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is comparatively easy; but when the pla-
centa completely covers the os and the bag
cannot be passed around the anterior lobe,
it becomes a question whether it is better
to pierce the placenta with the bag or to
do a bimanual version by the insertion of
two fingers aided by outside manipulations
with delayed extraction of the child after
the foot had been pulled down.

The choice between these two methods
under such circumstances will depend upon
the condition of the mother and the child.
The bag treatment improves the chances of
the child; but if the child is dead or pre-
mature, this does not have weight. A pre-
mature child, being small with a soft cra-
nium, is not so likely to tear the cervix. If
the mother is in great weakness from
hemorrhage, delayed extraction after ver-
sion will probably stop the hemorrhage
more quickly, as, with the bag after the os
is dilated, delivery must still be effected.

Altogether the rule may be laid down
that, when the os is partially dilated with a
live child, the bag treatment offers the best
results when it can be introduced into the
ovum and when urgent symptoms are not
present. In 387 cases where the bag alone
was used and introduced into the ovum
where possible, the maternal mortality was
5 per cent. The most successful of this
numl^er was Hannes* 143 cases treated by
the bag alone with no deaths from hemor-
rhage, although there were 8 deaths from
other causes, as previous infection, eclamp-
sia, etc. The hystereurynter reduces the
mortality of the children from 70 per cent,
to 30 per cent, according to figures col-



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lected from these series. The greater hope
of life that the elastic bag or hystereurynter
gives the fetus may be judged from Thies'
report of the results from Bumm's clinic.
Taking all births into consideration, the
fetal mortality was as follows : spontaneous
delivery, 20 per cent. ; vaginal gauze plug-
ging. 33 per cent. ; combined version with
slow extraction, 80 per cent. ; combined ver-
sion with rapid extraction, 64 per cent.;
vaginal Caesarean section, 50 per cent. ;
hystereurynter or elastic bag, 14 per cent.

Combined version with delayed extrac-
tion is very fatal to the child and should be
restricted as much as possible to urgent
cases where the mother's condition de-
mands immediate control of the hemor-
rhage. If the interest of the mother alone
is to be considered, Braxton-Hicks' version
and delayed extraction remain the safesc
method if the cervix is partially dilated.

There are certain necessities for success-
ful treatment by the hystereurynter. The
bag must be of large size, as big as a nor-
mally large fetal head. It should measure
10 to 12 cm. in diameter and contain from
500 to 600 cm. (about 20 oz.). The bag
treatment in this country has achieved a
bad reputation because the small de Ribes
bag, intended for induction of labor, has
been used and inserted outside the ovum.

The bag should be inserted within the
membranes with a special forceps for the
purpose, and with antiseptic precautions.
The bag may be boiled and kept ready for
use in glycerine which will preserve it, as
rubber is apt to crack and spoil if kept dry. ^
It may be boiled with the glycerine in a
large preserve jar and the jar wrapped in
a sterile towel ready for use.

The bag remains in position for 3 to 5
hours as a rule. If the control of the
hemorrhage is good, no weight need be at-



tached ; but, if the bleeding is not perfectly
stopped, a 2 lb. weight may be attached on
a cord running over a pulley, as in fracture
extension, on the end of the bed. If the
weight is attached, a stout elastic band
should intervene between the bag and the
cord of the weight. In this way, sudden
pull on the uterus, caused by the patient
drawing away from the weight, is avoided
and the danger of cervical laceration is les-
sened. The weight should only be attached
to those cases where there is considerable
hemorrhage or labor is unduly prolonged.
After the use of dilating bags, the operator
should be necessarily cautious in doing ver-
sion and breech extraction, as there is
danger of uterine rupture.

The advantage of the bag is that com-
pression is applied directly to the placenta
forcing it back into its place. Tamponage
on the contrary forces the placenta away
from its bed and tends to increase hemor-
rhage. The bag acts as a tampon, as a
labor promoting element, and as a gentle
dilating force.

Cervical tamponage is a makeshift
method, only to be resorted to when the
bags are not at hand. It is often ineffectual
in controlling hemorrhage and of little use
as a cervical dilator. The percentage of
infection after packing is larger than after
any other method. It is useful when the
cervix is partially dilated and hemorrhage
must be controlled until other measures
are undertaken.

Antiseptic moist gauze should be used
and it is well if the antiseptic is a styptic
also.

