CHAPTER I.

DIAGNOSIS OF PREGNANCY.

A few of the early signs of pregnancy are not made available to the physician ordinarily when his opinion is demanded. A woman is naturally unwilling that her physician, if he be a man, should make even a digital examination, and this makes it more necessary that the nurse should know all the rational signs.

One of these signs is the changed color of the mucous membrane of the vagina and labia. This membrane is of a pale red color, but it becomes of a violet hue during the time of menstruation, and if a woman becomes pregnant, the violet or deep red color becomes continuous.

There is also, even in the commencement of pregnancy, a peculiar odor to the secretion from the vagina and os uteri, which has been compared to that of the vernix caseosa.

There is no sign of pregnancy by which we can always distinguish it in its early stages; in some instances nearly all the rational signs are absent. The general condition of a pregnant woman is changed in a greater or less degree, but all are not changed alike.

Generally she is plethoric, the pulse is fuller and quicker; the quantity of circulating fluid is augmented, the quality altered by the increase of fibrine; but these changes are not always obvious. Well marked sympathies are excited in various organs; the nervous system may suffer especially; the woman’s temper and disposition may change; she may become capricious, may have likes and dislikes in eating, especially if her digestion is weak; there may be loss of appetite, heartburn, increased flow of saliva, toothache, excitability of mind, sleepiness, etc.; but even when many of these symptoms are present, even when the liver and kidneys are affected, so that the skin is sallow or discolored in patches, and irritability of the bladder causes much pain and distress, these various signs may only furnish a sum of probabilities amounting _almost_ to certainty.

In some cases of pregnancy the skin, instead of becoming sallow, is more florid, with occasional eruptions on the face.

Some women become fat during pregnancy; others lose flesh; their faces, in the early months, are pinched and pointed, and their features altered.

_Milk in the breasts_, especially in the first pregnancy, is a sign which is said to be reliable; but it is true of some women that, during their period of menstruation, their breasts enlarge; there is a sensation of fullness, with throbbing and tingling pain in them, and that a milk fluid may be secreted; the same symptoms that are present with others at the second month of pregnancy.

Another change is a more marked sign in the breasts. There is at first a soft and moist state of the skin, and the little glandular follicles around the nipples are bedewed with a secretion. This may often be seen at the second month, and it may also be noticed that the veins of the breast look more blue, and that the breasts themselves are firmer and more knotty to the touch.

There are, however, other signs which are more to be depended on than these that have been mentioned.

Females _cease to be regular during pregnancy_. A healthy married woman, during the period of child-bearing, bases her prediction upon this sign, and is seldom disappointed. But women are not all healthy; disease and disorder of the womb, or other organs of the body, especially of the lungs, may cause suppression of the catamenia; and, on the other hand, the discharge may recur for several months after conception, or even monthly during the period of utero gestation; and, in anomalous cases, some young married women, who had hitherto been quite regular, ceased to menstruate for several months without any known cause.

_Morning sickness_ is one of the earliest signs of pregnancy, as it often occurs within two weeks. The nausea may be slight or it may be very distressing; it may happen to be soon relieved, but it usually continues for three or four months or longer. It varies also as regards the time of day during which it continues to be bad; but if it recurs at the regular time and in the regular manner, it is of great value as an evidence of pregnancy, when combined with other symptoms.

_A dark brown areola_ around the nipple may usually be noticed at the end of the second month; this is a distinguishing sign, especially if it be a first pregnancy. A month or two later, the dark color is more obvious, and it is darker in persons with dark hair, etc. It may be described as being a dark circle, somewhat swollen, or with a puffy turgescence, both of the nipple and the surrounding disk; the surface of the areola studded over and rendered unequal by the prominence of the glandular follicles, the integument covering the part soft and moist; sometimes small mottled patches, of a whitish color, scattered over the outer surface of the areola, and for about an inch all around it.

These marks are quite plain at the fifth month, and at six months a number of silvery _streaks_ may be observed.

