CHAPTER XXII THE DIAGNOSIS OF UTERINE PREGNANCY, ABORTION, (Part 2)

sacro-iliac and pubic joints of the pelvis are relaxed during later pregnancy; in women with sacro-iliac disease the motion is excessive, and the gait is decidedly wobbly; in other women the gait may be little if any affected. The Figure. — The prominent breasts and protuberant abdomen will be noticeable if the physician has been acquainted with his patient previous to pregnancy. The Breasts. — Besides the changes in the breasts noted as to be found during the first three months, there appears at the fifth month a secondary areola outside the primary areola which is next to the nipple, consisting of a network of pigment around light spots, each spot representing a circle round the opening of a sebaceous follicle. These light spots may extend all over the breasts, but are LAST SIX MONTHS OF PREGNANCY 427 most marked next to the primary areola. Skillful stroking of the breast toward the nipple will force colostrum from the nipple after the third month. This is a valuable sign of pregnancy, although milk has been found in the breasts of virgins and even in young children of precocious development. The Vulva. — The vulva, vagina, and cervix have the same ap- pearance as during the first three months, except that the engorge- ment of the tissues is now more marked. The vaginal discharge is increased in amount. The bimanual touch detects the fetus by internal ballottement after the fourth month, for by this time the quantity of liquor Fig. 180. — Primary and Secondary Areolae in a Brunette. ("American Text-Book of Obstetrics.") I amnii is sufficient, and the fetus is large enough to permit the examiner to feel its bobbing about in the uterus. Ballottement may be practiced with the patient in the dorsal or in the standing position, preferably the latter. The physician introduces one or two fingers into the vagina and makes a quick, sharp, upward push against the uterus. In a moment the fetus, which is heavier than the fluid in which it is suspended, settles against the examin- ing finger with a distinct tap. This sign is available during the fifth and sixth months. After that the fetus has grown so large that it can not be moved about freely. After the seventh month the cervix is very soft and the os is patulous. The Abdomen. — Pigmentation of the linea alba of the abdomen is noticeable, especially in brunettes, after the third month. It consists of a dark line about half an inch wide extending from the 428 NORMAL UTERINE PREGNANCY symphysis pubis around the navel to the tip of the ensiform car- tilage. In the later months of pregnancy streaks of white or pink appear in the skin of the flanks, the breasts, and the lower abdomen, the so-called linese albicantes. The protrusion of the abdomen in pregnancy after the fifth or sixth month is generally asymmetrical, being more marked on the right. The umbilicus is apt to protrude in the last two months. ' 1- . \ . Fig. 181. — Enlargement of the Uterus at the Different Weeks of Pregnancy. ("American Text-Book of Obstetrics.") The fundus uteri is two or three fingers' breadth above the sym- physis at the end of the fourth month and reaches the umbilicus at the close of the sixth month. The parts of the fetus may be felt in favorable cases by the twentieth week (the fifth month), being a most valuable sign of pregnancy. Excess of liquor amnii, a rigid and thick abdominal LAST SIX MONTHS OF PREGNANCY 429 wall, or tense uterine walls prevent the detection of the fetal parts. Fetal movements can be felt by the end of the sixth month with a fair degree of constancy and often much earlier. Placing the hand quietly on the abdomen it is allowed to rest there for several min- utes. A very gentle throb is felt if in the sixth month, later the movements are stronger. During the sixth month external ballotte- ment may be practised, a hand on each side of the abdomen being able to push the fetus to and fro; also intermittent uterine con- tractions, rhythmic and painless, occurring every five to ten minutes and lasting a minute or two, may be distinguished by placing the hand on the abdomen and waiting. A sudden motion with the hand or a cold hand will often cause a contraction. These contractions can be made out through the abdomen after the fourth month, but are to be felt by bimanual touch from the begin- ning of pregnancy. . A uterus distended by retained menstrual blood or by an intra-uterine tumor has these same rhythmical contractions. Auscultation