion also 

 would seem justified by the condition of the conceptus, which apparently was 

 unable to prevent a return to the normal menstrual cycle. The absence of decidua 

 at the time of operation also suggests that what was reported as a return of normal 

 menstruation on June 25 may have been hemorrhage accompanying the expulsion 

 of the decidua. 



Since, in the present case, the chorionic vesicle was so degenerated and so 

 completely isolated in a large clot, and especially since no well-implanted villi 

 were found in the sections and gross portions examined, it is not at all probable 

 that the hemorrhage that caused the rupture was due to a contemporaneous 

 invasion of the vessels by the fetal trophoblast, such as occurs in uterine and tubal 

 implantations, and as has been actually described also in ovarian implantations 

 by Franz (1902) and by others. In the present and in similar cases in the litera- 

 ture it would seem that hemorrhage was made possible also by degenerative 

 changes in the highly vascular stroma of the ovary, which had been greatly com- 

 pressed and stretched by the proportionately large blood-clot, the organization 

 of which would seem to have been precluded by its size alone. 



The fact that relatively few unruptured ovarian pregnancies are recorded 

 suggests that the old tenet that rupture is less likely the more advanced the preg- 

 nancy becomes, probably is open to serious doubt, as suggested by Banks (1912), 

 who believed that the tubes can accommodate themselves more readily than the 

 ovary. Banks stated that in the majority of cases of ovarian pregnancy rupture 

 occurred in the first two or three weeks, and Caturani (1914) also expressed 

 doubts regarding the dictum that rupture of the ovary is less likely the more 

 advanced the pregnancy. No one will deny, I presume, that the symptoms of 

 rupture may have been totally absent, as reported in the cases of Norris (1909) 

 and Grimsdale (1913), but this does not necessarily imply that the ovarian stroma 

 or the germinal epithelium still surrounded the full-term conceptus. Such an 

 occurrence would be possible only if the ovarian stroma and the overlying ger- 

 minal epithelium underwent an astonishing hyperplasia. Although such a thing 

 is conceivable, it is decidedly significant that no one has reported any such finding 

 or observed the presence of mitotic figures. 



