instances all go to prove that ovulation, the essential feminine process in conception, is not at all dependent upon menstruation, although it is probable that each menstrual epoch is associated with the escape of an ovum either at its height, shortly before, or shortly after its appearance. In other words, it is not necessary for a menstrual discharge to accompany each escape of an ovum.

Leopold and Mironoff' find that menstruation is usually accompanied by ovulation, but not rarely is unattended by ovulation. It is not dependent upon the maturation and rupture of a Graafian follicle, but the presence of the ovary and a sufficient development of the uterine mucosa are necessary. Ovulation is connected with menstruation in so far as it requires for its occurrence a congestion of the sexual organ lasting several days. Ovulation occurs independently of the time of menstruation, but under physiologic conditions, rarely. Usually menstruation occurs with ovulation; less frequently it may occur without ovulation ; and least frequently ovulation may occur without any sign of blood at a regular menstrual period.

To still further complicate matters, there may be total absence of menstruation, the result of occlusion of some portion of the lower birthcanal (atresia of the cervix uteri, vagina, or vulva; imperforate hymen), with a vast accumulation of the fluid and great distention of the uterine and abdominal cavities, thus closely simulating an advanced pregnancy, with total suppression of menstruation. The persistence of menstruation during the first trimester of pregnancy, in addition to confounding the diagnosis, will be a confusing element in the determination of the duration of a given case.

The morbid conditions that are frequently associated with menstrual suppression without coincident gestation, and which are frequently overlooked by the examining physician, are incipient phthisis, chlorosis, anemia, hemorrhage from wounds or other mucous surfaces (vicarious menstruation), various forms of insanity, hysteria, sudden and decided change of climate, and the development of certain pelvic tumors as ovarian cysts, and occasionally uterine myomata. An important fact worth noting is that the menstrual suppression of pregnancy is generally associated with a steady improvement in the body-health, which is not true of the foregoing conditions. Anxiety, as after illicit intercourse, may temporarily cause menstrual suppression.

Feigned Menstruation.-Occasionally women will feign menstruation in order to conceal an illegitimate pregnancy. This is accomplished by staining the underclothing and napkins with other mammalian blood, which is not readily distinguishable from the menstrual flow; or even, as has been noted, with preserved menstrual blood. In the former case microscopic examination will generally' show the absence of the typical vaginal epithelium, and such blood is much more predisposed to coagulation than are the true blood and acid vaginal discharge. Progressive Increase in the Size of the Uterine Body.— This is a fairly presumptive sign of pregnancy after the first trimester, 1 Arch. f. Gyn., Bd. xlv., H. 31.

VOL. II.-4

1

although not an infallible one. The tumor of pregnancy, at first ovoid in shape, becomes progressively more and more pear-shaped, occupies a median position with a slight inclination to the right, is smooth in contour and of a soft and elastic consistency, and is freely movable. It is of rapid growth, occupying fixed positions at certain periods of gestation (Fig. 1). Thus, at the second month, the fundus is about on a level with the top of the symphysis pubis; at the fourth month it is midway between this point and the umbilicus; at the sixth month it is at the um

bilicus; at the seventh month it is midway between the umbilicus and the xiphoid cartilage; and at the ninth month it has fallen about one inch. The percussion-note over the uterine body is dull, due to the upward and backward displacement of the bowels. Other conditions that may simulate such a tumor at an early or later period are a subinvoluted uterus, retained menses forming a hematometra, a non-nodulated fibrous or myomatous tumor, gaseous distention of the bowel, ascites, an ovarian cyst centrally situated, and tumefactions of the abdominal organs, as the liver and spleen. It is very important that an

error be not made in this diagnosis, since many a woman has had her life embittered and the physician his professional reputation injured by such a mistake. Legal action can readily be grounded upon such an error. Intestinal flatus will be detected by the percussion-note; ascites and ovarian cyst, by variation in the area of dulness and the elicitation of fluctuation; the absence of correlated signs of pregnancy will distinguish other growths, while the uterine contractions may be noted in true pregnancy when the cold hand is laid upon the surface of the abdomen. Etherization in doubtful cases will be imperative.

Braxton Hick's Sign.-Intermittent uterine contractions capable of recognition after the third month of gestation must be regarded as an exceedingly valuable proof of gestation. No other known tumor than a uterine growth will present this phenomenon. At regular intervals from the fourth to the tenth month of gestation, varying from five to twenty minutes, the uterine tumor will harden and remain contracted for the space of from three-fourths to five minutes. This process is absolutely painless and is not recognized by the woman herself. The mere grasping of the uterus may cause it to appear. It is never absent in pregnancy, whether the fetus is living or dead.

The Uterine Souffle or Placental Bruit.-This is a very constant but non-diagnostic sign of pregnancy, since it may occasionally be detected in other uterine and ovarian tumors or conditions of marked

pelvic congestion. It is a rhythmic blowing sound occurring synchronously with the woman's heart-beat, commencing about the tenth week of gestation, and persistent throughout; it is situated low down and to one or the other side of the uterine tumor. It is produced by the rush of blood through the enlarged uterine arteries, and is generally most prominent in anemic individuals. It must not be mistaken for a similar sound, known as the cardiac souffle, which is produced by the passage of the blood through the foramen ovale.

