congestion of pregnancy, because of the additional mechanical factorpressure by the gravid uterus upon the pelvic veins. In association with other signs of the advancing gestation it possesses some signifi

cance.

An absolute diagnostic symptom is the detection, by the vaginal finger, of the fetal parts.

ABDOMINAL SIGNS.

Cutaneous discoloration of the abdomen is present in the vast majority of pregnant women. The line of discoloration-linea fusca or nigra, the yellow, brown, or black line-supplants the linea alba, and may extend as far as the xiphoid cartilage. It is most marked in brunettes, and may be altogether absent in blondes. It is by no means diagnostic, however, as boys and unimpregnated girls may present the linea fusca. The linea alba also darkens at the menstrual epochs and in certain forms of pelvic disease, as ovarian cystoma and uterine

myoma.

Progressive enlargement and protrusion of the abdomen is an essential sign of pregnancy, but it is patent that the same symp

tom must occur whatever be the nature of the intra-abdominal growth. The protrusion in pregnancy first becomes evident about the fourth month, and is most marked in women of small stature. The same errors of fallacy are to be noted as in the case of uterine enlargement.

The striæ are the purplish lines of discoloration that appear on the distending abdomen in the iliac region and toward the flanks (Fig. 4). They are not diagnostic of pregnancy, but may result from any excessive distention of the abdominal walls, as from cysts or ascites.

A change in the condition of the umbilicus is noted in pregnancy, and while this alteration may result from other causes of distention, it is most commonly associated with gestation. At the sixth month the umbilical depression is obliterated, and after that date there is a progressively increasing protrusion to term.

The percussion-note over the growing uterus is flat, while to the sides and above there will be found an area of tympany known as

the "coronal resonance." Any solid or fluid tumor, however, will give the same result; hence it is not characteristic.

Abdominal ballottement is an absolute sign of pregnancy, elicited by steadying the uterus with a hand placed on each side of the abdomen. An impulse given by one hand will cause the fetus to impinge upon the opposite hand; the shock is more distinct when the fetus is small and undersized.

All women are essentially constipated, but in pregnancy this may become an exceedingly prominent symptom. This results from the stagnation of the pelvic circulation, and is accentuated by direct mechanical pressure of the enlarged uterus upon the lower bowel. It is of value as a diagnostic means only when taken in connection with the other symptoms of early pregnancy.

Quickening and Fetal Movements.-By quickening is meant the first fetal movements appreciated by the mother. It usually occurs about the middle of the fifth month of gestation, but may be felt as early as the third month (twelfth week). It is peristaltic in nature, and when noticed, the woman is said to be "quick with child." All subsequent sensations of fetal life are designated as fetal movements, and they constitute an absolute sign of pregnancy. They are not invariably present, however; hence their absence does not indicate the absence of gestation. It is likewise possible for the woman to mistake intestinal peristalsis and choreic movements of the abdominal muscles for the sensation of quickening. The use of the stethoscope or of an anesthetic will demonstrate this condition. Active fetal movements can rarely be appreciated by the

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FIG. 5-Diagram illustrating the points of maximum intensity of the fetal heart-sounds in vertex and breech presentations.

physician before the middle of the sixth month. The placing of the cold wet hand on the abdomen will sometimes cause an exaggeration of their intensity. Once detected, they steadily grow stronger with the advancing weeks. They appear either as distinct blows, as from the spasmodic movements of a fetal limb, or as a peculiar undulating movement, advancing across one side of the abdomen as the swell of a wave; this is produced by a straightening of the fetal ellipse, the back coming in contact with the uterine and abdominal walls. These movements may be absent throughout pregnancy, and the woman be delivered of a living fetus, as when there is an excess of

liquor amnii; or they may be suppressed for variable periods only. Several examinations should be insisted upon before the positive absence of movements is asserted. At times the movements of the fetal limbs in the liquor amnii or in contact with the uterine wall will produce faint indescribable sounds, which, if distinctly heard, are characteristic of pregnancy. It is exceptional, however, for this sound, termed the fetal shock, to be heard. When present, it is usually preceded by a churning sound known as the fetal bruit.

The fetal heart-sounds constitute an absolute and unmistakable sign of pregnancy. They may be detected as early as the third month, although usually not until the fifth month; from this time they grow steadily in intensity as the fetus develops. They simulate the muffled ticking of a watch placed under a pillow. The rate is about twice that of the maternal heart-beat, or from 120 to 160 beats a minute. This sign may be absent or indistinguishable in women with very fat abdominal walls, in hydramnion, when there is an excessive amount of flatus in the intestines, or when the fetal back is directed posteriorly, the sounds being most distinct over the dorsum of the fetus. Commonly they are best heard at a point below the level of the umbilicus, and to the right or left, according to the position of the fetal back (Fig. 5).

GENERAL SYMPTOMS.

Certain urinary changes are noted in gestation, none of which, however, is of positive diagnostic value. Frequency of micturition and vesical irritability are common, and are valuable presumptive signs of early gestation if taken in connection with menstrual suppression and moderate uterine enlargement. The presence of kiestein, or the formation of a fatty pellicle upon the urine which has been allowed to stand for some hours, at one time regarded as of special diagnostic value, is now known to bear no relation whatever to pregnancy.

Pressure exerted by the tumor of pregnancy upon the sacral plexus of nerves is common during the later months, and may be productive of intense neuralgic attacks or of the so-called "dead limbs." These manifestations may follow the pressure exerted by any pathologic growth.

