A System of Midwifery Part 6

PART II

NATURAL PREGNANCY AND ITS DEVIATIONS.

CHAPTER I.

SIGNS OF PREGNANCY.

_Difficulty and importance of the subject.--Diagnosis in the early months.--Auscultation.--Changes in the vascular and nervous systems.--Morning sickness.--Changes in the appearance of the skin.--Cessation of the menses.--Areola.--Sensation of the child's movements.--"Quickening."--Ausculation.--Uterine souffle.--Sound of the foetal heart.--Funic souffle.--Sound produced by the movements of the foetus.--Ballottement.--State of the uterine.--Violet appearance of the mucous membrane of the v.a.g.i.n.a.--Cases of doubtful pregnancy.--Diagnosis of twin pregnancy._

There is, perhaps, no subject connected with midwifery, which is of such importance, or which, from its difficulty and the serious questions it involves, demands such attentive consideration, and requires so familiar an acquaintance with every part of it, as the diagnosis of pregnancy. The responsibility which a medical man incurs in deciding cases of doubtful pregnancy, and in thus giving an opinion which may not only affect the fortune, happiness, character, but even life itself of the individual concerned, is rendered more painful by the perplexing obscurity of the circ.u.mstances under which these cases sometimes occur, being not unfrequently complicated with diseases which add still farther to the difficulty of coming at the truth, and occasionally rendered peculiarly obscure by wilful and determined falsehood and duplicity.

To render this subject more intelligible to our readers, we propose first to consider the general effects which pregnancy produces upon the system, and then to describe those changes and phenomena which are _peculiar_ to this state, and which may therefore be taken as so many means of diagnosis.

Under all circ.u.mstances, the diagnosis of pregnancy must ever be difficult and obscure during the early months; the development of the uterus is still inconsiderable, and the effects which it may have produced upon the system, although appreciable and even distinct, are nevertheless too capable of being also produced by other causes, to warrant our drawing any decided conclusion from them.

The effects over the whole animal economy, which result from the presence and advance of this great process, are very remarkable, and show themselves in every portion of it.

The vascular system undergoes a considerable change; the actual quant.i.ty of blood in the circulation appears to be increased; the pulse is harder, stronger, and more full; in many instances the blood, when drawn, exhibits the buffy coat, as in cases of inflammation; the v.a.g.i.n.a is more vascular, it is warmer, and the secretion of mucus considerably increased; there is a disposition to headach, and occasional flushing of the face; the animal heat over the whole body is increased. In the nervous system we also observe distinct evidences of a change having taken place: the irritability is increased; there is weariness, la.s.situde, and a peculiar alteration of taste and disposition; women, who otherwise are of a cheerful disposition, are now gloomy and reserved, and _vice versa_; in some the temper becomes fretful and hasty, and in those who are naturally so, a most agreeable change for the better is sometimes observed.[30] Some are liable to spasmodic affections, palpitations, spasmodic cough, vomiting, fainting, headach, toothach, &c.: under this head will come the "morning sickness," which is so commonly observed during the first weeks; the nature and treatment of which will be considered under the DISEASES OF PREGNANCY; on the other hand, women who are constantly suffering from spasmodic affections, for instance, asthma, &c. are now entirely free from them, and appear to be insensible to causes which, in the unimpregnated state, would induce an attack. To changes in the nervous system must we, in great measure, attribute not only the sickness just mentioned, but also those extraordinary longings or antipathies for certain articles of food or drink, and in some cases, as in chlorosis, for substances which, under other circ.u.mstances, would excite disgust. In many, the changes in the function of the digestive apparatus does not amount to actual disease, the stomach merely refusing to digest articles of food which before had agreed with it: but in others, producing severe cardialgia, acidity, or even vomiting. Hence, we not unfrequently observe that women who had hitherto enjoyed a good digestion, now suffer from dyspepsia, and are obliged to be exceedingly careful in their diet; whereas those, in whom the digestion had been previously weak, are now able to digest almost any thing. The secretions of the whole alimentary ca.n.a.l are altered both in quality and quant.i.ty; the saliva frequently becomes tenacious, white, and frothy (_Dewees_,) and at times is so much increased in quant.i.ty as to amount to actual salivation; the secretions of the stomach are remarkably altered, as shown by the copious formation of acid in some cases during pregnancy; the mucus is ropy, and frequently vomited up in considerable quant.i.ties.

