dress, also, may be so managed as, in a great degree, to conceal the size.

The writer was once called on to attend a young unmarried female of respectability, whom he found in labor, and he was assured by her mother that, up to that hour, she never suspected that her daughter was pregnant, not having perceived any alteration in her size; and the young lady had danced all night at a ball, about a week before her delivery: she had completed more than seven months.

It is, perhaps, still more important to recollect, that although pregnancy should exist, if the child die, the development of the uterus will be arrested, and the enlargement of the abdomen will not continue to increase, but, on the contrary, will obviously diminish; the dead foetus being retained in utero for several months, and the patient, although really many months pregnant, may not exhibit any increase of size beyond what is natural to her; or, being near the end of her nine months, may not be larger than she was at four or five. The writer has seen many cases of this kind, which gave rise to great doubt. In the month of May, 1831, he was requested to see a lady who considered herself in the eighth month of pregnancy, and was rendered miserably solicitous about her condition, because she had irregular discharges from the uterus, and felt no motion of the child. On examination, her abdomen was found perfectly flat, and even depressed, and no tumor of any kind could be detected in its cavity; but the uterus, examined per vaginam, was evidently enlarged and soft, and its mouth and neck had undergone the changes which accompany early pregnancy; the breasts were flaccid, and the areola had an imperfect faded appearance. The lady had begun to experience the symptoms of pregnancy in October, which continued till the beginning of January, when they suddenly ceased, and she became liable to vaginal discharges. All doubt about the case was solved shortly after the writer's visit, by the expulsion of an ovum with a blighted foetus, which had evidently not arrived at three months' growth, and during its long stay in the uterine cavity, as an extraneous body, had become incrusted with a reddish calcareous deposit.

Dr. Gooch relates the case of a lady, to whom a similar cir

cumstance occurred, in two successive pregnancies.' There are, then, two conditions, in which the size of the abdomen, instead of increasing, may diminish, or remain stationary; first, about the second month of healthy pregnancy, when the inflation of the intestines subsides; and secondly, when the ovum is blighted, or the foetus dies, the increased vascular supply being withdrawn, the growth of the uterus is arrested.

Connected with this condition of blighted ovum, and the consequences thence arising, are many considerations of great interest and importance, on which I propose to dwell fully, in a future chapter on pregnancy under unusual circumstances.

Dark Abdominal Line and Umbilical Areola.-In a large proportion of cases of pregnancy, there is observable, along the middle of the abdomen, a colored line, of about a quarter of an inch in breadth, extending generally from the pubes to the umbilicus, but, not unfrequently, thence to near the ensiform cartilage; its hue is some shade of brown, but sometimes partaking of the yellowish tint of ochre, and sometimes amounting to a full-bodied dark umber. In several instances, I have observed, in addition to this line, a dark-colored disk occupying and surrounding the umbilicus, and to which we may not improperly apply the name of umbilical areola. It has an area varying from an inch to an inch and a half in diameter, and in general it varies in depth of tint, according to the color of the hair, eyes, and skin of the woman, as do the dark line and the mammary areola; but unlike the latter, there is no turgescence, or elevation of its surface above the surrounding skin; neither are there on it any promi nent follicles. Like the other analogous colorations resulting from pregnancy, this areola is liable to many varieties, having, in some cases, the well marked characters already spoken of, while in others, it is merely like a dirty patch, or soil on the skin, without any definite form, or distinct color. These two indications, although so closely identified in many respects, are not, as may be inferred from what has been already stated, necessarily found together, nor when so found, are they always equally marked. The dark line frequently exists without the umbilical areola, but I have never seen the latter unaccompanied by the

1 Op. citat., p. 222.

former: but if the areola is of less frequent occurrence than the dark line, it is of higher value as a positive indication; inasmuch as, so far as I know, it is formed only in pregnancy; while the dark line has been observed in female cases altogether unconnected with that state, and also in males.

When both signs coexist, their relation is this; the dark line, as it ascends from the pubes, when it arrives within an inch, or less, of the umbilicus, sweeps off in a curve towards the left, and merges into the circumference of the areola, and when again leaving it, to ascend towards the ensiform cartilage, it is observed to issue on the opposite, or right side, curving towards the middle line and then running straight upwards. These abdominal discolorations are most distinct in women of dark hair and eyes, and strongly colored skin, and at advanced stages of pregnancy, and soon after delivery; the dark line, however, I have seen so early as the second month, extending from the pubes to the umbilicus, and in another case, at six months, it reached nearly to the ensiform cartilage; the umbilical areola I have not seen well marked, except at more advanced periods.

