[Reprinted from the Transactions of the Philadelphia County Medical Society, 1894.] 
THE DIAGNOSIS OF PREGNANCY DURING THE 
FIRST THREE MONTHS. 
By CHARLES P. NOBLE, M.D., 
LECTURER ON GYNECOLOGY, PHILADELPHIA POL yUtrWRTTSURGEON-IN-CHIEF OF THE 
KENSINGTON HOSPITAL FOR WOMEN. 
[Read November 14, 1894.] 
It is a current belief among the profession, which is supported by 
the authority of obstetical text-books, that the diagnosis of pregnancy 
during the first three months is difficult or impossible. It is the pur- 
pose of this communication to combat this teaching. In my judgment, 
a practitioner skilful in making the bimanual examination will be 
able, ninety-nine times out of a hundred, in cases of suspected preg- 
nancy, between the sixth and twelfth weeks, to definitely determine 
whether or not pregnancy exists. This statement is based upon ten 
years' experience. During this time a very large number of such 
cases have come under observation. My opportunities for seeing cases 
of early pregnancy have been unusual. During the first five years 
of my practice I was connected with the dispensary of the Phila- 
delphia Lying-in Charity, where at that time large numbers of women 
(mostly illegitimately pregnant) came for the purpose of ascertaining 
whether or not they were pregnant. Thus my attention was early 
called to the critical study of this subject. During the past five years 
I have seen the usual number of cases which come to one in charge 
of a large hospital service for the diseases of women, in addition to 
those seen in private practice. While no notes have been kept of the 
total number of cases seen, it is apparent that the number is quite a 
large one. My reason for referring to this fact is that it gives em- 
phasis to the statement that, of the total number of patients seen 
in which a diagnosis of pregnancy was arrived at, I know of not a 
single instance in which the element of time did not bear out the 2 
CHARLES P. NOBLE, 
correctness of the opinion. Of the cases seen, of course, there were 
certain ones in which a diagnosis was reserved, owing almost invariably 
to the extreme development of fat, which interfered with a satisfactory 
bimanual examination. I think, however, that one per cent, would 
cover such cases. 
The one sign above all others which establishes the existence of 
pregnancy during the first three months is dwelt upon little, or not 
at all, by obstetrical text-books. My attention was first drawn to this 
sign by an article written by Grandin, of New York, it being called 
the sign of Hegar. Dr. Grandin and others were wrong in naming 
it as Hegar's sign, but they were entirely right in estimating it as a 
thoroughly reliable evidence of pregnancy. The shape of the unim- 
pregnated uterus is pyriform, flattened from before backward. When 
the cavity of the womb is occupied by a growing ovum certain 
changes in the form of the womb and in its structural peculiarities 
rapidly ensue. As is well known, the corpus and fundus of the womb 
develop with great rapidity, in order to make room for the growing 
ovum, while, on the other hand, the cervix grows more slowly, and 
even toward the end of pregnancy its size has not greatly augmented. 
Within six weeks after the beginning of pregnancy the ovum has 
grown sufficiently to cause the corpus and fundus of the womb to 
assume a distinctly spheroidal shape. As during this time the cervix 
has altered very little in its form, we have present, to make use of 
geometrical terms, a spheroidal body posed upon a cylinder. If one 
will picture this state of affairs he will see that the sphere juts out 
from the cylinder prominently and in every direction. In other 
words, when examining the pregnant uterus between the sixth and 
twelfth weeks, the uterus will be found enlarged to correspond with 
the period of the pregnancy; the corpus and fundus will be found as 
a spheroidal body, and the corpus can be easily made out as jutting 
boldly out from the cervix in front, behind, and at each side. In my 
experience this sign is of the utmost value and absolutely reliable. 
The judicious practitioner, however, will not neglect to make use of 
corroborative signs and symptoms. The spheroidal body of the womb 
will be found softened, and as it is held between the two hands in 
bimanual examination a feeling of semi-fluctuation can easily be made 
out. This softening and semi-fluctuating feel should be found in all 
cases. 
What conditions could be confounded with pregnancy by giving EARLY DIAGNOSIS OF PREGNANCY. 