The bowels are in some cases much relaxed; in others, constipated. This latter condition, however, may in part be attributed to the pressure of the gravid uterus obstructing the peristaltic motion.

The changes in the appearance of the skin during pregnancy are also worthy of notice. Women, who are naturally pale and of a delicate complexion, have frequently a high colour, and _vice versa_; in some the skin a.s.sumes a sallow or cadaverous hue; copper-coloured blotches appear on the face and forehead: in others the skin appears loose and wrinkled, giving the patient an aged haggard expression, and destroying her good looks. Mole spots become darker and larger, and these, with a dark ring beneath the eyes and the changes already mentioned, combine to alter the whole appearance of the face. In some women a considerable quant.i.ty of hair appears in those parts of the face where the beard is seen in the other s.e.x; it disappears after labour, when the skin resumes its natural functions, but returns on every succeeding pregnancy. In others a similar appearance takes place upon the b.r.e.a.s.t.s. The secretions of the skin are more or less altered; women who perspire freely have now a dry, rough skin; whereas those who at other times have seldom or never a moist skin, have copious perspiration, which is not unfrequently of a peculiarly strong odour. Cutaneous affections, also, which have been very obstinate, or had even become habitual, sometimes disappear, or at least are suspended during the period of utero-gestation. Similarly favourable changes are observed for a time in severe structural diseases of certain organs: the fact of well-marked phthisis apparently disappearing whilst pregnancy lasts, is well known.

The b.r.e.a.s.t.s become larger, blue veins are seen ramifying beneath the skin, and the circular disc of rose-coloured skin which surrounds the nipples becomes remarkably changed in colour, &c.; appearances, the description of which we shall defer until we come to the consideration of those phenomena produced by pregnancy, which may be looked upon as diagnostic.

The urine undergoes various changes; it is sometimes considerably increased, at others it is very high-coloured, or shows a peculiar milky sediment. A case has been quoted by Dr. Montgomery from Professor Osann's _Clin. Rep._ for 1833, p. 27., where the patient in three successive pregnancies was affected with diabetus mellitus, which each time completely ceased on delivery, and again returned when she became pregnant. None of the changes above enumerated excepting of those of the b.r.e.a.s.t.s, whether taken separately or conjointly, will enable us to form a correct diagnosis as to the existence of pregnancy. The appearance and feel of the abdomen during the early months afford no sure data: in fact, there is not a single symptom of pregnancy at this period, upon which we can rely with any degree of certainty.

_Cessation of the menses._ One of the most remarkable changes produced by pregnancy, and one which most constantly appears, is the cessation of the menstrual discharge. From its occurring so uniformly and so soon after conception, it is generally used by women as the best means of reckoning the duration of their pregnancy: still, however, it is very far from being a certain sign, and never can be depended upon by itself in forming our diagnosis. It is well known how many causes produce suppression of the catamenia, independent of pregnancy; and, on the other hand, ample experience has shown that suppressed catamenia are by no means a necessary consequence of pregnancy.