One would be disposed to expect, that the perfection of color in marks of this kind, would be in proportion to that of the mammary areola in the same person; such, however, is by no means the case, for I have repeatedly seen the latter very strongly colored, when the abdominal line and areola were scarcely discernible, or altogether absent; and on the other hand, I have seen the abdominal line distinctly marked and well colored, when there was hardly a shade of color in the mammary areola. In very many cases, the dark line is not perceptible at all, and still more frequently is the umbilical areola absent; both marks are, like the mammary areola, liable to fade if the child die during gestation; the shade and depth of color are apt to vary, in the same case, without any obvious cause. Making all due allowance for such exceptions and discrepancies, the dark abdominal line is an evidence of pregnancy entitled to much consideration, and has considerable value as a corroborative indication; if it be accompanied by the umbilical areola, I believe we have a decisive proof of pregnancy.

So far, then, for these appearances, as signs of existing preg nancy, but they have also another value as evidences of recent

delivery; in which respect they will again be referred to, when we come to consider that part of our subject; to which the reader is referred.

State of the Umbilicus.-It has been already stated, p. 137, that during the first two months of pregnancy, the umbilicus is rather retracted, and more depressed than usual, in consequence of the descent of the uterus; but when this organ begins to ascend, the umbilicus gradually rises also, so that in the third month, it is restored to its natural state, and in the fourth, it is found less hollow than before conception; in the fifth or sixth, it is nearly on a level with the surrounding integuments, and in the sixth or seventh, completely so; and towards the close of gestation, it projects, in most persons, above the surface. "The navel also," says Denman," according to the progress of pregnancy, is constantly emerging till it comes to an even surface with the integuments of the abdomen: and to this circumstance much regard is to be paid in cases of doubtful pregnancy."

The production of these changes by the enlarged uterus suggests what we find to be fact, namely, that any solid tumor enlarging the abdomen may also be capable of effecting the elevation of the umbilicus; which latter circumstance, therefore, of itself, can afford us no certain information that the distending agent is a gravid uterus. Yet, I know from experience, that a morbid tumor in the abdomen, of a size and elevation as great as those of the uterus in the seventh month, may coexist with a perfectly depressed umbilicus; a striking instance of this I saw in consultation with Dr. Churchill, and I have thought that the reason probably was, that the tumor was prevented from pressing forward by adhesions, which are so constantly formed between such growths and the parts behind, or around them: how far the fact observed may serve to establish a diagnosis, I cannot venture to pronounce, but I do not know of any single instance, in which the gravid uterus had acquired such a size, without elevating the umbilicus; so that, in any case in which pregnancy is supposed to be advanced to the seventh or eighth month, if we find the umbilicus depressed and the belly flat, it will prove certainly that gestation has not healthily advanced to such a period, although it will not be, as asserted by Dr. Gooch, decisive evidence against the existence of pregnancy; which may be present, but not su fi

ciently advanced to effect the change, or the uterine development may have been arrested by the death of the foetus. It has been already remarked that in the enlargements of the abdomen from flatulence and fat, the umbilicus is generally found more than usually sunk in; but of course, we will not hazard an opinion until we have collected all the collateral evidence ascertainable in the case.1

CHAPTER VII.

CHANGES IN THE UTERUS.-STATE OF THE OS AND CERVIX UTERI.

-SIZE OF THE UTERUS.-ITS CONTENTS, SITUATION, AND CONSISTENCE.

HAVING thus carefully investigated the circumstances of the case, as far as we can discover them by the report made to us, or infer them from the presence or absence of the usual symptoms, or sympathetic changes already enumerated, we proceed, in the next place, to an examination of the uterus itself, having for our object to ascertain the following points: the state of the os uteri and cervix; the condition of the organ with regard to development, and the degree to which it may be enlarged; the correspondence of such degree of enlargement with the other circumstances of the case; the cause of its increase, and the nature of its contents: on our successful investigation, or at least careful examination of which points, conjoined with an inspection of the breasts, must be founded our most satisfactory and decisive kind of information. Strong and plausible assertion, or an artful and well-arranged fabrication, may mislead or bias our judgment; disease may simulate, or conceal the condition of pregnancy; but, with proper care, we shall assuredly obtain our least fallible means of judging from the changes in the breasts, discoverable by the eye, and those of the uterus, ascertainable by the hand, either

On the value to be attached to the state of the umbilicus, see Gooch, op. cit., p. 209. Mauriceau, Malad. des Femmes Grosses, tom. i. p. 93. Denman, Introduction, p. 215, 5th ed., above quoted.