The funic or umbilical souffle is a high-pitched, whistling sound synchronous with the fetal heart-beat, and heard best, although even then with difficulty, over the fetal chest. It is produced by tension of the cord with stenosis of its vessels, and has but slight value as a diagnostic sign of pregnancy. It is claimed that it is more readily heard when the cord is wrapped around the fetal body.

Irritability of the bladder is produced early in gestation, and in the closing month by direct pressure of the uterine body upon the base of the bladder. It is, in primiparous women, a sign of much value, especially if it be associated with a history of coitus and of menstrual suppression. It is by no means diagnostic.

VAGINAL SIGNS.

Jacquemin's Sign.-A bluish or purplish discoloration of the vagina is a positive sign of pregnancy. In many cases of gestation I have never failed to find it present, and in some thousands of gynecologic cases I have not seen it accompanying any other condition than

pregnancy. Jacquemin originally declared it to be a certain sign in women who have no hemorrhoids, and this statement has been confirmed by many obstetricians. It may be recognized as early as the fourth week, though it is often not well marked until the third month. Dependent as it is upon the pelvic congestion, it must increase in intensity pari passu with the advancing pregnancy. Toward the close of gestation the mucous surface of the vulva may be almost black in color. In the earlier weeks the discoloration may be first noticed beneath the urethral orifice, digital compression showing the sluggishness of the circulation. It is claimed that certain neoplasms may produce such a discoloration, but this must be quite exceptional. The absence of the discoloration cannot be construed as an argument against the existence of pregnancy; its presence is practically diagnostic.

The vaginal pulse is a frequent sign, and valuable as a presumptive symptom of early gestation. It consists in a distinct pulsation of the vaginal arteries consequent upon the high arterial tension of the pelvis. It is not invariably present, and may accompany other conditions, as fibroid tumors, extra-uterine fetation, and inflammatory pelvic conditions. Flattening of the anterior vaginal vault may likewise be noted, and was regarded by Barnes as strongly suggestive of pregnancy. It results from backward traction by the upward-tilted

cervix.

Leukorrhea is of no special value as a means of diagnosis, even though the woman has never suffered from it prior to the supposed gestation. It is always present to a certain degree, but may be due to many other conditions. It is associated with more or less puffiness of the vaginal walls and vulvar tissues, and is directly dependent upon the increased pelvic congestion.

Softening of the cervix (Goodell's sign) is a very suggestive symptom, especially in primiparous women. It is due to edema of the cervical tissues beginning around the os uteri, and is present as early as the second or the third week of pregnancy. As formulated by Goodell, the rule of practice is as follows: If the cervix be as hard as the tip of the nose, pregnancy presumably does not exist, but if it be as soft as the lips, the existence of gestation is probable. It is accompanied by a considerable degree of dilatability of the cervix, especially in multiparous women. The same softening may be noted in certain pelvic inflammatory conditions, at the menstrual epochs, and accompanying the growth of soft myomata. After the fifth month the cervix will also be found to have shortened materially, and the external os points more toward the sacral hollow. By term the cervix has become fully obliterated, the internal os, however, remaining closed until labor begins.

Hegar's sign, or softening and compressibility of the lower uterine segment, is regarded by many as almost diagnostic of early pregnancy. Soft uterine myomata, however, may occasionally produce such softening of this lower segment as closely to simulate the gestation sign. Bimanual palpation is necessary to elicit the change, the right hand resting upon the abdomen just above the symphysis, while the

thumb of the left hand enters the anterior vaginal fornix and the indexfinger passes far up the rectum (Fig. 2); approximation of the thumb and finger below while the uterus is depressed by the external hand will reveal the undue softening of the uterine tissues. Between the second and fifth months of gestation Hegar's sign may be regarded as one of great value. Anesthesia may be required in order to detect it in some cases, and in a large number of cases it cannot be elicited.

In vaginal ballottement, or the balancing of the fetus between the fingers, we have an absolutely diagnostic sign of pregnancy, which, however, is available only from the middle of the fourth to the eighth month. It is elicited by allowing the woman to stand, or by placing her upon her back with the abdominal muscles partially relaxed and the shoulders elevated. The index- and middle fingers of the left hand are introduced into the anterior vaginal fornix, while the fundus is steadied by the right hand placed on the abdominal surface (Fig. 3). The fingers in the vagina then give a sudden impulse to the anterior uterine

FIG. 2.-Method of eliciting Hegar's sign of pregnancy (Sonntag).

FIG. 3.-Vaginal ballottement.

wall, when the fetus, which is displaced upward in the liquor amnii, impinges upon the abdominal hand and gently falls again upon the vaginal fingers. A double thumping is thus noted. There is no other condition that could possibly produce a similar sensation, although some claim that an extra-uterine polypus with a long pedicle will respond to the test. It is not always present, however, being absent in twin pregnancy, in absence or deficiency of the liquor amnii, and in placenta prævia.

Uterine fluctuation is considered by Rasch as an important sign of early pregnancy, recognizable from the second month. It is elicited by placing two fingers of the left hand in the anterior vaginal fornix and steadying the fundus by the right hand placed on the abdominal wall. Gentle tapping by the external fingers will transmit a wave to the vaginal fingers through the agency of the liquor amnii.

Varicosities in the vaginal wall and around the vulvar orifice are indicative of pelvic congestion and are usually most prominent in the