Although the fact has been contradicted by men of experience, still the regular appearance of the menses for the first few months of pregnancy is of such frequent occurrence as to place the matter beyond all doubt: in stating this, we do not allude to occasional discharges of blood from the v.a.g.i.n.a, but to regular periodical appearances of fluid distinctly bearing all the characters and peculiarities of the catamenia. This fact has been noticed so long ago, as by Mauriceau, who says, "I know a woman who had four or five living children, and who had with every child her menses from month to month, as at other times, only in a little less quant.i.ty, and was so till the sixth month, yet notwithstanding she was always brought to bed at her full time."[31]

It is rare, however, to meet with the catamenia at so late a period, although cases do now and then occur where it lasts throughout pregnancy; more frequently it does not continue beyond the third or fourth month. The source of this discharge appears to be from the vessels of the upper part of the v.a.g.i.n.a[32] and from the cervix uteri;[33] the gradually shortening of the latter as pregnancy advances may be considered as the reason why, in the majority of instances, the discharge diminishes after the second or third month, and usually ceases by the fifth or sixth. Dr. Dewees supports the same opinion with some excellent observations which are worthy of attention. "We are" says he "acquainted with a number of women who habitually menstruate during pregnancy until a certain period, but when that time arrives it ceases: several of these menstruated until the second or third months, others longer, and two until the seventh month; the last two were mother and daughter. We are certain there was no mistake in all the cases to which we now make reference. First, they (the menses) were regular in their returns, not suffering the slightest derangement from the impregnated condition of the uterus; 2. they employ from two to five days for their completion; 3. that the evacuation differed in no respect from the discharge in ordinary, except that they did not think it so abundant; 4. there were no coagula in any one of these discharges, consequently it could not be common blood of haemorrhage; 5. in the two protracted cases, the quant.i.ty discharged regularly diminished after the fourth month, a circ.u.mstance perhaps not difficult of explanation." (_Compendious System of Midwifery_, -- 235.)

It occasionally happens that the first appearance of the catamenia after conception is more abundant than usual, a circ.u.mstance which had been noticed by Dr. W. Johnson in 1769, and confirmed by Dr. Montgomery in his admirable work on the signs of pregnancy, who also confirms the general fact of the menses occasionally appearing during pregnancy by his own experience, and by very ample references. (_Op. cit._ p. 46.)

The rarest and most extraordinary deviation of this kind from the usual course of things is the appearance of the menses _only during pregnancy_.

Cases of this sort have been recorded by authors of the highest respectability, so that there can be no doubt as to the correctness of their statements. Thus, for instance, Baudelocque says, "I have met with several women, who a.s.sured me that they had not had their menses periodically except during their pregnancies; their testimony appeared to me to deserve more credit, because they only applied for an explanation of this extraordinary phenomenon."[34]

By far the most interesting and detailed case of this nature is one described by Dr. Dewees. "A woman applied for advice for a long standing suppression of the menses; indeed she never had menstruated but twice. She had been married a number of months, and complained of a good deal of derangement of stomach, &c. We prescribed some rhubarb and steel pills; about six months after this she called to say that the medicine had brought down her courses, but that she was more unwell than before. The sickness and vomiting had increased, besides swelling very much in her belly; we saw this pretty much distended and immediately examined it, as we suspected dropsy; but from the feel of the abdomen, the want of fluctuation and the solidity of the tumour, we began to think it might be pregnancy, and told the woman our opinion. On mentioning our impression she submitted to an examination per v.a.g.i.n.am; this proved her to be six months advanced in pregnancy. After this she had the regular returns of the catamenial period, until the full time had expired; during suckling she was free from the discharge. She was a nurse for more than twelve months; she weaned her child, and shortly after was again surprised by an eruption of the menses, which as on a former occasion proved to be a sign of pregnancy." (_Op. cit._ -- 237.)

