SIGNS OF PREGNANCY. 511 PREGNANCY. CHAPTER XLIV. SIGNS OF PREGNANCY.-SUPPRESSION OF THE MENSES. QUICKENING.-SOUNDS OF THE FOETAL HEART.-FEIGNED PREGNANCY.-CONCEALED PREGNANCY.-PREGNANCY IN THE DEAD.-IMPREGNATION IN A STATE OF UNCONSCIOUSNESS.-LEGAL RELATIONS. SIGNS OF PREGNANCY. Suppression of the Menses.-It is well known that, in the greater number of healthy women, so soon as conception has taken place, this secretion is arrested. But there are certain abnormal conditions which must not be overlooked. There are some cases recorded which show that women in whom the menses have never appeared may become pregnant. This, however, is allowed by all accoucheurs to be rare; and, when it occurs, which we may readily learn from the account of the woman, it will be necessary to search for other signs in order to determine the fact of pregnancy. Irregularity as to the period at which the function takes. place is common among females. This irregularity may depend upon the age of the person, or upon disease, either of which causes it will not be difficult to recognize. The continuance of the menses after conception may make a pregnancy appear short. A case is reported in which a woman was married in the summer of 1856, and the menses continued after as before marriage. In Oct. 1857, they ceased for the first time, and in the following December the woman was delivered of a full-grown child: as the abdomen was not much enlarged, she thought that she was only two months pregnant. (New York Jour., 1859, p. 286.) There are numerous disorders of the womb under which, irrespective of pregnancy, the menses may become suppressed. The continuance of the menstrual discharge, when once set up, is not a necessary condition for impregnation. Murphy has reported the case of a woman who for sixteen years went on bearing children, eight in number, without having had during that period any appearance of the menses. Reid, who quotes this case, mentions five instances that fell within his own knowledge in which females became pregnant notwithstanding a long previous cessation of the discharge. (Lancet, 1853, ii. p. 236.) The absence of the menses as a consequence of pregnancy is generally indicated by the good health which a female enjoys; and although disease may coincide with pregnancy, yet a careful practitioner will be able to estimate from the general symptoms the probable cause to which the suppression is due. On the other hand, a discharge analogous to the menstrual sometimes manifests itself, not merely for several periods in a pregnant woman, but during the whole course of pregnancy. (Murphy's Obst. Rep., 1844, p. 9; also Henke's Zeitschrift der S. A., 1844, p. 265. See Ann. d'Hyg., 1873, t. 2, p. 140.) Whitehead has collected seven well-marked instances of menstruation during pregnancy. (On Abortion, p. 218.) These facts show that we should 512 FEIGNED MENSTRUATION-STATE OF THE BREASTS. be cautious in forming an opinion; we must not assert that, because a discharge continues, pregnancy cannot possibly exist, or, because there is no discharge, a female must be pregnant. The retention of the menses within the womb from any cause may produce enlargement of the abdomen and give rise to some of the external symptoms of pregnancy. Feigned Menstruation. The menses may be either suppressed or retained; but if there be any strong motive for the concealment of her condition, a woman may feign menstruation. Montgomery detected a case of this kind by the examination of the areola of the breasts. The woman had stained her linen with blood in order to make it appear that the menses continued, but she subsequently admitted that this was an imposi tion. There are no certain means of distinguishing between menstrual and ordinary mammalian blood. Prominence of the Abdomen.-A gradual and progressive enlargement of the abdomen is a well-marked character of pregnancy; the skin becomes stretched and the navel almost obliterated. This enlargement in general begins to be obvious about the third month, although there are some women in whom the enlargement may not become perceptible until the fifth or sixth month, or even later; still, it may be detected on examination. In fact, this sign can never be absent in pregnancy, although it may not be so apparent in some women as it is in others. The objection which exists to it is that numerous morbid causes may give rise to prominence of the abdomen. This is undoubtedly the fact, as we have occasion to witness in the various kinds of dropsy, or in suppressed and retained menses diseases which, in several instances, have been mistaken for pregnancy by eminent practitioners. On the other hand, instances are not wanting in which, owing to the persistence of menstruation, and the absence of quickening, the gravid womb has been actually tapped by mistake for an ovarian tumor; the operation being speedily followed by the birth of a child (Whitehead On Abortion, p. 186); but the history of a case will in general enable a practitioner to form a correct opinion. (Ann. d'Hyg., 1873, t. 2, pp. 142 and 144.) A Change in the Breasts.-These organs in a pregnant woman are full and prominent, and the areola around the nipples undergo changes of color which Montgomery and others regard as highly characteristic of the preg nant state. A mere fulness or pain in the breasts, and even in some rare instances the secretion of milk, may arise from other causes than pregnancy. Severe uterine or ovarian irritation or disease may cause the breasts to become painful, swollen, and secrete milk. The fulness of the breasts from pregnancy is not commonly observable until about the second or third month. A more or less transparent fluid is secreted by the glandtissue of the breast, and can be expressed from the nipples. Such cases, however, are not very common; but after a woman has once secreted milk the secretion may be reproduced in the breasts by very slight causes, quite independently of pregnancy. The areola is generally observed during pregnancy to become considerably darker in color and larger in diameter. The skin of which the areola is formed is soft, moist, and slightly tumid. The little glandular follicles about it are prominent, and often bedewed with a secretion: the change of color has been chiefly attended to. The areola are commonly well marked in from the second to the fourth month of pregnancy-the intensity of color being the last condition of the areola to appear. The promi nence of the glandular follicles does not always exist in pregnancy, and the areola may become large and dark-colored from other causes; eonsequently, these signs are only to be looked upon as corroborative. In PROOF OF QUICKENING. 