Surgical interference can do something for these cases, and help elim ination. We will return to this point under the head of Treatment.
The following lists of Kiwisch, Hecker and Hennig, will give some idea as to the relative frequency of these various modes of termination.
In Kiwisch's 100 unselected cases, death resulted In 132 cases, ;6 cures; 62 spontaneously, 14 after operations. Death occurred in 44 cases out of 56 after a spontaneous course, and 12 times after instrumental interference. Total mortality 42 per cent.
According to Hennig's statistics, in 150 tubal pregnancies 17 recov ered, of whom 11 were operated upon. - The rest all died after a longer or shorter time. 127 died without and 6 after operation. Total mortality 88 per cent.
From these tables we can get some idea of the duration of the various kinds of abnormal pregnancies.
It is worth noticing that in the cases left to themselves death occurred from internal hemorrhage after rupture of the oviduct in half of the 81 cases.
Although some of the cases may occur more than once in these various tables, yet they are of especial value; since each author regards the subject from one special point of view. Biwisch groups all the cases of extra uterine pregnancy together, without differentiating their special forms; and from his tables the practical physician may learn what he may expect when once he has diagnosticated the malady.
Hennig groups pure tubal and interstitial pregnancies together. More than half of these succumbed to internal hemorrhage during the first months; and the frequency of these cases teaches us how probably correct the diagnosis of extra-uterine pregnancy is when a woman who has had symptoms of pregnancy suddenly sickens or dies with the signs of inter nal hemorrhage.
Hecker collates mostly well advanced cases, probably largely tubo ovarian; and we see that his lists give the best prognosis, 42 per cent. against 88 per cent. in Hennig's list.
Etiology.—Extra-uterine pregnancy is rare; we have examined 1000 female genitals post mortem, and have not found tubal pregnancy once. Statistics as to its frequency are, however, unreliable, since it is to a great extent the serious and complicated cases which are received in our large . lying-in hospitals and clinics. During seven years in the three lying-in clinics, and the gynecological clinic of Professors Carl v. Braun and Spath in Vienna, among 60,000 cases, five cases of extra-uterine preg.
nancy were observed during life, and examined post mortem.
In regard to age it has been often noticed that extra-uterine pregnancy is less frequent in young than in old women. This is because the older women have borne children before, and frequently suffer from tubal catarrh; the ciliated epithelium is lost, and adhesions, constrictions, and bendings of the oviducts occur which interfere with the passage of the • ovum.
Fritze (1779), Virchow and Hecker have especially studied the causes of the affection. The two former agree in regarding stricture of the ovi duct from bands or adhesions, due to inflammation of the serosa, of the pelvic organs, as the cause of the affection. The women were either en tirely sterile until this abnormally situated pregnancy occurred, or they had not been pregnant for a long time subsequently to the birth of one or more children, and until extra-uterine pregnancy set in. (Hennig.) And extra-uterine gravidity is most common at the age when tubal dis eases are most frequently seen.
Hennig's cases of interstitial and tubal pregnancies give us the follow ing ages: Other changes besides stricture and bending of the tube may cause the faulty implantation of the ovum which we are considering. Closure of the uterine end of a tube; wandering of the sperms through a patent tube to the ovary belonging to a closed one; the presence of diverticula (which Carus supposed to be the cause of interstitial pregnancy); hernias of the mucosa of the tube, such as Blob has described—all these may lead to the occurrence of the accident. Nor must we omit to mention the exceptional occurrence of a branch of the tubal canal, arising in its inter stitial portion, which Baudelocque, the nephew, has called bifurcation (see Fig. 16), and has claimed as a rare cause of grossesse de la paroi de l'uterus (Graviditas intramuralis.) Hennig notes a malformation of the internal genitals which Kober16 saw, of a similar character; and he inclines to the opinion that they are foetal residua, analogous to the Gartner's canals found in many of the lower animals. We cannot doubt the possibility of this occurrence a priori; for there has been a case in which the ovum is to be seen im planted in the uterine substance, and it is difficult to understand how it gets there unless there is some anomaly of the interstitial portion of the tube.