There are other circ.u.mstances also connected with the catamenia, which warn us against placing too much confidence in its disappearance as a sign of pregnancy: a woman may become pregnant who has never menstruated, a fact which has been noticed by several authors, and which has been explained as well as confirmed by Levret in his _Art des Accouchemens_, -- 230:--"A woman," says he, "may conceive, although she has not yet menstruated, provided menstruation would otherwise have made its appearance shortly."[35]

Another circ.u.mstance, of much more frequent occurrence, is the fact that a woman may become pregnant without having had a return of the menses since her last confinement; hence we occasionally meet with cases where, from a rapid succession of pregnancies, the menstruation has not appeared for several years. From what has now been said, it will be seen, beyond all doubt, that the non-appearance of the menses cannot be looked upon by itself as a diagnostic of pregnancy, or _vice versa_: this is more particularly the case when any morbid condition of the system is also present; under such circ.u.mstances, little or no confidence can be placed upon it as a guide in forming our diagnosis. In cases where it is an object to conceal pregnancy, the appearance of the menstrual fluid upon the clothes has been imitated in order to deceive. (Montgomery, _op. cit._ p. 50.) Although, therefore, the cessation of the menses, when taken in connexion with other symptoms, will prove useful in a.s.sisting us to a correct opinion, nevertheless, when taken by itself, it will scarcely ever enable us to decide with certainty.

_Areola._ Among the earliest of those symptoms which must be considered as diagnostic are the changes observed in the appearance of the b.r.e.a.s.t.s; "they increase, become full; they are occasionally painful and grow hard: the veins in them are rendered conspicuous from their blue colour; the nipple becomes more bulky and appears inflated, its colour becomes darker, the surrounding disc undergoes a similar change, increases in extent, and is covered with little prominences like so many diminutive nipples."[36]

"The several circ.u.mstances (says Dr. Montgomery, p. 59,) here enumerated at least ought in all cases to form distinct subjects of consideration, when we propose to avail ourselves of this part as an indication of the existence or absence of pregnancy. One other, also, equally constant and deserving of particular notice, is a soft and moist state of the integument, which appears raised and in a state of turgescence, giving one the idea that if touched by the point of the finger it would be found emphysematous. This state appears, however, to be caused by infiltration of the subjacent cellular tissue, which together with its altered colour, gives us the idea of a part in which a greater degree of vital action is going forward than is in operation round it, and we not unfrequently find that the little glandular follicles, or tubercles, as they are called by Morgagni, are bedewed with a secretion sufficient to damp and colour the woman's inner dress.

These changes do not take place immediately after conception, but occur in different persons after uncertain intervals. We must therefore consider, in the first place, the period of pregnancy at which we may expect to gain any useful information from the condition of the areola. I cannot say positively what may be the earliest period at which this change can be observed, but I have recognised it fully at the end of the second month, at which time the alteration in colour is by no means the circ.u.mstance most observable; but the puffy turgescence, though as yet slight, not alone of the nipple, but of the whole surrounding disc, and the development of the little glandular follicles, are the objects to which we should princ.i.p.ally direct our attention, the colour at this period being in general little more than a deeper shade of rose or flesh colour, slightly tinged occasionally with a yellowish or light brownish hue.

During the progress of the next two months the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion.[37]

The extent of this circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of the colour."[38]

"In the centre of the coloured circle the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part of it which lies more immediately around the base of the nipple, is studded over, and rendered unequal by the prominence of the glandular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and lastly the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed at this period, especially in women of dark hair and eyes, numerous round spots, or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all round, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part. I have not seen this appearance earlier than the fifth month, but towards the end of pregnancy it is very remarkable, and const.i.tutes a strikingly distinctive character exclusively resulting from pregnancy. The b.r.e.a.s.t.s themselves are at the same time generally full and firm, at least more so than was natural to the person previously, and venous trunks of considerable size are perceived ramifying over their surface, and sending branches towards the disc of the areola, which several of them traverse along with these vessels. The b.r.e.a.s.t.s not unfrequently exhibit about the sixth month, and afterwards, a number of shining, whitish, almost silvery lines like cracks; these are most perceptible in women, who, having had before conception very little mammary development, have the b.r.e.a.s.t.s much and quickly enlarged after becoming pregnant."

