As to diagnosis in Ectopic Gestation, Williams (op. cit.), one of the authorities at present on the subject, says: "A positive diagnosis is occasionally made before rupture, but in the vast majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abortion. In advanced cases careful examination will usually disclose the real condition of affairs, and when full term has been passed the history is so characteristic that mistakes should hardly occur."
In the American Ecclesiastical Review for January, 1898 (vol. ix., n. i), Father René I. Holaind, S. J., published the answers of many physicians to six questions concerning extrauterine pregnancy. Among these physicians were Thomas Addis Emmet, Barton Cooke Hirst, Howard A. Kelly, W. T. Lusk, T. Galliard Thomas, Mordecai Price and his brother Joseph Price, William Goodell, and Lawson Tait,—all eminent authorities on this subject. The second question submitted was: "During pregnancy, at what time and by what means can a differential diagnosis be made between intra and extra-uterine pregnancy, and between abnormal gestation and pelvic or other tumour?"
In answer to this question Dr. Emmet said: "There can be no absolute certainty as to the existence of pregnancy in any case until the pulsation of the foetal heart can be detected. [After the eighteenth or twentieth week of gestation.] … A diagnosis is difficult in all cases of abnormal pregnancy, but an expert can, within a reasonable degree of certainty, arrive at a knowledge of the existing conditions between the second and third month."
Dr. Hirst said: "In almost all cases of advanced gestation the differential diagnosis can be made. In early cases it is not always possible unless conditions be favourable."
Dr. Howard A. Kelly said: "The differential diagnosis between intra and extrauterine pregnancy can usually be made from the sixth week up to the end of pregnancy. It is more easily made from the tenth to the twelfth week on." Writing in the American Text Book of Obstetrics (Philadelphia, 1896), he says: "In the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. … [{9}] The diagnosis of ectopic gestation after the death of the foetus is largely dependent upon the clinical history; if this be deficient, the diagnosis is frequently impossible."
Dr. Lusk said: " … The frequent discovery of the dead ovum in a tube when there has been no suspicion of pregnancy shows the difficulty of a diagnosis." In his text-book (The Science and Art of Midwifery, New York, 1890) is this remark: "Sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus, the physician assuming the risk of premature labour, should he find his supposition of extrauterine pregnancy an error." This means that sometimes the diagnosis is impossible without running the risk of causing abortion of a normal uterine pregnancy.
Dr. Thomas said, "After the second month the diagnosis is perfectly possible." This was also the opinion of Dr. Mordecai Price; and Dr. Joseph Price holds that the diagnosis can be made "after the third month, by exclusion." Dr. John F. Roderer, quoting Lawson Tait, says that "the diagnosis between intra and extrauterine pregnancy can not be made with certainty before rupture, nor can it be determined exactly whether an enlargement of the tube is either an ectopic pregnancy or some form of tumour."
Dr. Goodell's opinion was, "A differential diagnosis can rarely be made positively at any stage of extrauterine pregnancy."
The diagnosis, then, is difficult; and for the ordinary practitioner, the average physician, who does perhaps ninety-five per centum of the medical work of the world, the diagnosis is often impossible. There is no greater expert than Dr. Thomas Addis Emmet, and he says the diagnosis is difficult. Others hold that the diagnosis can be clearly made, and they speak truly as regards themselves, but ordinary skill finds the diagnosis almost impossible in many cases. Mordecai Price (The Pennsylvania Medical Journal, vol. viii. p. 223) in one year saw four cases which he and other physicians diagnosed as ectopic pregnancies with rupture of the tube. When the abdomen had been opened, uterine pregnancy was discovered with a ruptured tube in each case, and all the women died.