A more forcible indication of the pa tient's condition will be pain, which sig nifies both a stretching of the abnormal gestation sac and its subsequent rupture with hemorrhage either into the peri toneal cavity or into the space between the folds of the broad ligament. The pain is sharp and cramp-like; recurs in frequent paroxysms, and may be so se vere that it, in connection with the accompanying concealed haemorrhage, may result in ancemia and collapse. If the rupture occurs at a very early period the foetus (ectopic) may die and be ab sorbed together with the effused blood. The uterine gestation may terminate with an early abortion; but this rule need not be considered invariable. There is very little literature upon this phase of the subject.
When any woman, who has menstru ated regularly and who has passed her period from four to twelve weeks, is sud denly seized with pain in either iliac region, becomes faint, dizzy, nauseated, pale, generally unable to sit up, tender and sensitive over lower part of abdo men, having a frequent desire to go to stool without being relieved, and when, upon vaginal examination, a boggy mass is found at one side and posterior to the uterus, and a slight, bloody, shreddy, mucous discharge occurs, she has the classical symptoms of a ruptured tubal pregnancy. H. D. Ingraham (Buffalo Med. Jour., Aug., '95).
Extra-nterine pregnaney may be mis taken for (1) pyosalpinx with amenor rhoea; (2) myoma; (3) simple abortion; (4) retroflexion of the gravid uterus; (5) anteflexion of the gravid uterus, and (6) twisted pedicle tumors: (a) of the tube and (b) of the ovary. J. W. Tay lor (Brit. Gymee. Jour., :Nov., '9S).
Pain alone, when not accompanied by a clear history of menstrual irregularity, symptoms of pregnancy, and the presence of a tumor at the side of the uterus or in Douglas's pouch, known to be of re cent development, is pathognonionic of extra-uterine pregnancy only under cer tain conditions, viz.: the pain is of a sharp, colicky character. distinctly local ized on one side, attended with faintness more or less marked, and is usually fol lowed by intervals of hours or days of complete remission. The pulse is acceler ated during the attack, but there is no rise of temperature. The latter is an im portant symptom distinguishing ectopic from inflammatory conditions. The vio lent tearing pain attending intraperi toneal rupture is accompanied by the un mistakable evidences of internal }hemor rhage. In extraperitoneal rupture the symptoms vary in severity according to the amount of blood lost, but soon sub side, being succeeded by the usual evi dences of pressure resulting from a mass in the folds of the broad ligament which displaces the pelvic organs. A persistent
pain following the acute attack may in dicate localized peritonitis. E. C. Coe (Med. News, Apr. 21, 1900).
Shock referred to the abdomen occur ring in woman capable of pregnancy should invariably cause a suspicion of ectopic gestation, and, if the shock is pronounced, the abdomen should be opened. E. P. Davis (Amer. Jour. Med. Sciences, May, 1900).
In personal experience, based upon about fifty cases, it has usually been by exclusion that the diagnosis of ectopic gestation has been made. Women have been repeatedly operated upon who have given no history of amenorrhma fol lowed by irregular bleeding. These women had usually given a history of the last menstrual flow having been markedly less than usual. This is a point which deserves to be kept in mind. Again, ectopic gestation may exist with out associated uterine enlargement, and without enlargement of the lower uter ine segment—the so-called Hegar sign of early uterine pregnancy. As a rule, colicky pains were found fairly constant as a symptom of ectopic gestation. An exploratory vaginal section is of very great value. It should be done in every case in which the clinical history in the least suggests the possibility of ectopic gestation. When precedent amenor rhma is followed by bleeding, one can be sure that the pregnancy is not normal. If under amesthesia examination shows an enlarged and congested tube, the in dication for operation is stringent. E. H. Grandin (Medical Record, Jan. 5, 1901).
Concealed hmorrhage, pain, and shock may demand immediate surgical assistance, and this will be the rule when the gestation-tumor has reached the size of a hen's egg or something larger. Even a smaller tumor upon the fimbriated ex tremity of the tube may rupture and cause these symptoms, the danger to life being very great, since the h2emorrhage is into the peritoneal cavity with no re sisting tissues to check it. (This form of ectopic gestation has been termed tubal abortion by Bland Sutton.) If the rupt ure takes place into the space between the folds of the broad ligament, develop ment of the foetus may continue to term, the uterine gestation continuing pare, passe or ending in abortion. A number of eases have been recorded in which the ectopic foetus has been capsulated in the abdominal cavity and has become an inert mass, uterine gestation supervening once or oftener without apparent dis turbance from this foreign body. This seems less remarkable, however, when one realizes how frequently pregnancy is successfully accomplished in the pres ence of all sorts of pelvic and abdominal tumors.