The gauze may be left until the cervix is
sufficiently softened and dilated to allow a
bag to be inserted or bimanual version to
be done. The packing is not effective un-
less the gauze is packed well within the



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cervix and up against the placenta and the
vagina packed full of gauze also in order
to afford support and counter pressure.
The gauze should be moist as it then may
be packed more firmly and care should be
taken not to bruise the vaginal mucosa in
the manipulation. A vaginal fSpeculum
should be introduced with the patient upon
a table and in a good light, the cervix should
be caught and steadied with a bullet forceps
and the gauze packed firmly. The patient
should be put to bed and watched carefully
for evident bleeding or signs of concealed
hemorrhage.

Maison, in a report of 154 cases treated
by various methods, had the highest mor-
tality, 25 per cent., with tamponage and
lost 70 per cent, of the children. The
deaths were from bleeding and infection.

Other methods do not show as good
results as the ones referred to. Bon-
naire's method of bimanual dilatation
of the cervix and immediate delivery
has a higher mortality than the previous
methods. He has reported 171 cases treated
by this method with a mortality of 18 per
cent. The disadvantages of the method
are the amount of time required to dilate
the cervix, twenty minutes to one hour in
Bonnaire^s hands, with constant loss of
blood, the danger of laceration of the
cervix, and the difficulty of completely dilat-
ing the cervix so that the head may come
through without traumatism.

Steel dilators after the type of Bossies
instrument are very dangerous and only of
use to dilate the cervix sufficiently to allow
version to be done or to insert a bag. A de
Ribes bag may usually be inserted through
a cervix admitting two fingers, and to obtain
this amount of dilatation the Goodell two-
pronged dilator does as well as the more
complicated and expensive instrument of
Bossi.



Caesarean section, much vaunted of re-
cent years by surgeons, is not favored by
obstetricians. Holmes' collection of Caesa-
rean sections for placenta previa gave a
maternal mortality of 20 per cent, and an
ultimate fetal mortality of 64 per cent.
Little encouragement here to advocate the
operation. Jewett, in a later paper, col-
lected 95 cases, not including Holmes' col-
lection, wtih a maternal mortality of 11.5
per cent, and a direct fetal mortality of 34
per cent., the ultimate fetal mortality of
children dying in the puerperium not being
stated. The combined series give a ma-
ternal mortality in 125 cases of 13.6 per
per cent.

The ease with which Caesarean section
can be done deludes operators into the
belief that it is a simple operation and
without mortality ; but the facts remain that
the mortality of all classes of Caesarean
section is, in 3,000 collected cases, 7 per
cent. How much greater will the dangers
be in placenta previa where the patient,
weakened by hemorrhage and contaminated
by examinations, is unfit to stand such a
radical surgical procedure. To treat these
cases by Caesarean section is but to add an-
other greater danger to that already exist-
ing.

The only excuse for a Caesarean section
in any condition is to save a living child
and, if there is a direct fetal mortality of at
least 34 per cent, with a probable ultimate
mortality one-fourth greater, a living child
will hardly be obtained in as many cases as
in the bag treatment and the safe method
of version and delayed extraction will save
more mothers. It is doubtful whether the
125 cases with 13.6 per cent, mortality rep-
resents the true estimate of mortality, as
no large clinic statistics have yet been re-
ported and, with isolated cases, it is human



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nature to rq)ort successes and allow failures
to be forgotten.

When Caesarean section is not done until
the end of the period of dilatation, there is
no security against a fatal after hemor-
rhage, for, by that time, the insertion of the
placenta in the isthmus or cervix has already
been stretched and, with defective contrac-
tion of this segment of the uterus, hemor-
rhage is likely to follow. The hemorrhage
comes mainly from the lacerated vessels in
the upper part of the cervix and, with a
Caesarean wound in the uterus, this would
be difficult to control by gauze packing or
other means.

Vaginal Caesarean section has been ad-
vocated in placenta previa with an undilated
cervix. Bumm was its most weighty ad-
vocate; but now he, Sigwart says, has
abandoned the operation. The amount of
hemorrhage is greater from a cut wound
than from a torn one and, in these incisions
of vaginal Caesarean operation, the bleed-
ing is sometimes severe and difficult to con-
trol. If the placenta is situated posteriorly,
it may be possible that anterior hysterot-
omy may be of value, but it is difficult to
decide when this condition occurs. Also,
if the placenta is posteriorly situated, the
elastic bag may be passed around the an-
terior lobe.

Incisions into the cervix, when the os is
not fully dilated are, however, occasionally
of use, although they need not go so far as
to include the surface of the uterus above
the vaginal vaults.

