The Prospective Mother, a Handbook for Women During Pregnancy. J. Morris Slemons
delay an absolutely positive diagnosis, since the proper method of examination reveals these movements to the physician almost as early as the patient feels them.
About the time these movements become perceptible another positive sign is available. The physician whose ear has been trained to catch such sounds when he listens over the lower part of the mother's abdomen will hear the fetal heart-beat. Other sounds may be audible there, but the character and the rate of the heart-sounds are distinctive. Since the child's heart beats almost twice as fast as the mother's, under ordinary conditions it is impossible to confuse one with the other. The mother never feels the beating of the child's heart, but occasionally she will mistake for it the throbbing of her own blood vessels.
Ability to hear the fetal heart not only provides a means of confirming the existence of pregnancy in doubtful cases, but also enables the physician to reassure his patient if she fails temporarily to feel the child move. Sometimes the presence of twins is recognized in this way. Toward the end of pregnancy the heart sounds are also of material assistance in determining what position the child has permanently assumed.
There is a third positive sign of pregnancy to which the physician has recourse, but generally it is inapplicable as early as those already mentioned. In the latter months of pregnancy it is possible to outline the child through the mother's abdominal wall. Although this procedure adds little or nothing to our resources for making an early diagnosis, the information it ultimately affords proves one of the greatest aids in the practice of obstetrics.
THE PROBABLE SIGNS.—Obviously, phenomena for which the child is responsible—such as have just been described—supply the most trustworthy evidence of pregnancy; and these phenomena alone are accepted as positive signs. But there are earlier manifestations which intimate very strongly that conception has taken place. Shortly after pregnancy has become established changes begin in the uterus, as physicians call the womb, and soon reach the point where they may be recognized by a simple examination which enables the physician to express an opinion little less than positive. As one result of pregnancy, for example, the supply of blood is increased to all the organs concerned with the reproductive process. Partly on account of this congestion and partly on account of embryonic development, the uterus becomes altered in a number of ways. Although these changes occur regularly in pregnancy, they may also occur when the womb is enlarged from other causes; therefore, if a physician should make the diagnosis of pregnancy whenever they were found, he would make it somewhat too frequently. With a little patience, however, he excludes the chance of being misled; a second examination, approximately four weeks after the first, will generally place the existence of pregnancy beyond question, for under normal conditions the degree of enlargement which takes place in a pregnant womb during a given interval is absolutely characteristic.
THE PRESUMPTIVE SIGNS.—Although women are most often led to suspect that they are pregnant by symptoms which are of such doubtful significance that they must be regarded as merely presumptive evidence, the practical value of these symptoms is attested by the fact that subsequent developments rarely fail to confirm the suspicion. Perhaps they prove misleading once or twice in a hundred cases; the number of mistakes is small, because the diagnosis is commonly made not from only one of these doubtful signs but from a group of them. In order of importance the doubtful or presumptive signs of pregnancy are these: (1) cessation of menstruation, (2) changes in the breasts, (3) morning sickness, (4) disturbances in urination.
The Cessation of Menstruation.—The failure of menstruation to appear when it is expected is nearly always the first symptom of pregnancy to attract attention, and, as a rule, when this happens to healthy women during the child-bearing period—which usually extends from the fifteenth to the forty-fifth year—it may be taken to indicate that conception has occurred. But there are exceptions to this very good rule. Besides pregnancy we are acquainted with several conditions that cause temporary suppression of menstruation; and to understand its significance we must learn something of the menstrual process itself.
Menstruation is a function of the womb and in all probability is brought about through the influence of the ovaries. The bleeding, popularly regarded as the entire menstrual process, is, in fact, indicative of only one of its stages; the others give rise to no symptoms whatever. What the stages in the menstrual process are, what relation they bear to each other, and what the significance of the whole process is, are problems that have been solved with the aid of the microscope. In this way the mucous membrane lining the womb has been studied both at the time of the periods and in the interval between them, and we have learned that it is constantly undergoing changes intended to facilitate the reception and the maintenance of an embryo. Anticipating these duties the mucous membrane receives a more abundant supply of blood; it also increases in thickness and all the structures which enter into its composition become more active. Unless conception takes place these preparations, which represent the most important phase in the menstrual process, are without value; and therefore failure to conceive means that the mucous membrane will return to the same condition as existed before the preparations were begun. The congestion is relieved by rupture of the smallest blood vessels, and there follow other retrogressive steps which completely restore the various structures to their former state. Then there is a pause, though it is not long, until preparatory changes are again initiated, or, as we say, another Menstrual Cycle is begun. Each cycle lasts twenty-eight days, and includes four stages, namely, a stage of preparation, of bleeding, of restoration, and of rest.
Although pregnancy may become established at any time during the interval between the periods of bleeding, it is more likely to be established just before a period is expected or shortly after it has ceased. Furthermore, whenever conception does take place, the preliminary preparations for the reception of the embryo are followed by much more elaborate arrangements for its protection and nutrition. Under these circumstances the hemorrhagic discharge does not appear.
Were there no other condition to bring about the cessation of menstruation, the diagnosis of pregnancy would be greatly simplified. But any one can appreciate the fact that diseases of the womb may interfere with the menstrual process. Menstruation is influenced, also, by the ovaries. As a result of age, for example, the ovaries undergo changes which invariably bring about the permanent cessation of menstruation, called the menopause. This event occurs prematurely if both the ovaries are removed by operation. In view of these facts it is not surprising that sometimes ovarian disorders abolish menstruation. An impoverished state of the blood, or nervous shock and strain, or constitutional debility may also interrupt the regular appearance of the menstrual discharge.
The value of menstrual suppression as an evidence of pregnancy is not, however, to be discounted to the extent that we might expect. This is true because the ailments which lead to confusion are relatively infrequent, and also because they exhibit characteristic symptoms which are foreign to pregnancy. Often these symptoms are obvious to the patient herself; if not to her, they will be obvious to her physician. It is about the doubtful cases, naturally, that a professional opinion is sought, and on that account physicians are perhaps inclined to overestimate the difficulty women have in learning for themselves whether or not they are pregnant. As a matter of fact, it is unusual for a prospective mother to fail to reach a correct decision—a decision for which she relies chiefly upon the suppression of her menstrual periods.
It is doubtful whether menstruation ever continues after conception has taken place. Instances in which the menstrual function is believed to persist are not uncommon, and yet in all probability the discharge regarded as menstrual has a different origin. In most cases it should be interpreted as meaning that there is some danger of miscarriage. Since miscarriage often occurs about the time a menstrual period would ordinarily be expected, there is unusual opportunity for confusing the symptoms. At all events women err much more frequently in suspecting that they are pregnant than in overlooking the condition. Indeed, pregnancy is not likely to be overlooked unless menstruation has been irregular or suppressed for a month or more previous to conception. Thus, in the case of nursing mothers in whom menstruation is already suppressed and who are, moreover, deprived of certain evidence that the breasts give, pregnancy may sometimes advance several months before it is recognized.
The Changes in the Breasts.—Various sensations in the breasts are accepted by women as a reliable sign of pregnancy; thus throbbing, tingling, pricking,