513 females of dark complexion, the areola are naturally dark irrespective of pregnancy; and in some advanced cases these changes in the areola are entirely absent. (Edin. Month. Jour., March, 1848, p. 693.) Montgomery has described as a sign of pregnancy the existence of a brown line extending from the pubes to the navel, especially in women of dark complexion, and a dark-colored but not raised areola of about a quarter of an inch in breadth around the navel; but this also may be produced by uterine or ovarian disease. Quickening. The signs above given are applicable to the early as well as to the late stages of utero-gestation; but that which we have here to consider is one which is rarely manifested until about the fourth or fifth month. Quickening is the name applied to peculiar sensations experienced by a woman about this stage of pregnancy. The symptoms are popularly ascribed to the first perception of the movements of the fœtus, which occur when the womb begins to rise out of the pelvis; and to these movements as well as probably to a change of position in the womb, the sensation is perhaps really due. The movements of the foetus are perceptible to the mother before they are made evident by an external examination. The term is derived from an old Saxon word "quick," signifying living; as, at the time when medical science was in its infancy, it was considered that the fœtus only received vitality when the mother experienced the sensation of its motion. On the occurrence of quickening there is generally a great disturbance of the system indicated by syncope, nausea, and other distressing symptoms. After a short time the woman recovers; and, if sickness has hitherto attended the pregnant state, it has been frequently observed to disappear when the period of quickening has passed. No evidence but that of the woman herself can satisfactorily establish the fact of quickening, and this it is necessary to bear in mind; since, in some cases in which pregnancy is an object of medico-legal importance, proof of quickening may be demanded by law. Reid remarks (Lancet, 1853, ii. p. 237), with respect to this sign, that few women can tell the exact day on which they first feel it; and a large proportion cannot place it within a range of fourteen days, which is of little assistance in the calculation of the probable date of delivery. Women who profess to be most exact in noting the period of quickening differ with each other as to the time. There is much self-deception as to this symptom. The discovery of the movements of a child by an examiner is really a proof that the usual period of quickening is past, but their non-discovery at the time of examination is no proof whatever that the woman has not quickened; since the movements are by no means constant, and may be accidentally suspended even at several successive examinations. Besides, cases occur in which well-formed, healthy women do not experience the sensation of quickening during the whole course of pregnancy; and, what is of more importance, the movements of the child may be at no time perceptible to the examiner. The uncertainty of quickening as a sign of pregnancy is too well known to require more than adverting to. Women have been known to mistake other sensations for it, and in the end it has been proved that they were not pregnant. A woman may declare that she has felt quickening when she has not; and unless the movements of the child are perceived by the examiner at the time, how is he to confirm or disprove her statement? Quickening, then (so far as it concerns the statement of the woman), cannot be relied on as a proof of pregnancy; but if the movements of a child can be felt by the examiner through the abdomen, this is clear evidence, not only of the woman being pregnant, but of her having passed the period of quickening. According to the general experience of 514 SOUNDS OF THE FETAL HEART. accoucheurs, quickening takes place from the tenth to the twenty-fifth week of pregnancy; but the greater number of instances occur between the twelfth and sixteenth week, or between the fourteenth and eighteenth week after the last menstruation. From these observations, it will be seen that an examiner may sometimes detect the movements of the child about the third or fourth month, at others not until the fifth or sixth, and in other instances not at all throughout pregnancy. Ahlfeld found that in forty-three cases in which the day of its occurrence was noted, it ranged from 108 to 134 days-the average being 132.7 days. (Amer. Jour. Med. Sci., Oct. 1870, p. 567.) Even in those cases in which the movements of the child have indisputably existed, they are not at all times to be perceived; hence several examinations should be resorted to before any opinion can be fairly expressed from their absence. The best mode of examining the abdomen for foetal movements is to allow the hand to remain at rest on the abdomen. If the patient has quickened recently, the impulse is slight, and generally at only one spot, which, however, is seldom the same. Should she have advanced further, then the movements will be more rolling, and the parts of the child be detected at the same time. In making these examinations, a diagnosis may be facilitated by previously immersing the hand in cold water and then suddenly applying it to the abdomen. When the movements of the child are distinctly perceived through the skin of the abdomen, they constitute a certain sign of pregnancy; but their non-discovery at a particular time is no proof that a female is not pregnant. The jury of matrons probably trusted to this sign; hence their verdicts commonly turned out to be erroneous. There is another source of fallacy which may present itself when an artful woman is desirous of making it appear that she is pregnant-namely, that a woman may simulate the movements of a child by a peculiar action of the abdominal muscles. Medical practitioners of repute have been deceived for a time by this artifice; but this occurred before the discovery of chloroform and the stethoscope. Sounds of the Fatal Heart.