There are other circumstances 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 circumstance, 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 versâ: this is more particularly the case when any morbid condition of the system is also present; under such circumstances, 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 assisting 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 breasts; “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 circumstances (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 circumstance 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 principally 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 constitutes a strikingly distinctive character exclusively resulting from pregnancy. The breasts 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 breasts 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 breasts much and quickly enlarged after becoming pregnant.”
In enumerating these various changes which are observed in the breasts, 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 dysmenorrhœa, &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 circumstances; the body of a young female was brought into the dissecting room, which at the first glance he pronounced 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 fœtus.
Movements of the fœtus. 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 practitioner, 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 fœtus 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 asserted 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 vaginam. 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 tincæ, 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 fœtal 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 circumstance until three years afterwards, when a masterly essay on the subject was read before the Académie Royale de Médecine 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 fœtal heart.