In the treatment of the incomplete form,
the mainstay of treatment is the elastic bag.
Its advantages are that it can be easily in-
serted and it controls the hemorrhage. The
placenta, not covering the os completely,
does not obstruct its passage; the mem-



branes are easily ruptured and the elastic
bag may be inserted within the membrane,
much reducing the mortality.

Version and breech extraction must be
reserved for those cases of incomplete pla-
centa previa in which the os is fully dilated
with unruptured membranes or urgency of
delivery is demanded. The greater possi-
bility of obtaining a living child in incom-
plete placenta previa renders it expedient
that all possible means should be taken to
this end.

When the insertion of placenta is high in
the uterus and the membranes present at
the OS, the hemorrhage may sometimes be
controlled and labor hastened by rupture
of the membranes. This gives the best
chance of a live child.

The treatment by rupture of the mem-
branes alone, however, should be confined
to mild cases with a high insertion of the
placenta. The main reliance in the treat-
ment of incomplete placenta previa should
be the large elastic bag, lo to 12 cm. in
diameter and with a capacity of 500 c. c. of
water. Version and breech- extraction
should be reserved for those urgent cases
with a fully dilated cervix and much bleed-
ing.

The dangers of placenta previa by no
means cease with delivery of the child, but
in a large proportion of cases, hemorrhage
occurs after labor. This bleeding does not
as a rule occur immediately after delivery,
because of the fall in blood pressure coin-
cident with the birth of the child; but
usually takes place within an hour. This
delay of the hemorrhage makes it of a most
insidious and dangerous character. A very
large percentage of all deaths in placenta
previa are due to this form of hemorrhage.
In Hammer's series, three of eight deaths
were from postpartum hemorrhage due to



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atony of the uterus. In Warren's series of
ninety-four cases, postpartum hemorrhage
was present in 15 per cent, and, of six
deaths in all, two were from this cause.

It is, therefore, necessary to take meas-
ures to prevent the occurrence of this
hemorrhage. A dose of one of the good
preparations of ergot should be given hy-
podermatically immediately after delivery
of the child. It is better to use one of the
physiologically tested preparations, for
much of the ergot upon the market is inert.
Pituitrin, an extract of the pituitary body,
is very efficient in stimulating the uterus to
contract and has been used with good suc-
cess by Foges and Hofstatter in sixty-five
cases of postpartum hemorrhage. The
uterus contracts firmly and remains in that
condition for some time. It promises to be
useful in placenta previa.

The question of uterine packing with an-



2.

3.

4.
5.
6.

7.
8.

9.
10.

11.
12.

13.
14.
15.
16.



Muench. Med, Woch., Nov. 19,
Ann, de Oyn. et d*0h8tet..



ZWEIFEL.

1907.
CONVELAIRE.

Aug., 1910.
FUTH. Zentr. f. Oyndk,, 1907, 12.
WARREN. Lancet, Feb. 3, 1906.
HAUCH. Mon. f. Geh, u, Qvnak,, 1910,

xxxi, 5.
BONNAIRE. Preaae Med,, 1909, xvii, 66.
MULLER, L. Placenta Praevia, Stuttgart,

1877.
HANNES. Zeit, f, Oynak., 1909, 3.
THIES. Mon. f. Gel), u. Gynak,, 1909,

xxix.
MAISON. Zentr, /. Gynak,, 1910, 18.
HOLMES. Jour, Amer, Med, Assn., May

20. 1905.
JEWETT. Amer, Jour. Ohstet., June. 1909.
SIGWART. Zentr. f. Gyn,, 1910, 28.
HAMMER. Munch, Med, Woch,, 1, 35.
FOGES AND HOFSTATTER. Zentr. f.

Gynak., 1910, 46.



CHAPTER XVII.

OVARIAN PBEONANOY, WITH
PORT OF A CASE.



RE-



Introduction. — The occurrence of ovarian
pregnancy was first proven by Catherine
tiseptic gauze to prevent hemorrhage imme- von Tussenbroek who accidently discovered



diately after delivery is an important one.
If a patient is in a hospital where she can
be carefully and minutely watched, and if
the uterus has contracted well, uterine pack-
ing may not be necessary ; but if the woman
is delivered in a house where the prepara-
tion for packing would involve some delay,
or if the woman is weak from bleeding and
can spare no more blood, uterine packing
should be done as a prophylactic against
hemorrhage.

In other words, the uterus should be
packed with gauze to prevent hemorrhage,
or preparations should be made so it can
be done instantly in case hemorrhage
should begin. After delivery in placenta
previa, no patient should be left without
constant medical supervision for several
hours after delivery.

REFERENCES.