In enumerating these various changes which are observed in the b.r.e.a.s.t.s, we fully agree with Dr. Montgomery in saying, that the alteration in the colour of the areola is by no means that upon which we can depend with most certainty: in the first place, we frequently meet with so little discolouration during the earlier months as to be altogether inappreciable; we have also already shown that if the patient be a brunette, and has already had children, the colour of the areola cannot be trusted to, as it never entirely disappears after her first pregnancy. On the other hand, we occasionally meet with a considerable change of colour in the unimpregnated state, arising from uterine irritation, as in dysmenorrhoea, &c. Where, however, this is accompanied by the other changes above enumerated, there can be, we apprehend, no doubt as to the existence of the pregnancy. Dr. Smellie, and also Dr. W. Hunter both considered the areola as proof positive of pregnancy. The latter one decided upon a case of pregnancy under very extraordinary circ.u.mstances; the body of a young female was brought into the dissecting room, which at the first glance he p.r.o.nounced to be pregnant, but the accuracy of his diagnosis was not a little doubted when it was ascertained that a perfect hymen was present: to decide the point he had the abdomen opened when the uterus was found to contain a small foetus.

_Movements of the foetus._ The sensation to the mother of the child moving in the uterus, cannot be looked upon as a certain sign of pregnancy, for even women who have had large families of children are frequently deceived in this respect by the movement of flatus in the intestines, by occasional spasmodic twitchings of the abdominal muscles, &c.; but when the motion of the child can be distinctly felt by the hand of an experienced pract.i.tioner, it will no longer admit of any doubt: this, however, is a symptom which can seldom be made use of before the middle of the sixth or seventh month.

_Quickening._ This leads us to the subject of quickening as a symptom of pregnancy. The very vagueness of the term _quickening_ is of itself a sufficient objection to its use as a source of information on these points. Strictly speaking, it refers to that moment of pregnancy when the woman is supposed to have become _quick with child_, or in other words, when the foetus becomes endued with life, "an error," as Dr. Montgomery observes, "which the continued use of the term was obviously calculated to foster and to prolong" (p. 75.) As far as we can understand, the word "quickening" at the present day refers to two different events during pregnancy: the one is when the motion of the child first becomes perceptible to the mother; the other consists of those effects which are frequently observed when the uterus quits the pelvis, and rises into the abdominal cavity, viz. fainting, sickness, &c.; in either case it will be evident that no correct conclusion can be formed by this means. It may safely be a.s.serted that until the last twenty years we possessed only three diagnostic marks of pregnancy, viz. the appearance of the areola, a series of changes but little understood; the being able to feel the movements of the child through the abdominal parietes, and the head of it per v.a.g.i.n.am. Hence Dr. W. Hunter in describing the uncertainty of the signs of pregnancy says, "I find I cannot determine at four months, I am afraid of myself at five months, but when six or seven months are over, I urge an examination."

In the primipara, the changes which pregnancy produces upon the os and cervix uteri are generally sufficient to lead to an accurate conclusion.

The round dimple-like depression which the os uteri forms, the soft cushiony state of the cervix, are changes which we consider as peculiarly the effects of pregnancy, but their distinctness and certainty ceases when the patient has had several children; the irregular shape of the os uteri, its thickened edges, hard here and there, and the os tincae, itself more or less open, the cervix scarcely, if at all, shortened, even at a late period of gestation, tend not a little to perplex the diagnosis furnished by this mode of examination; and where disease is complicated with pregnancy, the difficulty is greatly increased, and not unfrequently so much, that scarcely a single satisfactory point will be obtained.

