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menstruate at the proper term; but this cannot be considered as conclusive evidence of conception, since so many and such various causes are found to obstruct and divert the regular course of the menstrual function. A second failure, especially if it be not accompanied with any signs of depraved health, renders the suspicion still more valid; while after a third and fourth omission, the change of form, and at last the perceptible motion of the embryo put all doubt to flight. I may say, however, with great confidence, that the audible or palpable movements of the foetus afford the only true and infallible signs of the existence of pregnancy. But, the audible are far more to be relied on than the palpable signs, at least after the sixth month.

There are many accidental or correlative signs which establish a probability of the existence of pregnancy: among these I may mention nausea and vomiting; a gradual increase or development of the mammæ; a change of the areolae of the breast, which become more protuberant or elevated, and acquire a dark brown hue, much to be relied upon, especially in first pregnancies. The nausea is mostly found to occur in the morning, and is attended in some individuals. with a distressing heartburn and salivation or spitting of saliva. Some people are affected with gravel, or dysury, from the extension of irritation to the neck of the bladder, or from pressure of the enlarging womb upon the posterior surface of that organ. An irritable state of the temper indicates it in some women, which is attri butable to the general malaise that must attend the gastric embarrassments which the early stages of pregnancy are so commonly found to produce. Toothache, earache, styes on the eyelids, morph on the skin, a dark aureole around the eyes, and strange, unaccountable longings or appetites are also signs of pregnancy, rather to be noted after pregnancy is fully ascertained, than to be depended upon as sure evidences of its existence.

By means of the Touch, pregnancy may be doubtfully ascertained, before quickening has taken place, but not surely. By the Touch we can readily learn that the womb is enlarged, altered in form, and contains something; but I do not see how any physician can ab. solutely aver what that something is, unless he can perceive a spontaneous motion in it; so that even the ballottement, or tilting the embryo upon the point of the finger, does not furnish, to my mind, any sure evidence that the tilted body is an embryo. I adhere, therefore, to the opinion I have already expressed, that we have no certain signs of pregnancy except those derived from the visible, palpable, or audible motions of the child.

Auscultation, either by means of the stethoscope or the direct appli

cation of the ear to the abdomen of the woman, enables us to perceive two very distinct sounds, one of which is the beating of the heart, and the other that which has been called the placental souffle, bruit de souffle, or bellows-like sound; the latter being occasionally attended with a sound like the cooing of a dove. Whenever we can distinctly hear the beating of the foetal heart, so as even to count the number of its pulsations, all doubt must be at an end. The placental sound, or the souffle, is a very distinct sound, which has been supposed to indicate not only the presence of a foetus, but also that it lives; the rushing or blowing sound being said to always cease as soon as the foetus expires: it was said to be, in some way not yet sufficiently understood, connected with the movement of the blood in the placenta, and to cease, of course, with the cessation of that movement, which is itself dependent on the systole of the foetal heart.

Upon a more scrupulous inquiry as to the value of the bruit de souffle, in the diagnosis of pregnancy, it has at last been found that the earlier opinions of it were erroneous, and I believe that there are few wellinformed physicians to be now met with who give it even the smallest portion of their confidence in the doubtful discriminations that they are sometimes compelled to make. It is not to be doubted that the sound is produced by the rush of blood in vessels, and in my opinion, sustained by very long practice in obstetric auscultation, it depends upon the motion of blood in the iliacs and hypogastrics. I have certainly heard the same sound after delivery as before the child was born; and I have heard it, as dependent upon pressure by tumors within the abdomen. Hence I have not the least confidence in it as a means in obstetric diagnostication. The sounds of the foetal heart need never be mistaken. They can be detected at the fourth month, when the opportunity is good. M. Depaul has heard them much earlier. To look for them earlier than the fourth month is, however, in general, merely to lose one's time and find a disappointment.

It is perhaps, on some accounts, of less consequence to be able to ascertain the existence of pregnancy in the married than in the unmarried woman. The lapse of twenty weeks, and sometimes of sixteen weeks, makes it surely known; and the married woman, who has no motive to keep it a profound and important secret, readily imparts a knowledge of her situation, or her suspicions relative thereto, to the physician, or her friends. Not so with the unmarried female, whose reputation depends upon the concealment of her misfortune or crime. I have frequently been sorely embarrassed by uncertainty as to the condition of a patient whose ruddy cheeks and embonpoint seemed quite incompatible with a suppression of the catamenia, and whose

complaints of aches and pains might possibly be merely assumed as a means of deceiving the medical adviser. Physicians are frequently applied to by the unfortunate or guilty for relief from "obstructions," when the applicant has only a design to obtain some powerful deobstruent or emmenagogue, which may serve to procure an abortion, that she knows no honest or respectable medical practitioner could be induced to procure for any pecuniary reward whatever. I hold it, therefore, to be a duty, in all cases, or ranks, to compare the complaints of amenorrhoea with the appearance of the patient, and if some evident malady does not accompany the supposed suppression, to withhold all medical aid, until time or necessity discloses the indications that are to be fulfilled. In physic, nothing should be taken for granted. It is too much to expect that a female, who has it at heart to conceal her pregnancy, will confess it to a medical man. Experience teaches us the very contrary.

