CHAPTER IX.

Signs of Pregnancy-Uncertainty of Duration of Pregnancy-Precocious Pregnancy-Unconscious Pregnancy-Pregnancy in the Dead.

THE subject of pregnancy is an important one medicolegally, as women, on the one hand, frequently deny that they are pregnant, in order to avoid disgrace or to procure an abortion, and on the other hand as often affirm that they are pregnant, having no reason to think that they are in that condition, in order to extort money, to defraud the heir-at-law, to stay capital punishment, to avoid attendance upon a trial, etc. Actions for damages against physicians and others involving questions of pregnancy often arise in cases in which it is claimed that errors in diagnosis were committed, or that slanderous reports were circulated against the character of a virtuous woman. A pregnant female was exempted by the old Roman law from capital punishment, and the law is the same in most modern countries. Hence, the summoning of twelve matrons or discreet women in old times under the writ of de ventre inspiciendo to determine whether a woman was pregnant or quick with child—an office now performed by the city's physician or by a jury of physicians.

1

The signs of pregnancy may be described as being of two kinds uncertain and certain. The former kind, as the name implies, is, from a medico-legal point of view at least, but of little importance as compared with the latter.

1 "Quod prægnatis mulieris damnatæ pœna differatur quoad pariat" (Beck, op. cit., vol. i. p. 250).

Among the uncertain signs of pregnancy may be mentioned the suppression of the catamenia, morning sickness, enlargement of the abdomen, quickening, development of the breasts, kiesteine in the urine, the violet color of the vagina.

Suppression of the menses, when occurring after intercourse, only in a woman who had hitherto been regular, may be regarded as a very probable sign of pregnancy. As the menses may continue, however, throughout pregnancy, as they may only appear during that condition, as they may never appear at all, even in women who bear children, and as they are also absent in certain diseases, it is evident that neither their absence nor their presence can be regarded as a proof of pregnancy or non-pregnancy. But it should be mentioned that not unfrequently women desiring to conceal their pregnancy stain their linen with blood and even with menstrual blood, borrowed for that purpose.

Nausea is usually an accompaniment of pregnancy, occurring frequently as early as the second or third week after conception. It generally passes away about the time of quickening, but may continue throughout the whole period of pregnancy. In many cases of pregnancy nausea is absent; on the other hand, it is of frequent occurrence in many diseases. But little importance can therefore be attached to nausea alone as a sign of pregnancy.

The enlargement of the abdomen in a pregnant woman becomes evident at the end of the third month, the uterus then rising out of the pelvic cavity. By the end of the fifth month the uterus is halfway between the pelvis and the umbilicus, and at the sixth month at the umbilicus. During the seventh month it is at a point

midway between the umbilicus and ensiform cartilage, reaching at the end of the eighth month the ensiform cartilage. During the last month the tumor widens and falls forward. Enlargement of the abdomen may be due, however, to ovarian dropsy and tumors, ascites, flatus of the intestines, impacted feces, enlargement of the spleen and kidney, and distention of the bladder. The medical examiner would certainly not be justified, therefore, in expressing the opinion that a woman was pregnant simply because there was enlargement of the abdomen.

Quickening is the first perception by the mother of the movements of the foetus. These movements, which occur usually some time between the sixteenth and the twentyfourth week, may be due either to the uterus or to the foetus. Nervous, excitable women, especially those wanting children, frequently imagine, however, they are pregnant, mistaking the movements of their intestines or the contractions of their abdominal muscles for those of a fœtus. Quickening, being entirely a subjective symptom, is, therefore, a very unreliable sign of preg

nancy.

The breasts usually develop during the period of pregnancy, becoming larger and fuller as the secretion of milk increases. Large veins make their appearance, the nipples become more prominent, the areola widens and darkens in hue, especially in brunettes. Enlargement of the breasts, however, is not a proof of pregnancy, inasmuch as it occurs in cases of uterine fibroids, and in various other ovarian and uterine disorders. Even the secretion of milk would not warrant the statement that a woman was pregnant, since milk is secreted occasionally by unimpregnated women, young girls, and even by men. Indeed there have been cases in which the secretion of milk by men has been

so copious that they have been able to perform, for years, the office of wet-nurse.'

By kiesteine is understood the fatty pellicle which forms on the urine of pregnant women that has been standing some days. It appears to consist of a combination of casein and phosphates. As kiesteine is not peculiar to the urine of pregnant women, being found sometimes in the urine of men, its presence cannot be regarded as a proof of pregnancy. The violet color of the vagina, appearing about the fourth week of gestation, due to venous congestion, may be regarded as a valuable sign of pregnancy, but an uncertain one, since it is not invariably present.

Ballottement.-Among the so-called "positive signs" of pregnancy are included ballottement, change in the body and cervix of the uterus, the active movements of the child, the pulsation of the foetal heart, the uterine and umbilical sounds. By ballottement is determined the presence of a fœtus about the fifth or sixth month of pregnancy. In performing it, the woman is made to stand upright and the finger of one hand is introduced into the vagina up to its mouth, while the other hand is placed upon the abdomen, so as to steady the uterine tumor. If the tip of the finger be now suddenly pushed up against the os uteri, a sensation, should a foetus be present, will be felt like that of a body rising and falling in a liquid. This is, however, an uncertain sign of pregnancy, since any floating tumor in the uterus will impart the same sensation to the finger as that due to the fœtus.

At about the fifth month of pregnancy, the os uteri is directed backwards, and has a velvet-like feeling; the shortening of the cervix becomes evident at this time and continues until the ninth month, when the cervix ceases

1 1 Dunglison: Human Physiology, eighth edition, vol. ii. p. 520.

to be distinguishable from the body of the uterus. The active motions of the child can usually be felt about the fifth month of pregnancy, or even earlier, by placing a cold hand upon the surface of the abdomen. Intestinal movements must not be mistaken, however, for those of a foetus. It should be remembered also that not unfrequently in cases of pregnancy the movements of the foetus are not perceptible.

The uterine sound, a peculiar blowing or whistling sound, synchronous with the maternal pulse, and due probably to the passage of blood through the uterine arteries and placental vessels, can usually be heard over most of the abdomen as early as the middle of the third month of pregnancy, but more distinctly as pregnancy advances. As uterine sounds can, however, be heard in cases of enlargement of the uterus as from tumors, such signs are very unreliable signs of pregnancy, and the same may be said of the umbilical sounds due to the flow of blood through the umbilical vessels.

Pulsation of the Foetal Heart.-Indeed, of all the socalled "certain signs" of pregnancy, the pulsation of the foetal heart is the only certain and positive one, and then only when it can be so distinctly heard as to be counted. The foetal sound is not synchronous with the pulse of the mother, the fœtal heart beating at a rate of one hundred and thirty-six beats to the minute, and even faster. It resembles the ticking of a watch, and is heard over different parts of the abdomen, but best between the ilium and the umbilicus on either side. It may be heard as early as the middle of the fifth month, but much more distinctly as pregnancy advances.1

1 Scanzoni: Lehrbuch der Geburtshülfe, Vierte Auflage, Wien, 1867, vol. i. S. 160.