_Auscultation._ Of late years, an immense advance has been made in the diagnosis of pregnancy, by means of the stethoscope. M. Major of Geneva,[39] in 1819, observed the interesting fact that he could hear the pulsations of the foetal heart through the parietes of the mother's uterus and abdomen: he appears, however, to have carried his researches no farther; and little attention was excited to the circ.u.mstance until three years afterwards, when a masterly essay on the subject was read before the Academie Royale de Medecine of Paris, by Lejumeau de Kergaradec.[40] In this interesting memoir, the author has described two sounds, which are perfectly distinct from each other in point of character. One of them consists of single pulsations, synchronous with those of the mother's heart, accompanied with the deep whizzing rushing sound, which may be heard over a large portion of the uterus at once; the other of sharp, distinct, double pulsations, producing a ticking sound, and following a rythm, which is not synchronous with that of the maternal circulation.

Kergaradec supposed that the former sound was produced by the circulation of the blood in the spongy structure of the placenta, and hence called it the _souffle placentaire_; later observations[41] have, however, shown that it is not connected with the placenta, but depends upon the increased vascularity and peculiar arrangement of the uterine vessels during the gravid state. The other sound is produced by the pulsations of the foetal heart.

_Uterine souffle._ The uterine sound, or _souffle_, may invariably be heard in one or other of the inguinal regions, and usually over a considerable portion of the uterus, extending anteriorly or along the sides of the organ; and according to the observations of Professor Naegele jun.,[42] there is no part of the uterus, capable of being osculted, in which this sound may not be heard. He considers that the souffle, which is so uniformly heard in the lower parts of the uterus, especially in the inguinal regions, seems to be produced by the uterine arteries before they enter the uterus; these vessels, as soon as they arrive at the broad ligament, a.s.sume a different character, become larger than they were on branching off from their original trunk, and are much contorted before entering the parietes of the uterus. Dubois first pointed out the similarity which exists between the sound heard in the gravid uterus, and that of aneurismal varix, where there is a direct pa.s.sage of blood from an artery into a vein: the sound in this latter condition is produced by the current of blood rapidly issuing from the dilated artery, and mixing with the slower flowing stream of the dilated vein. The circulation of blood in the dilated arteries of the uterus present a considerable resemblance, in many respects, to that of the above-mentioned disease.

That the uterine sound is not confined to that part of the uterus where the placenta is attached, as was supposed by Professor Hohl,[43] is proved by the fact that we can frequently hear it in two different and sometimes opposite parts of the uterus at the same time, which, if his opinion be correct, would indicate the presence of twins; and yet the result of labour has proved that the uterus has contained but one child, and that the placenta had neither been attached in the one or other of these situations. The very circ.u.mstance which we have already mentioned, of this sound being invariably heard in one, if not in both, of the inguinal regions, shows that it is independent of the vicinity of the placenta; nevertheless, it must be allowed, that as the uterine vessels undergo the greatest degree of development at this part, the sound will usually be at least as distinct here as in any other portion of the uterus.

The uterine souffle is the first sound which auscultation detects during pregnancy; it may be heard as early as the fifteenth or sixteenth week, but cases now and then occur where it has been even distinguished in the thirteenth or fourteenth week, and Dr. Evory Kennedy, has given some very interesting examples where he was able to hear it with certainty at the twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy, _op. cit._ p. 80.) During these earlier periods, the sound is weaker, but extends over the whole uterus, from the diminutive size of which it can be heard most readily immediately above the symphysis pubis; in fact, there is every reason to suppose, that the uterine souffle might be detected at a still earlier period, if the uterus were at this time within reach of the stethoscope. As pregnancy advances, it becomes more distinct and powerful, and is occasionally so to a remarkably degree. During the latter periods of pregnancy, it frequently presents considerable modifications of tone, especially where there is general or local vascular excitement, as in cases of fever, or dispositions to haemorrhage, where the vessels are usually distended, or where (Naegele, _op. cit._ p. 86,) the placenta is situated near the os uteri, it a.s.sumes a piping, tw.a.n.ging sound of considerable resonance: the same is also observed where, either from the weight of the gravid uterus or any other cause, pressure has been exerted on any of the main arterial trunks: hence, as we shall show more fully when speaking of labour, a remarkable change is produced in the tone of the uterine souffle by the first contractions of that process. The causes of these modifications are not always very easily explained; we sometimes observe the souffle on the same side of the uterus vary rapidly in its degree of intensity, and occasionally even disappear for awhile without our being able to a.s.sign any satisfactory reason for such changes.