Pigmentation of the face, forming the so-called chloasmata, liver-blotches, or liver-patches, is common in women of dark complexion. The discoloration is most marked upon the forehead and cheeks and around the eyes. If general over the face, it constitutes the mask of pregnancy. Such a condition may be present during menstruation and in association with uterine and ovarian disease.

Nausea and vomiting, the well-known "morning-sickness" of pregnancy, is a valuable reflex symptom, dependent upon irritation of the peripheral uterine nerves consequent upon progressive stretching of the uterine muscular fibers. It may immediately follow conception, although it usually does not appear until the sixth or seventh week. One-third of all pregnant women do not suffer from this symptom

(Giles), and, again, it may be produced by many conditions other than pregnancy. If it occur, it presents itself in 70 per cent. of the women in the first month, very rarely in the fifth and seventh months, and seldom in the second, third, or fourth month. Its duration varies from a few days to throughout the entire pregnancy, but it is rarely protracted beyond the fourth month. The nausea may be slight or severe, and generally appears immediately on rising-hence its popular name. It may occur, however, at any time during the twenty-four hours, and especially after the ingestion of food. Other conditions that may produce nausea and vomiting are uterine displacements, uterine tumors, endometritis and metritis, chlorosis, gastro-intestinal disease, ovarian and tubal disease, and menstrual retention from atresia.

Alterations of disposition and other nervous phenomena may become prominent symptoms of gestation, and are strongly suggestive because of their unwonted presence. A fretful, irritable, or moody change will be noted, and this may be associated with the morbid craving for strange and disgusting articles or for certain kinds of food. There may be noted an unusual tendency to syncope and fainting fits. Neuralgic pains are of frequent occurrence, especially Beccaria's signan intense pulsating pain in the occipital region. Owing to the increased amount of circulating fluid with compensatory hypertrophy of the left ventricle, the woman's pulse generally becomes somewhat accelerated, reaching not infrequently 90 or 94 beats a minute, and this may be associated with an annoying sensation of throbbing and palpitation. The cardiac symptoms are dependent upon the hydremic condition of the blood. During pregnancy the entire glandular system of the body shows increased functional activity. This is especially noticeable in the salivary glands, which may throw out an abundant watery secretion (the salivation of pregnancy).

Finally must be noted an important series of mammary changes which are strongly suggestive of the existence of pregnancy, although not absolutely diagnostic. These changes are all peculiarly well marked in primiparæ, and include general enlargement and bagginess of the organs; enlargement of the glands of Montgomery; the deposit of pigment around the nipples; the development of colostrum ; erectility of the nipples; tortuosity of the superficial veins; and pricking sensations around the nipples. The pigmentation assumes the form of areolæ surrounding the nipples, and are most prominent in brunettes. The colostrum is a very valuable sign, and consists of a serolactescent fluid appearing during the third month and persisting until the third day of the puerperium. The enlargement of Montgomery's glands results in the formation of tubercles clustering around the nipples and strongly suggesting advancing gestation. The presence of milk or milky fluid is not an absolute proof of gestation, since it has been noted in the breasts of males and in young and unimpregnated women. Again, the absence of mammary changes does not contraindicate the existence of pregnancy.

THE DIAGNOSIS OF PREGNANCY.

The diagnosis of pregnancy will be made by reference to the signs just enumerated, many of which will be present in any given case. While considered separately some of these signs would not be absolutely diagnostic, when taken in combination with others a fairly presumptive diagnosis of gestation may be made. After the date of quickening the presence of the positive signs will make the diagnosis absolute. The signs to be looked for will naturally vary with the period of pregnancy to which the woman has advanced.

For convenience in examination, pregnancy is universally divided into three three-months' periods or trimesters, each of which has its own peculiar manifestations. Thus, one would not look for the positive signs prior to distention of the abdominal walls-that is, in the first trimester. In the first half of the first trimester an absolute diagnosis is not possible. There are present, however, in the first trimester, the two most important subjective signs of pregnancy: namely, menstrual suppression and nausea and vomiting. Associated with these will be found the vesical irritability, the increase in the anteroposterior diameter of the uterine body, the mammary changes, and the four soft signs: namely, the softened cervix, the soft and boggy uterine fundus, the softened lower uterine segment, and the softened and enlarged mammæ. The coexistence of these signs will be strongly presumptive of an existing gestation.

In the second trimester of pregnancy-the fourth, fifth, and sixth months-there will be developed the positive signs of the condition. Thus, by the beginning of the fourth month Jacquemin's sign (blue discoloration of the vulva and vagina) will be well marked, and Braxton Hick's intermittent uterine contractions may be detected; by the middle of the fourth month ballottement may be elicited, and quickening occurs shortly afterward; and by the beginning of the fifth month it is possible to detect the fetal heart-sounds.

In the third trimester the fetal presentation may be ascertained by vaginal exploration, and abdominal palpation will disclose the fetal outlines.

Another interesting series of correlated subjects will now arise. One of the parties in a question at law may be a young girl, presumably too young for the question of gestation to arise; or, on the other hand, she may be an elderly woman well beyond the usual date of the menopause. Thus, it may be inquired, How early is gestation possible, or what is the latest period at which pregnancy has been noted? Again, is it possible for a woman to become pregnant without a consciousness of the fact at the time of conception? Can she be pregnant any length of time and yet be unaware of her condition? Again, is there any reason why the woman should endeavor to conceal an existing pregnancy; or is there, on the other hand, anything to be gained by her by feigning to be in the pregnant state?