3 
rise to the same or similar signs as those described ? These, I think, 
are practically two : 1. Hematometra, due to an imperforate cervix. 
The practical man will realize that this condition will seldom embarrass 
him in making a diagnosis of pregnancy, as the average practitioner 
meets with it not more than once in a lifetime. Moreover, the history 
of the case would put him on his guard with reference to it, as hema- 
tometra occurs either as the result of a congenital defect, and is then 
found in young girls about the age of puberty, whose history is suffi- 
ciently characteristic to at least make the practitioner watchful; or it 
occurs later in life as the result of atresia of the cervical canal, brought 
about by inflammatory conditions of a destructive nature. These 
cases likewise are very rare, and their history is quite suggestive. 2. 
Certain cases of intramural fibroid tumor, in which, owing to pelvic 
congestion, the walls of the uterus become quite soft. But here also, 
in my experience, the conditions are not typical. The uterus is not 
uniformly enlarged, it projects perhaps anteriorly and not posteriorly, 
the semi-fluctuating feel cannot be made out, or some other evidence 
is present, to make the examiner aware that he is not dealing with 
pregnancy. 
So far as I know, these are the only conditions which at all simu- 
late an early pregnancy. 
It is well to say a word about conditions which prevent the ex- 
aminer from making out this characteristic sign of pregnancy. It 
will be readily seen that if pregnancy occurs in a womb which 
already contains a fibroid tumor, that the sign is not available. This 
is equally true when the pregnant uterus is jammed in between tumors 
of the ovary. Extreme development of adipose tissue may prevent 
its recognition, on the one hand by making the abdominal hand un- 
available, or on the other by preventing the examining finger from 
reaching high enough upper vaginam to make out the form and con- 
sistency of the uterus. It will occasionally happen also that preg- 
nancy takes place in a womb bound down by adhesions, in a pelvis 
in which the structures are distorted as the result of former inflam- 
matory processes. In such cases the development of the pregnant 
womb is frequently atypical. All the conditions described have been 
encountered, and my remarks concerning them are based upon experi- 
ence. In such cases the examiner usually finds enough to awaken 
his suspicions, but not enough to form a positive diagnosis, and thus 
is obliged to reserve his opinion. 4 
EARLY DIAGNOSIS OF PREGNANCY. 
Certain other corroborative evidences of pregnancy are very valu- 
able during this period. The violent discoloration of the vagina, 
most marked beneath the urethra, frequently appears as early as the 
sixth week, and is usually well developed as early as the third 
month. To an experienced observer, who has been accustomed to 
note the difference between the slight blueness due to pelvic conges- 
tion and the intense discoloration which is present in pregnancy, 
owing to the changes in pelvic circulation, this sign is of great value 
Evidences of pelvic congestion, such as velvety softness of the 
vaginal walls, marked pulsation in the vaginal and uterine arteries, 
unassociated with inflammatory conditions, have a definite corrobo- 
rative value. 
Softening of the cervix has a certain but very slight importance, 
by no means commensurate with the stress which is placed upon it by 
writers and practitioners. The cervix often becomes soft and pulpy 
as the result of pelvic congestion unassociated with pregnancy ; and, 
on the other hand, a cervix which is the seat of cicatricial or chronic 
hyperplastic changes will not become softened until the latter months 
of pregnancy. Therefore, in my judgment, very little dependence 
should be placed upon its condition. 
About the fourth month the pregnant womb rises out of the pelvis. 
It is evident that when this takes places the valuable sign which we 
have critically discussed is no longer available. At this time, and 
until the foetal heart-sounds can be heard, the sign of Hegar, namely, 
the extreme softening of the lower segment of the uterus as contrasted 
with the firm cervix, is of the greatest value. These two signs, it 
will be seen, are complementary to each other. The sign we have 
discussed in this paper is of value prior to the ascent of the womb 
from the pelvic cavity, the sign of Hegar from that time until the 
foetal heart can be heard. 
The statements contained in this paper have purposely been made 
emphatic, in the hope that they will attract the more attention on the 
part of the profession. I have not hesitated to be emphatic, because 
my experience has been sufficient, and has extended over such a period 
of time as to convince me of the absolute truth and reliability of the 
evidences of pregnancy under discussion.