The uterine souffle taken by itself, although a very valuable sign of pregnancy, can scarcely be looked upon as one which is perfectly certain and diagnostic, since a similar sound may be produced by aneurism of the abdominal aorta and its large branches: there is much reason to think that the uterus, enlarged from other causes than that of pregnancy, and pressing upon the iliac arteries, will produce a similar sound. Professor Naegele, jun., has also shown that the sounds of the patient's heart may sometimes be heard very low in the abdomen, even as far as the ossa ilii, a circ.u.mstance which seems to have depended upon the sound being transmitted through the intestines distended with flatus. Where any of these causes of abdominal souffle have existed in connexion with suppressed catamenia, swelling of the b.r.e.a.s.t.s, &c., we might be liable to be deceived if we allowed ourselves to be entirely guided by this sound.

With regard to the foetal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the foetus appears to have no effect upon their rapidity, for even at the earliest periods at which we can detect these sounds the rate of the pulsation is the same as at the full term of pregnancy.

Although Dr. Kennedy has in a few cases detected this sound even before the expiration of the fourth month, it will not in the majority be possible until a later period. "At the fourth month it frequently requires not only close attention, but considerable perseverence to detect the foetal heart; and at this period it has occurred to us to examine patients whom there was strong reason to suppose pregnant, and after spending a considerable time in endeavouring to detect this sound, we have been on the point of giving up the search as hopeless, when it has been suddenly discovered in the identical spot that had before perhaps been explored without success." (Kennedy, _op. cit._ p. 101.)

The sound of the foetal heart is usually heard at about the middle point between the scrobiculus cordis and symphysis pubis, usually to one side, and that, generally speaking, the left. The extent of surface over which the sound may be heard varies a good deal, and depends, in great measure, on the distance which intervenes between the foetus and stethoscope; hence, when the uterus is distended with a large quant.i.ty of liquor amnii, or when the uterine and abdominal parietes are very thick, it is heard over a much larger s.p.a.ce, although with diminished intensity; on the other hand, when there is but little liquor amnii in the uterus, it is audible over a small portion only, but is remarkably distinct: this is peculiarly the case during labour after rupture of the membranes. The rapidity and strength of the foetal pulsations appear to be entirely independent of the mother's circulation; violent exercise, spirituous liquors, &c., which will raise her pulse to a considerable degree, have no influence whatever on the foetal pulse. In cases of fever, where the mother's pulse has ranged between 110 and 120, and even higher, not the slightest change was observable in the sound of the foetal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnoea, and also in tubercular phthisis; in cases where the patient has been bled; in cases of menstruation during pregnancy; and even in severe flooding, and when the mother's pulse has been greatly reduced, no perceptible change has been observed in that of the foetus. (Naegele, _op.

cit._ p. 39.) Dr. Kennedy has observed some remarkable cases where the foetal pulse appeared to vary in accordance with that of the mother (_op.

cit._ p. 91;) but when we bear in mind the frequent changes in point of rapidity, &c., to which the foetal heart is subject, independent of any thing of the kind in the mother's pulse, and that similar changes are constantly observed in the child shortly after birth; and, moreover, that very considerable acceleration of the maternal pulse has decidedly no effect upon that of the foetus in many well-marked instances, we cannot agree with him in supposing that a connexion of the sort to which he has alluded exists. The double pulsations of the foetal heart can only be heard at one point of the uterus at a time, provided there be but one child; but if there be twins, then the sound is heard in two places at once. It has been supposed by some authors (_Dubois_) that the heart of the second child could not be distinctly heard until labour, when the membranes of the first child had ruptured. Generally speaking, both sounds can be heard pretty distinctly during the last weeks of pregnancy, one of them being low down on one side, and the other high up in an opposite direction. Although in some twin cases there is an evident difference of rhythm between the two foetal hearts, still in many others they are so nearly synchronous as to be scarcely if at all distinguishable in this respect. Hence, therefore, from the known variable character of the foetal pulse, it will be necessary that the sound of each heart should be ausculted at the same moment, minute for minute, by two observers, and thus the slightest appreciable difference between them determined.