CASE. I was requested some time since by a lady to visit a favorite servant, whose situation excited her apprehension, as she had failed to menstruate for the antecedent seven months, and was already considerably swollen with something like dropsy. Being directed to the young person's apartment, I found her in bed, covered up to the throat with bedclothes, but the face that peeped out from above them actually shone with ruddy health, or agitation, or both. The pulse was natural, the tongue clean, the respiration normal, and the entire physiognomical expression as healthful as possible. She informed me that she had a stoppage of the courses for the last seven months, and felt very bad, and was now alarmed at a swelling of the stomach, which had increased greatly of late. Suspecting that she had an important secret, I asked some questions about pains in the stomach, and, upon permission obtained, placed my hand on the abdomen, being almost certain that I should feel the motions of a foetus; but, however long I held my hand on the abdomen, no movement of the child could be felt; so that, although I was certain she was pregnant, I was as yet unprepared to tell her so. I at length got permission to apply the ear against the side of the abdomen, and distinctly heard the placental souffle, and afterwards the stroke of the foetal heart. Upon this assurance, I told her she was pregnant. "If I am," she replied, "I wish God may strike me dead!" and continued, with much temper and even passion, to declare that I maligned her and slandered her. I was obliged to leave her without the least assent, on her part, to my diagnosis, although she knew perfectly well that I spoke only a truth with which she had been long acquainted. She went out of town,

and was confined in the country with a fine boy. Many examples of similar perverseness, in denying pregnancy, the signs of which were perfectly plain to me, and ought to have been obvious to the most careless observer, have fallen under my notice; so that I deem it a solemn duty, previously to the exhibition of any medicines, to ascertain that some signs of disordered health are present, in order that I may not commit the unpardonable fault of provoking an abortion, instead of removing a morbid obstruction of the catamenia.

Let me, however, warn the young beginner here, to take special care, in his diagnosis, that he shall first know the woman to be preg nant before he dare venture to say so. How could a gentleman commit a more unpardonable, or more insulting error?

I might here abstain from any further enumeration of the signs of pregnancy; for I am accustomed myself to decline giving an opinion in any case, until I am sure that I cannot be mistaken, which I never can be when I hear the foetal heart, clearly and distinctly repeating its beats in the womb.

Quickening is not a sign to be depended on by the medical attendant, though it may convince the patient herself; for the woman may perceive it, when the physician cannot. Her convincement ought not to be equivalent to his own convincement. Even the sensible motions felt upon palpation of the abdomen may deceive both the woman and the doctor. Multitudes of such deceptive cases of "danse de la matrice" are met with in a long career of practice. I have seen a woman who had the sensible motions of a child in her belly, though she had given birth to a fœtus at full term only six weeks before, and of whom several physicians who examined her had declared the motions to be caused by a child, yet her cervix uteri was an inch long in the vagina, and the abdomen so soft as to allow one to push his hand down so far as to feel the spinal column. She was not and could not be pregnant. Many of my patients have engaged their monthly nurses and called me in, who were found, when I arrived, to be troubled with tympanitis only. Tenues in auras evadit.—See certain cases in my Letters to the Class, under the article Tympanitis.

The toothache, the ephelis, the hordeolum, the nausea, salivation, pica, pouting of the navel, and even milk in the breast, are merely inferential signs, and are by no means to be depended on. I repeat, that I can rely only on the heart's motion heard in auscultation, and that sign cannot be detected until the fourth month. This is the rule; the exceptions, few in number, are those in which it has been found in the pregnant woman as early as three months and ten days, as in the instance now to be related from Depaul, Traité Théorique et Pratique

d'Auscultation Médicale, p. 248, where he gives us the following account:

CASE. "Madame T, who has already borne several children, had her courses on the 10th to 15th April. From the 17th to the 20th of same month, she cohabited with her husband; he then left Paris on a journey of a fortnight. Upon his return early in May, he found his lady confined to bed with the early symptoms of a typhoid fever, which in a few days became perfectly well marked, and continued twenty-four or twenty-five days. Her convalescence required a lapse of time nearly as long; and no sexual relation occurred until after her recovery. Nevertheless, upon the first of August following, as her courses had not reappeared, I was requested to see her with a view to determine whether this retention, which was very naturally attributed to the severe disease she had lately suffered, might require the employment of certain remedies for its cure. I confess that I was at first inclined to give up the idea of a pregnancy, begun previously to the commencement of the typhoid fever. I was little inclined to suppose its existence computing it from the new sexual relations succeeding her convalescence; but the examination per vaginam enabling me to detect a notable development of the volume of the uterus, I fell back upon the first opinion, of the propriety of which I became fully convinced, when, after having applied the stethoscope at various times upon the inferior region of the abdomen, I discovered the double pulsations, which were repeated 140 times a minute, while the pulse of the mother was only seventy-six. I could not hear the souffle uterin. Her confinement occurred in the following January."

M. Depaul, if the above case is to be relied on, heard the double sounds 100 days, or three months and ten days after the fecundation had taken place. The pregnancy continued 174 days after the audition of these foetal sounds.

Probably few such early detections will be made by all the readers of this paragraph.

Inasmuch as I have spoken at length on the signs of pregnancy in my Letters, I shall beg to refer the Student, for further information, to that volume sub voce.

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