_Quickening_ is one of the most important signs of pregnancy, and occurs about the fourth or fifth month; not because the child is then first alive, but because the womb then rises higher in the abdomen, and because the child has reached a further state of development. Quickening is a proof that the woman is near half her time gone; though it may happen that the sensation is observed as early as the third or fourth month, instead of at four and a half months. In some cases women do not know the time when they quicken, as only a slight sensation is felt; this some compare to the fluttering of a bird. But a lady may at that time be faint, or giddy, or sick, though there seemed to be nothing more than a mere pulsation. Subsequently, however, the movements become stronger and more frequent. The motions of the child may be felt by a third person on placing the hand on the woman’s abdomen, especially if the person’s hand be cold. I have known one case in which, by placing my hand on the woman’s abdomen, I caused motions which simulated active movements of the child, although there was no fœtus present.

INCREASED SIZE AND HARDNESS OF THE ABDOMEN is characteristic of pregnancy. Enlargement of the abdomen may be from flatulence, but such enlargement is not persistent; the belly is large one hour and small the next, and on pressing the bowels firmly, a rumbling of wind may be heard, which perhaps may move about, and on percussing (tapping) the part, a hollow sound may be elicited, as from a drum. A large abdomen may be due to fat, but there is a soft and doughy feeling that is characteristic of fat. On the contrary, in pregnancy, hardness, solidity and resistance to pressure characterize the gravid uterus, and the enlargement is not only persistent, but gradually increasing. It is true that when a very fat woman is pregnant, percussion or palpation of the abdomen may be fruitless, and any certain diagnosis cannot be made, but in most cases, if we are careful to observe these conditions, and also whether there is a distended bladder and rectum, the diagnosis can be made after the fourth or fifth month.

To make an examination by percussion and palpation, let the female lie down, with the head raised and the thighs flexed on the abdomen; then examine with both hands, especially near the pubis. Pressure with the ends of all the fingers, gradually moving them upward, will enable us to detect the womb, if it rise above the symphasis, and also the size and height of the fundus.

_Ballottement_, or _repercussion_, is used as a means of deciding upon the presence of a fœtus; a means that is most available about the fifth and sixth month. The female examined should be in an upright position, or if she be in bed, her shoulders should be raised. We are directed to introduce the forefinger into the vagina and touch the cervix uteri, or, rather, in front of the neck upon the walls of the uterus; then slightly jerking upward by slightly flexing the first joint of the finger; observe if something recede from it and fall again in a moment. The ballottement is said to be a sensation “analagous to that produced by placing a ball of marble in a bladder full of water and then striking the bladder with the finger just under where the ball rests, when the latter is thrown up and falls from its own weight upon the finger that displaced it.”

When the vaginal touch is practiced, while one finger remains in the vagina, palpation of the uterus with the other hand may assist in the diagnosis by depressing the uterus, or by holding it firmly in place. Then the jerk of the finger upon the head of the fœtus causes it to float upwards a little in the liquor amnii and descend.

AUSCULTATION is used to decide many cases of doubtful pregnancy. The pulsations of the fœtal heart are generally perceptible by the fifth month. The examination may be made by applying the naked ear to the abdomen of the mother, she being placed on her back in the bed with her head raised.

The _fœtal pulsations_ are frequent, generally from 120 to 140 a minute. The _uterine souffle_ or bellows murmur may often be heard as early as the fourth month; it is synchronous with the mother’s pulse; its seat is said to be the uterus, and some believe that it indicates the position of the placenta. This sound and the _pulsation of the umbilical cord_ are not very important diagnostic signs, and the same may be said of the presence of _kiestiene_ in the urine, which may, however, be detected as early as the third month.

Some of the ailments that attend pregnancy I will now merely mention: There may be irritability and a disposition to inflammation; violent and obstinate vomiting; indigestion and depraved appetite, heartburn, costiveness, hemorrhoids, liver spots or blotches, especially about the face; diarrhœa or dysentery; strangury, with a frequent inclination to void the urine; leucorrhœa; varicose veins in the legs, thigh and abdomen; inquietude, and sleeplessness; dropsy, or an œdematous condition of the lower extremities; prurigo vulva; either of these may be more or less troublesome, but can hardly be regarded as diagnostic signs. Some remedies for these will be mentioned hereafter. (F. 69, 72, 75, 81, 131, 173, 206, 220).

The abdominal walls are often distended beyond what the woman is able to bear without inconvenience, as the skin may become inflamed and crack. It is much more common that the true skin beneath the epidermis cracks, and, although the outside is not altered, there often remains upon the abdomen of women who have had children a number of small marks, or little whitish streaks.