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child, the question may settle itself beyond dispute. If it be necessary to determine the question before that time, then the diagnosis must be made from the signs that may be elicited during the course of the possible pregnancy. In normal cases the presence of the fetus in the uterus is positive proof of the pregnancy; but the woman may be pregnant and still have no fetus in her womb. The fetus may be in the abdominal cavity: as in some of the extrauterine pregnancies; or the fetus may have undergone such morbid changes as to make the usual fetal structures indistinguishable: as in the hydatidiform mole; and yet there can be no doubt as to the previous impregnation and conception.

2. Presumptive signs in general. In normal pregnancy certain objective signs and subjective symptoms are regularly present on which to base the diagnosis. These signs may be divided into those which give presumptive evidence in favor of the pregnancy, and those which afford positive proof of its presence. The presumptive signs may, in general, be classified as those depending on (1) changes in the uterus itself; (2) changes in the breasts; (3) sympathetic changes in the rest of the body. The positive signs are demonstrations of the presence of the fetus.

3. Suppression of the menses.- Beginning with the changes in the uterus, we note first the cessation of the menses; normally, during both pregnancy and the subsequent lactation; but suppression of the menses for a single period may be due to various other causes; for example, scarlet fever; acute rheumatism; slight disturbances of general health, and emotional disturbances. Longer periods of suppression may be due to greater constitutional disorders; such as typhoid, nephritis, tuberculosis, anemia, diabetes, nervous disturbances, et cetera. In the later years of a woman's life the menopause, which sets in with the omission of the regular monthly periods for one or more months, might easily be mistaken for a possible preg

nancy.

Again, the menses may continue during the first few months of pregnancy, or, if there is not a true menstrual flow, there is at least something which is, by the laity, easily mistaken for it; as in the case of an abortion at the end of the fourth or fifth week. Exceptional cases are reported where there have been monthly discharges continuing throughout the whole period of pregnancy.1 Hence, the presence of the menses cannot be taken as proof of the absence of pregnancy.

Williams's Obstetrics, 1903, p. 164.

3

On the other hand, pregnancy may begin in a period when the menses are absent from some cause or other: as, during lactation, which is very commonly the case; or in a girl, before the menses have been established;2 or in old women, after the menopause has apparently set in. In these cases it is needless to say that the absence of the menstrual periods gives no clue as to the existence of pregnancy. Hence, although, under ordinary circumstances, the cessation of the menses is a sign of considerable importance, and is, in the majority of instances, the first sign of existing pregnancy noted by the woman, yet it cannot be taken as at all a positive sign.

4. Enlargement of the abdomen.- Enlargement of the abdomen, due to the increasing size of the uterus, generally becomes apparent at the end of the third month, when the uterus rises out of the pelvis. The increase in size is gradual, and at a fairly definite rate during the first eight and a half months, till the uterus reaches its maximum size with its fundus at the ensiform cartilage. This gradual increase in size of the abdomen is very suggestive of pregnancy, especially when it is associated with the uterine mass of pyriform shape, the base of the mass being towards the thorax. With the enlargement of the uterus and the consequent stretching of the abdominal walls, there are formed in the skin the stria which give it a peculiar appearance, not diagnostic of pregnancy, but very suggestive of it. Enlargement of the abdomen may be due to numerous other causes besides pregnancy, such as a distended bladder, ascites, pelvic tumors, and even flatus in the intestines; some of which may even follow approximately the usual rate of growth of the pregnant uterus.

5. Rhythmical contractions. In the gravid uterus there are regular, rhythmical contractions, which occur about every twenty minutes, and may be felt from the time when the uterus rises out of the pelvis until labor, and are considered as positive as any sign afforded by the mother. Winter in his Lehrbuch der Gynäkologischen Diag nostik, p. 170, quotes a case of doubtful diagnosis, in which the question was settled on this one symptom of rhythmical contractions; and where the emptying of the uterus a few days later proved the pregnancy, but the presence of a blood-mole in place of a normal

the Am. Jour. of Med. Sciences, April, 1844; Lancet, Sept. 1853, p. 206; and Montgomery, Signs and Symptoms of Pregnancy, 2d ed., p. 77.

'Dr. Gregory, of Missouri, relates the discharge. See, also, cases reported in case of a woman who had six living children, and had never menstruated. Dr. Gillette communicated to the Société d'Emulation de Paris the case of a woman thirty-five years of age, who had never menstruated or had any vicarious

3 N. Am. Med. and Surg. Journ., Vol. I., p. 741. See § 161, post.

fetus. But even this sign may occur in other conditions of the uterus.*

6. Pseudocyesis. There are recorded a number of cases where enlargement of the abdomen, together with some of the other signs of doubtful value, and the firm belief of the woman in her pregnancy, have deceived the physicians so completely that operations have been performed for the removal of the child; then, when the abdomen was opened, nothing was found but the intestines distended with gas. These cases of pseudocyesis show clearly how misleading are the presumptive signs of pregnancy, no matter how certain they may seem to be.

7. Discoloration of linea alba.- Associated with the enlargement of the abdomen there is frequently a brown discoloration of the linea alba, beginning at the pubes, and ascending toward the ensiform cartilage with the rise of the uterus. But, like the enlargement of the abdomen, this pigmentation may be due to many other causes, and is of even much less value, because dependent upon the general pigmentation of the body.

8. Prominence of umbilicus.-The relative height of the umbilicus, relatively depressed in the early months, and protruding in the later months, has also been considered, but is of practically no value.