_Funic souffle._ Dr. Kennedy has shown that, where a portion of the umbilical cord pa.s.ses between the child's body and the anterior wall of the uterus, or crosses any of its limbs or other projections, pulsations are heard synchronous with those of the foetal heart; although not possessing the same characters. "In some cases where the uterus and parietes of the abdomen were extremely thin, I have been able," says Dr.

K., "to distinguish the funis by the touch externally, and felt it rolling distinctly under my finger, and then, on applying the stethoscope, its pulsations have been discoverable remarkably strong; and, on making pressure with the finger for a moment on that part of the funis which pa.s.sed towards the umbilicus of the child, I have been able to render the pulsations less and less distinct, and even, on making the pressure sufficiently strong, to stop it altogether." (_Op. cit._ p. 121.) In many cases where the umbilical arteries, by their convolutions round a limb, or by any other cause, are subjected to slight pressure, a distinct whizzing sound is produced, which is called by Dr. Kennedy the _funic souffle_.

The sound of the foetal heart must be looked upon as a sign of the highest value in the diagnosis of pregnancy, since, however complicated and obscure the other symptoms may be, whether from co-existing disease, wilful deception, &c. if this sound be once heard unequivocally, the real nature of the case is satisfactorily established beyond all possibility of doubt.

Another sound in the gravid uterus has been lately noticed by Professor Naegele, junior, which promises to equal that of the foetal heart, as a certain diagnostic of pregnancy, and must be looked upon as a valuable addition to our means of ascertaining the truth in cases of this sort. The movements of the foetus may be distinguished by the stethoscope at a very early period of pregnancy, long before they are perceptible to the hand of the accoucheur, and in many cases before the patient has been aware of them herself. According to Professor Naegele's observations, these sounds may usually be heard some little time before the foetal heart is audible, and are sounds which can neither be feigned nor concealed: they can only be heard in the gravid uterus, and under no other circ.u.mstances.

Although the sounds of the heart and movements of the foetus are unequivocal proofs of pregnancy, which may be heard at a very early period, still it must, in some degree, remain uncertain at this time, how far their absence can be looked upon as a proof of its non-existence.

Under such circ.u.mstances, the examinations require to be conducted with the greatest possible care, and to be repeated at favourable opportunities, until no doubt as to the correctness of their results can any longer exist.

The soft cushiony feel of the cervix uteri is a change produced by pregnancy, which, in our opinion, has not received that attention which it deserves; as far as we are able to judge, this condition of the cervix is peculiar to pregnancy, and exists very shortly after conception. We occasionally meet with a soft flaccid state of the os and cervix uteri in certain diseases; but the feel which this communicates to the finger is very different to that above-mentioned, which resembles more the elastic inflated condition of the nipple during pregnancy, than any thing to which we can compare it.

_Ballottement._ At the beginning of the seventh month we shall be able to feel the head of the foetus upon examination per v.a.g.i.n.am. If we direct our finger against the uterus, midway between the os uteri and symphysis pubis, and suddenly exert a slight degree of pressure, we shall become sensible of having struck against something hard within the cavity of the uterus; upon repeating the experiment immediately, we shall probably not feel it, the foetus having risen in the liquor amnii to the upper parts of the uterus; but if hold our finger still for a few moments, it will, by this time, have again descended, and we shall again feel it; at other times, when the foetus is larger and heavier, the head will rest like a light ball, on the tip of the finger, from which circ.u.mstance it has received the name of _ballottement_ by the French authors.