1. MAISON and WILLIAMS. Boston Med,
d Surg. Jour,, June 3, 1909.



a case while making pathological examina-
tions. She made her examination and re-
port of a specimen handed her by Kouwer.
This was the first complete demonstration
of ovarian pregnancy in 1899. Since that
time a number of cases have been reported
and all that are well examined and un-
doubted are collected in a table in this
paper. The first nineteen cases were col-
lected in Norris' table in 1909, and nine
cases have been added to that table includ-
ing the one here reported. An example
of the fact that if an operator is on the
watch for this condition it is more likely
to be found is that of 28 cases, two each
are reported by Webster, Norris and Mis-
colitsh.

Diagnosis. — The requirements of an un-
doubted ovarian pregnancy are that ( i ) the
tube on the affected side be intact, (2) the
fetal sac occupy the position of the ovar\',



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(3) it must be connected to the uterus by
the utero-ovarian ligament, (4) definite
ovarian tissue must be fovmd in the sac wall
and at different places in the sac wall.

These conditions are required to distin-
guish ovarian pregnancy from advanced
tubo-ovarian or abdominal pr^^ancy where
the ovarian tissue is plastered and flattened
over the sac wall and so incorporated in the
sac wall as to be impossible to distinguish
whether the pregnancy is ovarian or not.

It is very difficult to say whether certain
advanced ectopic pregnancies are tubal or
ovarian in their origin, and it is almost im •
possible to prove their original site. For
this reason, in this series so collected, all
advanced and dubious cases must be ex-
cluded.

For an exact diagnosis .microscopic ex-
amination must show evidence of preg-
nancy within the ovary, i. e., chorionic villi
must be found. The presence of decidual
cells alone is not sufficient evidence of
ovarian pregnancy; for decidual cells may
be present in various places, such as the
broad ligament over peritoneal surface in
ectopic pregnancy. Also, it may be pos-
sible that the mere presence of decidual
cells in the tube is not evidence that gesta-
tion has occurred there and not in the
ovary, as it is possible that such cells may
exist in the tube during an ovarian preg-
nancy. Decidual cells may sometimes be
found in the uninvolved tube when a tubal
pregnancy is in the opposite side, and again
as may be seen from the discussion of bilat-
eral tubal pregnancy, decidual cells some-
times exist in a tube containing blood when
no other signs of tubal pregnancy exist.
So that decidual cells in the tube are no
evidence for or against the presence of an
ovarian gestation.



The occurrence of hemorrhage from the
ovary sometimes occurs without ovarian
pregnancy and from ovarian hematoma.
Hedley^ has reported 18 such cases with
free peritoneal blood, and has described the
course and pathology of the condition.
Savage^ has divided hematomata of the
ovary into two types: (i) hematoma of the
Graflian follicle, (2) hematoma of the
corpus luteum. In the first type, he found
the wall of the hematoma was lined by a
single layer of epithelium which he re-
garded as a membrana granulosa, lying on
a basement membrane and external to these
were the two layers of tissue which ap-
peared to correspond to the theca interna
and theca externa. The cells of the inner
layer showed early lutein cell formation
and there were ill-developed Qraffian fol-
licles near the cavity of the hematoma and
some opening into it.

The second type — ^hematoma of the
corpus luteum — ^had an outer cell of ovarian
tissue which was for the most part con-
gested; the inner part of the wall showed
newly formed fibrous tissue, poor in cells,
and near to the lining in between the long-
itudinal strands of this tissue, there were
blood extravasations, many round cells and
many large rounded or cuboidal cells con-
taining yellow coarse granules. The nuclei
of these cells were relatively small and, in
many instances, seemed to be crowded
towards the periphery of the cell. The
cause of these hematomata is supposed to
be abnormal congestion of the ovary with
hemorrhage into immature follicles.

It has been suggested that it might be
possible that ovarian pregnancy be a cause
of some of these hematomas. This seemed

» Hedley.

"Smallwood Savage. Brit. Qyn, Jour,, xxl.
285.



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possible because several cases, as von Tus-
senbroek's and Kelly and Mcllroy's, were
discovered accidentally in the routine ex-
amination of surgical specimens. How-
ever, search does not bear this out. Still
the similarity of the picture at operation
between ovarian hematoma and ovarian
pregnancy, both causing hemorrhage, is
very striking and requires careful examina-
tion to distinguish one from the other.

The clinical course of ovarian pregnancy
has nothing to distinguish it from ectopic
pregnancy generally. The rupture occurs
in the same way; the shock and collapse
may be as extreme and the hemorrhage is
sometimes great. The condition is chiefly
of interest because of its rarity.