9. Cervix and lower uterine changes,-vaginal flattening; uterus anteflexion; cervix softening; Hegar's sign.-As pregnancy advances, certain changes take place in the cervix and lower portion of the uterus, which are of much importance in diagnosis. First, as the uterus increases in weight, it descends in the pelvis, making the cervix to come nearer to the vaginal outlet, the uterine end of the vagina apparently to flatten and the uterus to become anteflexed. This condition lasts until the third or fourth month, when the uterus rises out of the pelvis, becomes palpable from the abdomen, and will be found to have lengthened the vagina. Along with this rise out of the pelvis, changes in the consistency of the cervix become definitely apparent. The normally cartilaginous, hard cervix becomes softer, the softening beginning in the region of the external os during the second month, and involving the whole cervix at the end of pregnancy. There is also a softening and thinning of the lower segment of the body of the uterus going on at the same time; but this softening of the lower uterine segment, which is nearly characteristic of pregnancy, goes on more rapidly than the softening of the cervix. The

'Williams's Obstetrics, p. 164.

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of Pregnancy, 2d ed., p. 405; and SimpMontgomery, Signs and Symptoms son, Times and Gazetteer, 1859, p. 225.

softening of the lower uterine segment gives the condition on which Hegar's sign is based, determinable in the second month, according to Williams. When the attempt is made to palpate the body of the uterus bimanually, with the vaginal fingers in the posterior fornix and the abdominal fingers in front of the uterus (so that the cervix lies between the fingers of the two hands), the cervix seems to be entirely separate from the body of the uterus, and the lower segment of the uterus is not felt. This Hegar's sign is one of the most characteristic of the early signs of pregnancy, and is of great importance.7

10. Quickening. With the development of the fetus, there comes in the fifth month, usually, what is called "quickening:" when the mother first feels the movements of the child inside of her. This symptom was formerly given much weight, because at that time the child was supposed to receive its spiritual nature, to become animate. Such ideas have now become entirely obsolete in the scientific world. The time of perfecting the child is at its conception. After that, in all ways, it is merely a question of growth and development. The time of quickening, however, is still of some importance in reckoning the duration of pregnancy in cases where conception occurs during a period of suppressed menses. Then we can count from the quickening as though it occurred in the fifth month. But here, again, the value of the statement must be weighed carefully, as there is no way of proving that the movements felt by the mother are those of the child.

11. Genital coloring. Another sign due to the development of the genital tract under the influences of pregnancy is the permanent congestion of the vagina and external organs. These assume a peculiar bluish or violet color, and at the same time become soft and velvety to the touch, while their mucous secretion is greatly increased in quantity. These signs are, however, of only slight value; the difference in color being only a slight one, and the same color being also produced by other changes causing congestion of this part of the body.

12. Kiestein.— The presence of a peculiar formation in the urine, -kiestein, to which formerly considerable importance was attached, is also being relegated to the past, as of no importance, since it does not occur in all cases of pregnancy, and does occur in nonpregnant women, and also in men.8

Williams's Obstetrics, p. 163.

Playfair's Midwifery, 6th Amer. ed.,

'Ibid.; and Reinl, Prager Med. 1893, p. 148.
Wochensch, 1884, Nr. 26; Sonntag,
Hegar's Sign of Pregnancy, Amer. Jour.
Obstet. 1892, Vol. XXVI., p. 145.

13. Changes in the breasts. Among the most important signs of pregnancy are the progressive changes in the breasts. There is a steady increase in their size, which first becomes evident in the second month. With this there is an increase in the gland tissue of the breast, which becomes firm or knotty, and somewhat tender. The superficial veins become more and more prominent, and with the marked increase in size, striæ appear in the skin over them, similar to the striæ in the abdomen. The new ones are of a pinkish hue or sometimes of a bluish red, those of previous pregnancies being of a silvery color. The pigmentation of the breasts is also deepened, especially that in the nipple area. The nipples themselves become more easily erectile. Around the primary areola of the nipple there develops, usually about the middle of the pregnancy, a secondary zone of pigmentation, the secondary areola, in which, as well as in the primary areola, the tubercles of Montgomery appear. The secretion of colostrum becomes evident in the third or fourth month, and of milk in the last month. The value of these breast signs is considerable, and yet not positive; for the secretion of milk or colostrum may be set up by diseases of the uterus and ovaries, or even by local stimulation of the breasts. In the American System of Obstetrics there is an account of a girl eight years old, who suckled her small brother for one month; and references may be had also to women past the menopause, who have nursed infants. Even more surprising are the cases recorded of men who have suckled infants. The common occurrence of milk in the breasts of babies soon after birth is scarcely enough to the point to need comment. The changes taking place in the areolæ, that is, the pigmentation and development of the tubercles of Montgomery, are of perhaps greater value; but they, too, occur in diseases of the uterus, or ovaries, or breasts. Hence, they are not positive signs, though some authors consider that the true changes in the breasts of pregnancy can be differentiated from those of disease.10

14. Sympathetic changes,-morning nausea, mental derangements, et cetera. The third class of presumptive signs are the very uncertain sympathetic changes; such as the morning sickness of the early months, the derangements of appetite, abnormal cravings for food, and disgust for the ordinarily tasty dishes, salivation, with its loosening of the teeth, changes in the mental characteristics and temperament of the woman, et cetera. All of these are extremely variable in their occurrence, and of no legal value.

Amer. Syst. of Obstet., Vol. I., p. 36. I., p. 181; Winter, Gynäkol. Diag., p. 10 Routh, Brit. Med. Journ., 1864, Vol. 68.

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