Many specialists now are of the opinion that the diagnosis of ectopic gestation ordinarily is not difficult, but most physicians find it very difficult. Before rupture of the tube or a hemorrhage diagnosis is hardly ever made by any one, and no pelvic condition gives rise to more diagnostic errors. When there is rupture or tubal abortion the symptoms may lead the physician to mistake the condition for uterine abortion. In uterine abortion the onset of the symptoms is quiet, with gradually intensifying and regular pains, resembling labor, in the lower abdomen. In ectopic pregnancy the symptoms of a rupture or tubal abortion arise quickly, with irregular and colicky or very violent pains, localized on one side. In uterine abortion the external hemorrhage is more or less profuse, with clots; in ectopic gestation the external hemorrhage is slight or absent; the shock in the latter case is out of proportion to the visible blood loss. Parts of the ovum, or the presence of the whole ovum, as uterine, are found in ordinary abortion, but in the ectopic condition the ovum proper does not appear. An intrauterine angular pregnancy, or pregnancy in a uterine horn, causing the upper corner of the womb to bulge sidewise, may be mistaken for ectopic gestation. Pregnancy in a retroflexed uterus, tumors of the adnexa, the twisted pedicle of an ovarian tumor, a burst pyosalpinx, an appendicitis in pregnancy, or a combined intrauterine and ectopic gestation, also may confuse the diagnosis. When there is a dangerous hemorrhage from rupture or tubal abortion the diagnosis is usually made without difficulty from the collapse and other signs. The diagnosis as to whether the fetus in the pelvis is dead or alive may be made (1) from the absence or presence of symptoms of tubal rupture during the second and third months, or of mild symptoms indicating only slight bleeding; (2) from the continuation and progress of the evidences of pregnancy, as nausea, mammary changes, fetal movements, or audibility of the fetal heart; (3) from the presence of a loud uterine blood souffle; (4) from the absence of toxemia or suppuration; (5) from a growth of the uterus and a softening of the cervix; (6) from a gradual increase in the size of the suspected ectopic fetal tumor. In making the diagnosis great caution must be observed, as roughness in manipulation may start hemorrhage or rupture a thinned tube. The diagnosis may be made: (1) that ectopic gestation exists without symptoms of maternal hemorrhage, and the fetus is not viable; (2) that the same maternal condition may be present, but the fetus is viable; (3) that there may be symptoms of slight bleeding, and the fetus is inviable; (4) that there may be symptoms of grave maternal hemorrhage at any stage of the gestation.