The fetal heart sounds are proof positive of pregnancy. Oc- casionally they may be heard toward the end of the fourth month, but as a rule are not available as a means of diagnosis before the end of the fifth month. The entire anterior surface of the uterus must be explored with the stethoscope because of the variable position of the fetus, but the most usual situation is between the umbilicus and the left anterior superior spine of the ilium, because the back of the child is situated there in the commonest position, left occipito-anterior. The heart beat has been likened to the ticking of a watch under a pillow; it is double and has a rate of 120 to 150 beats a minute, being increased by the activity of the child, by fever of the mother, and at the begining of a uterine contraction, variations of twenty beats a minute being often observed in the same fetus. A uterine souffle, synchronous with the mother's pulse and heard best along the left side of the uterus, becomes audible during the fourth month and is a sign of an en- larged uterus, but not necessarily of pregnancy because it is heard also in large fibroids. A summary of the symptoms and signs of pregnancy by months, modified from Dickinson, is appended. 430 NORMAL UTERINE PREGNANCY Summary of Symptoms and Signs of Pregnancy by Months. History. Breasts. Abdomen. Pelvis. Miscellaneous 1. Amenorrhea throughout all months. 2. Nausea. Swell- ing and tin- gling of breasts. Frequency of micturi- tion. Enlarged. Veins show. Areola pig- m e n t e d. Follicles. Leucorrhea. Purplish discolora- tion vagina. Bulging an- terior fun- dus. Com- pressibility of lower seg- ment. Soft cervix. 3 Ditto Ditto Ditto Swelling of face and neck. 4. Nausea ceases. Colostrum. . . . Beginning en- largement. Pigmenta- tion of linea alba. Cervix softer. Fetal parts felt. More congestion of vagina. orations. 5. Quickening . . Secondary areola. Fetal heart sounds heard. Fetal parts felt. Uterine contrac- tions felt. Uterine souffle. Internal bal- lottement. 6. Ditto Ditto Fetal move- ments. Ext. ballotte- ment. Lin- ea3 albican- tes. Fundus reaches um- bilicus. Ditto. ....... Cervix high- er in the pelvis. Gait unsteady. Backward . pose. Promi- nent breasts and abdo- men. 7. Ditto Ditto Ditto No ballotte- ment. Ditto 8. Abdomen pro- gressively larger. Cervix very soft and os patulous. 9. DIFFERENTIAL DIAGNOSIS 431 Differential Diagnosis of Normal Pregnancy It has been my experience that in early pregnancy a malfor- mation of the uterus or a tumor of the uterus is most often mistaken for pregnancy, whereas in the later months an ovarian tumor is frequently confused with the pregnant uterus. It may be well to mention some of the most common mistakes in diagnosis, although there are so many that the advice as to the later months to regard all enlargements of the abdomen as due to pregnancy until the contrary has been proven, is certainly safe to follow. During the First Three Months Anteflexion with retroposition may closely simulate early pregnancy, especially if there is congestion of the cervix and an endometrial discharge. In anteflexion the cervix is not soft, there is no purplish discoloration of the anterior vagina, the corpus uteri is not elastic, the lower uterine segment is not compressible, there are no rhyth- mical contractions, and menstruation still persists, though irregular. An examination several weeks later shows the signs to be the same as at the last examination, and, additionally, markedly anteflexed uteri are generally sterile. Chronic subinvolution shows an enlarged uterus, but the tissues are firmer than normal, the body is not globular in shape or bulging anteriorly, and the lower uterine segment is not compressible. Purplish discoloration is absent. Menstruation, though scanty, is present. Fibroid of the anterior wall is of hard consistency; menstruation is present, purplish discoloration is absent, rhythmical contrac- tions may be present. Upon a second examination after an interval of two weeks or more, the sound may be passed and the situation and size of the fibroid determined. Retroflexion. — The congested fundus may simulate a gravid uterus. The uterus should be replaced as described in Chapter XIV., page 237, and another examination made in the course of a few days. Extra-uterine pregnancy is considered in Chapter XIX., page 340. It is always wise not to hurry in making a diagnosis in doubtful cases and ask for another examination, if necessary with an anes- 432 ABNORMAL