Clinical Report — Mrs. L., age 36, para I.
Small woman. Good previous history.
Severe cystitis 5 years ago. Operated upon
by Dr. Ellice McDonald for retroversion by
internal round ligament operation. Opera-
tion was done four years ago. When seen
complained of pain on left side. Menstrua-
tion has been absent for 37 days. Thought
she was pregnant. Tenderness on right side
on abdominal palpation. Tenderness on
movement. Uterus contracted and firm,
not enlarged. Cervix slightly patulous.
No softening of cervix, no contractions of
the uterus. Hegar's and McDonald's signs
not found. Light colored, bad smelling dis-
charge from cervix. Doughy mass was
felt posteriorly and to the left slightly dis-
placing the uterus. Diagnosis was made of
ectopic pregnancy which was concurred in
by Dr. H. M. Painter, who was called in
consultation. Immediate operation, Dr.
Painter assisting. Free bloody fluid was
found in the pelvis and on the left side in the
region of the ovary and attached to the
ovarian ligament was found a thin walled
cyst about the size of a large walnut from
the interior of which was attached a stringy
piece of dark reddish membrane (decidual
remnant). This was fixed to the inner
lining of the cyst way. This membrane
has evidently before the rupture covered
the interior of the cavity within the ovary.
The capsule was very thin in parts, varying



in thickness. One part was densely in-
filtrated with blood.

The tube was apparently normal and was
removed with the ovarian mass. There was
no trace of a fetus. Microscopic examina-
tion showed that the walls of the cyst were
formed of ovarian tissue with several
corpora lutea at various stages. Numerous
Graffian follicles were found. Numerous
chorionic villi could be seen, although in
many sections obscured by fibrin and clots.
In the walls of the capsule there were areas
of hemorrhages in the stroma. There was
a moderate round-celled infiltration in
places. Pigmentation was present almost
in all sections of the ovarian stroma. Here
and there were groups of large pigmented
cells with large nuclei. Here and there
were budlike masses with densely staining
multiform nuclei or protoplasmic cells with
nuclei. The tube was normal. Diagnosis
— ovarian pregnancy.

CASES BEPORTED IN LITERATURE.

ANNING & LITTLEWOOD.— Trans. Obst. Soc,

London, 1901. xlili, 14.
WEBSTER. — Trans. Amer. Qyn. Soc. 1904.

xxix, 65.
HEWBTSON ft LLOYD.— Brif. Med. Jour. 1906.

Sept 8.
VAN TUSSENBROEK.— Ann. de Oyn, et Ohst,

1S99 Dec.
DE LEON & HALLMAN.— i?ev. de Oyn. 1902.

June.
FREUND ft TUOUK.—Virchow's Arch. 1906.

Jan.
KELLY ft McILROY.-Vottr. Obst. d Oyn. Brit.

Emp. 1906. June.
THOMPSON.— Trans. Am. Gyn. Soc. 1902,

xxvll.
WEBSTER.— Trans. Amer. Gyn. Soc. 1907.

xxxii.
BOESBEECH.— ilfonat /. Oeh. u. Oyn. 1904,

XX, 613.
JACOBSON. — Contribution to the Science of

Med. ft Sur. N. Y. Post-Grad. School and

Hospital. 1908, 24.
MISCHOLITSCH.— Zenf. f. Oeh. u. Oyn. 1903,

49, 500.
NORRIS ft MITCHELL.— Surg. Gyn. Obst

1908, May.
KERR, J. M. MTJNRO.— Proc. Roy. Soc. Med.

1908 I 9
GOTTSCHALK.— Zent. f. Oyn. 1886, x, 727.
BANDEL.— Beitr. z. Klin. Chir. 1902, xxxvl,

657.
FRA^Z.— Hegar's Beitrdge. 1902, vl, 70.
SCHICKELE.— Beif. z. Oeh. u Oyn. 1906, xl,

307.
RUBIN.— Amer. Jour. Ohstet. 1911, May.
LEA.— ^owr. Ohst. d Oyn. for B. E. 1910.

Sept



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TUEEDY.— ^our. Ol)8t d Gyn, for B. E. 1910.
Feb.

Mcdonald, n. s.— /our. a. m. a, i909, m,

1253.
BARROWS.— Amer. Jour, Ohatet 1910, Dec.
YOUNG & RHEA.— Boston Med. d Surg. Jour.

1911, Feb. 23.



OCULAB DEFECTS AND THEIB BE-

LATION TO THE HEALTH AND



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