As for the symptoms peculiar to early pregnancy, they manifest them selves but slightly in case of ectopic gestation. As soon as the uterus be comes developed to any extent, however, hyperaemia and swelling of the vaginal portion appear. In cases where pregnancy is more advanced the vagina assumes usually the hyperaemic condition.
The mammas as a rule swell less, and do not contain as much colostrum as in normal pregnancy. IIennig explains this by saying that the irrita tion proceeding from the genitals to the sympathetic mammary nerves is not asgreat in a normal location of the ovum. In a few cases the have shrunk on the occurrence of death of the ovum, and the process of milk formation has been checked. There is no doubt that during extra uterine pregnancy, the sympathetic connection between the genitals and the mammas expresses itself, but not to the same extent as in uterine preg nancy.
Menstruation does not stop so regularly at the beginning of concep tion as in normal pregnancy. Later it reappears; in three cases which we ourselves observed, it appeared twice after a pause of two months; once it remained absent, and once it remained regular. &ccording to liennig, menstruation again appeared in thirteen women, in six once, three twice, two nine times. Occasionally the flow of blood loses its menstrual character and becomes continuous; instances are reported where large quantities of blood have been lost from four to thirteen weeks. Profuse hemorrhage, as described by Leopold, rarely exists in interstitial pregnancy, although Leopold has described an instance where it was neces sary to tampon the vagina. It is also not uncommon for a watery dis charge to appear, which is easily accounted for by the formation of a decidua in the uterus. It is noteworthy that after the death of the ovum, when there is no unfavorable reaction, menstruation returns. The other symptoms of pregnancy may also be present, and the cases are not rare where they appear with unusual violence, and cause great suffering. The symptoms in the breasts and the menstrual phenomena frequently occur in normal pregnancy, however, and therefore will hardly cause the patient or the physician to rightly appreciate them.
Only when the extra-uterine ovum bursts, or reaches an appreciable size, are alarming symptoms produced, which cause the physician to make an examination and ascertain the condition of the patient. Rupture of
the ovisac can occur at any time during the abnormal pregnancy, with out special symptoms, and as we have already seen, in some women it occurs early and in others late. The symptoms are those of general inter nal hemorrhage. Gaping, drowsiness, collapse, fainting, cold sweat, fre quent small pulse, at times vomiting, accompany the anaemic appearance. As a rule the woman is aware that she is in a dangerous condition, which may prove fatal. In Ilennig's collection twelve times the sensation of rupture was distinct, in one woman it was noticed at two different times, fourteen times it was a sudden pain, oftener the collapse was so sudden that the summoned physician arrived only in time to find the patient in an unconscious condition, or practically dead.
In a case with which I am familiar, a lady who had been well, com plaining simply of dragging sensations in her abdomen, in the evening was troubled with nausea, and before her physician could reach her she was dead. At the post-mortem a large amount of blood was found in the abdominal cavity, and a ruptured tubal cyst with a four months' foetus.
In a case which I saw myself, a lady who had not in the least sus pected her condition, went out to make some purchases, and in a few hours was seized with such pain that her friends had to take her home. When I saw her at ten o'clock, she was anemic, with closed eyes, cold hands, feet and face, spoke with difficulty, gaped considerably, complained of severe pain in the lower part of the abdomen, and at times was uncon scious, the pulse was very weak, or at times could not be felt. I positively made the diagnosis of extra-uterine pregnancy, with bursting of the ovi sac, and agreed with the family physician, Dr. Genser, that laparotomy in this instance was not advisable; the woman lived until two o'clock in the morning.
The severe symptoms of pain and anaemia may disappear, and on the death of the ovum not return. The symptoms, however, may recur at longer or shorter intervals, peritonitis may result, and the case after awhile terminate in death or recovery.