UTERINE PREGNANCY thetic. Nothing is to be lost and often much gained by adopting such a course. During the Last Six Months In the case of enlargements of the abdomen due to other causes than pregnancy the rate of enlargement does not coincide with that of the gravid uterus; if amenorrhea is present the duration of the absence of the menses does not correspond with the size of the tumor, supposing it to be pregnancy; and the distinctive signs of pregnancy are absent, namely, the fetal heart sounds, fetal parts felt, fetal movements felt, and internal and external ballottement. Menstruation usually persists. The differential diagnosis of ova- rian cysts, fibroid tumors, phantom tumors, and fat in the abdom- inal wall, distended bladder, ascites, tympanites, and the very rare hematometra, will be found in the chapter devoted to those subjects as shown in the index and need not be repeated here. In cases of rigid abdominal walls more than one examination and, in very doubtful cases, an anesthetic is indicated. THE DIAGNOSIS OF ABNORMAL UTERINE PREGNANCY The Diagnosis of Retroflexion and Incarceration of the Pregnant Uterus. — This not uncommon condition is characterized by a tumor of elastic consistency filling the pelvis, the cervix being high up behind the arch of the pubes. The symptoms and signs of pregnancy are present and in addition there are apt to be pelvic pains and retention of urine. Before attempting to replace the uterus a careful investigation of the urinary function should be made and queries asked whether there has been stoppage of urine or whether any bits of tissue have been passed with the urine, or the patient has suffered with symptoms of cystitis. Krukenberg, who with Rivington collected twenty cases of rupture of the bladder occurring in cases of incarcerated retroflexed pregnant uteri, advises against replacement of the uterus whenever there have been passed by the urethra portions of necrotic bladder wall because of the clanger of rupturing the bladder during replace- ment. He prefers to practice abortion. In any event the bladder should be thoroughly emptied by catheter before attempts at INTERSTITIAL PREGNANCY 433 replacement are carried out. These are done by placing the patient in the knee-chest position, making traction on the cervix with a tenaculum and at the same time rocking the fundus upward by the promontory of the sacrum by pressure on the uterus through the abdomen. Often the Sims position is more favorable for this pro- cedure, and sometimes it will be necessary to pack the vagina with cotton tampons and make a second attempt after an interval of forty-eight hours. In my experience the administration of an anesthetic is seldom necessary. The Diagnosis of Interstitial Pregnancy and of Pregnancy in a Rudimentary Horn of a Bicornute Uterus. — In Chapter XIII., page 198, are described the different sorts of anomalies of the uterus. E. Kehrer ("Das Nebenhorn des doppelten Uterus," 1899) col- lected eighty-two cases of pregnancy in rudimentary cornua. The diagnosis before operation in a majority of these cases lay between extra-uterine pregnancy, ovarian cyst and subserous myoma. The diagnosis of this condition intra vitam must always be considered extremely difficult. Kehrer cites five physicians who diagnosed the condition correctly and reports the cases in detail. The chief point of difference between tubal pregnancy and preg- nancy in the rudimentary horn of a uterus bicornis is that in the latter there is a thick pedicle or even no pedicle at all between the uterus and the gravid tumor, whereas in extra-uterine pregnancy there is a long slim pedicle, longer in ampullar and isthmial tubal pregnancy and shorter in interstitial tubal pregnancy. Interstitial 'pregnancy often simulates pregnancy in a rudimentary horn. The ovum developing in the uterine portion of the tube causes asymmetry of the uterus. Only when the conditions for examina- tion are most favorable can the separation between the pregnant horn and the main fundus uteri be felt. The sound may be passed into the main uterine cavity to prove that it is empty. I have seen two cases of interstitial pregnancy that became normal uterine pregnancies in the course of the third month as the fetus and its envelopes grew into the uterine cavity from the tube. As a rule the interstitial pregnant tumor is separated from the uterus by a shorter pedicle than the pregnant rudimentary horn of a double uterus. The Diagnosis That Pregnancy Has Occurred Previously. — In