-Another sign is that which is derived from auscultation. By the application of the ear or a stethoscope to the abdomen, at or about the fifth month of pregnancy (rarely earlier), the pulsations of the foetal heart may be recognized and counted. These pulsations are not synchronous with those in the arteries of the mother; they are much more rapid, and thus it is impossible to mistake them. Their frequency, according to Hope, is in an inverse ratio to the stage of gestation, being 160 at the fifth, and 120 at the ninth month. Sometimes, however, the foetal pulse may descend to 80 or even 60 beats in a minute. This sign, when present (like the fœtal movements), not only establishes the fact of pregnancy beyond all dispute, but shows that the child is living. The sound of the foetal heart is, however, not always perceptible; when the child is dead, of course it will not be met with; but its absence is no proof of the death of the child, because the hearing of the pulsations by an examiner will depend very much upon the position of the child's body, the quantity of liquor amnii, the presence of disease, and other circumstances. Thus the sounds may be distinctly heard at one time and not at another; they may be absent for a week or fortnight, and then will reappear; so that, although their presence affords positive evidence, their absence furnishes uncertain negative evidence; and several examinations should be made, in the latter case, before an opinion is formed. The earliest time at which the pulsations may be heard has been stated to be about the fourth month; but they will be best heard after the sixth month. The reason why the sounds of the fœtal heart are not always perceived is CHANGES IN THE MOUTH AND NECK OF WOMB. 515 owing, not only to changes in the position of the child, but to the vibra tions having to traverse the liquor amnii and the soft layers of the skin of the abdomen. The presence of much fat in these layers intercepts them. The point where the sounds can be most readily perceived is in the centre of a line drawn from the navel to the anterior inferior spinous process of the ilium on either side-perhaps most commonly on the right. When clearly detected, they furnish an unequivocal sign of the pregnant state. Besides the sounds of the fœtal heart, there are other sounds to which the name of " placental murmur" or uterine sounds has been given. These are heard from an earlier date, i. e. at any time after the third month. As they may occur in connection with fibroid tumors of the womb, they do not necessarily indicate pregnancy. In reference to these signs of the pregnant state it may be observed that, if the motions of the child or sounds of the heart be perceptible, no other evidence of pregnancy need be sought for. The mere suppression of the menses, prominence of the abdomen, and fulness of the breasts cannot alone establish the fact; but unless the morbid causes of these abnormal states of the system be clearly and satisfactorily obvious to the examiner, it is a fair presumption from these symptoms that the woman is pregnant. In any case in which a doubt exists we should require sufficient time to form a correct opinion. Changes in the Mouth and Neck of the Womb.-The signs hitherto mentioned are chiefly relied on in medical practice; but it must be remembered that no case can occur in civil or criminal jurisprudence in which it will not be in the power of a medical witness to make an examination of the woman. He may then form a safe judgment from the changes which take place in the neck of the womb, and from the sensation imparted to the finger by the presence of a rounded body (like the fœtus) floating in a liquid, when an impulse is given to the womb from below. Up to the fifth or sixth month of pregnancy, the neck of the womb, of its usual length, hard and firm, may be commonly felt projecting into the vagina. After that period, the womb rises into the pelvis, and the neck is spread out and is shorter and softer, the aperture increasing in size and becoming rounder. Towards the end of gestation, the neck of the womb appears to be lost, becoming like a thin membrane, and sometimes no aperture can be felt. A well-marked test of pregnancy is the motion perceptible to the finger on giving a sudden impulse to the child through the neck of the womb. Capuron calls this the touchstone in the distinction of the pregnant state; and, without it, he considers a medical jurist may be easily deceived. To this passive motion of a child the name of ballottement is given. It cannot be easily determined before the fifth or sixth month; but after the latter period, especially as pregnancy becomes advanced, it is always available. In the French schools, the method of applying the toucher and ballottement to pregnant females is systematically taught, and by a little. practice it may be easily acquired. This motion to the child can also be given through the abdomen, by external ballottement, in two ways; either by the patient lying on her side, the hand placed on the most dependent part of the womb, or by placing the patient on her elbows and knees; the womb will then fall forwards, the child also will fall in contact with the front wall of the womb, and its presence thus be made more perceptible. This latter mode is best adapted to the early stages of pregnancy. If we find amenorrhoea or suppressed menses, and a tumor distended to a size consistent with the duration of the amenorrhoea-if the tumor be more or less central, alternately relaxing and contracting, containing an |