medi- colegal cases the physician may be called upon to give an opinion 28 434 ABNORMAL UTERINE PREGNANCY whether or no a woman has ever borne a child. The answer will depend upon the physical examination alone. Following preg- nancy the breasts are flabby and more or less pendulous, the changes in the nipples and areolae previously described are to be sought, also linese albicantes on the breasts or about the lower abdomen or hips. A scar from a mammary abscess is good evidence of previous lactation unless other satisfactory explanation of its presence is forthcoming. By vaginal examination the hymen will be found destroyed and in its place the carunculse myrtiformes, the vagina will show a certain amount of relaxation and absence of the rugae; lacerations of the perineum or pelvic floor are proof of previous pregnancy. The uterus will be found a little enlarged and the os will be found round, not the os tincse of virginity. A tear in the cervix is proof positive of child-bearing unless there is a history of instrumentation. Erosions with endocervicitis must not be mistaken for lacerations and their effects. The Diagnosis of Multiple Pregnancy. — The diagnosis of multiple pregnancy rests on rinding an unusually large uterus, a groove in the fundus separating the fetuses, hearing two fetal hearts, each with a different rhythm, and on the palpation of two heads or two breeches. The Diagnosis of Pernicious Vomiting of Pregnancy. — Excessive vomiting of 'pregnancy or hyperemesis gravidarum, occurring most frequently between the third and the fifth week of pregnancy, is of three varieties, according to J. Whitridge Williams, reflex, neu- rotic, and toxemic. In the reflex variety, the vomiting is apparently directly attributable to the existence of some abnormality of the generative tract such as retroflexion or anteflexion of the uterus, erosions or cicatrices of the cervix, or an ovarian tumor, and it ceases promptly upon the correction or removal of the abnormality. The fact, however, that in many pregnant women the presence of similar lesions is not associated with serious vomiting would ap- parently indicate that its reflex origin is quite exceptional, and is evidence that some other etiological factor is usually concerned in the production of the vomiting. The failure of suggestive treat- ment and the lack of evidence of serious changes in metabolism make it improbable that the affection is neurotic or toxemic in origin. PERNICIOUS VOMITING OF PREGNANCY 435 In the neurotic variety the vomiting is dependent upon the existence of a neurosis — more or less clearly allied to hysteria — which may occur in women who had manifested no signs of im- paired nervous control previous to the occurrence of pregnancy. In such cases careful examination will fail to reveal the existence of a single physical condition which could account for the vomiting, while the most accurate chemical analysis of the urine will afford no evidence of serious metabolic disturbance; and, finally, char- acteristic lesions will not be found at autopsy in the rare cases which end fatally, as such patients die from starvation. Cure frequently follows the employment of apparently useless measures and unphysiological procedures, such as a vigorous lecture on the part of the physician, dilating the cervix, applying leeches to the epigastrium, or the administration of an anesthetic. A rigorous rest cure or suggestive treatment also may bring relief. Toxemic vomiting, on the other hand, is a very serious disease and is a manifestation of a profound disurbance in metabolism, of the exact origin of which we are ignorant. All that we know at present is that it usually ends in death, and sometimes leads to a fatal termination within a few days after the appearance of serious symptoms. In such cases the patient presents signs of a profound intoxication, and may die in coma without any evidence of star- vation. The urine, while diminished in amount as the result of the scanty intake of fluids, does not contain albumin or casts until shortly before death, and may apparently present a normal amount of urea, as determined by the Doremus method, so that its casual examination gives no clew to the gravity of the condition. In reality, however, there is a decided decrease in the amount of nitrogen excreted as urea and a marked increase in the amount put out as ammonia. Accordingly, while the total nitrogen output may be practically normal, the percentage of nitrogen eliminated as ammonia