velopment of the little glandular follicles, are the objects to which we should principally direct our attention, the colour at this period being in general little more than a deeper shade of rose or flesh colour, slightly tinged occasionally with a yellowish or light brownish hue. During the progress of the next two months the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple, whose colour varies in intensity according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light-coloured eyes, and delicate complexion. The extent of this circle varies in diameter from an inch to an inch and a half, and increases in most persons as pregnancy advances, as does also the depth of the colour."+

"In the centre of the coloured circle the nipple is observed partaking of the altered colour of the part, and appearing turgid and prominent, while the surface of the areola, especially that part of it which lies more immediately around the base of the nipple, is studded over, and rendered unequal by the prominence of the glandular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch; and lastly the integument covering the part appears turgescent, softer, and more moist than that which surrounds it; while on both there are to be observed, at this period, especially in women of dark hair and eyes, numerous round spots, or small mottled patches of a whitish colour, scattered over the outer part of the areola, and for about an inch or more all round, presenting an appearance as if the colour had been discharged by a shower of drops falling on the part. I have not seen this appearance earlier than the fifth month, but towards the end of pregnancy it is very remarkable, and constitutes a strikingly distinctive character exclusively resulting from pregnancy. The breasts themselves are at the same time generally full and firm, at least more so than was natural to the person previously, and venous trunks of considerable size are perceived ramifying over their surface, and sending branches towards the disc of the areola, which several of them traverse along with these vessels. The breasts not unfrequently exhibit, about the sixth month, and afterwards, a number of shining, whitish, almost silvery lines like cracks; these are most perceptible in women who, having had before conception very little mammary development, have the breasts much and quickly enlarged after becoming pregnant.'

In enumerating these various changes which are observed in the breasts, we fully agree with Dr. Montgomery in saying, that the alteration in the colour of the areola is by no means that upon which we can depend with

"In women with dark eyes and hair, this discoloration is very distinct; in women with light hair and eyes, it is often so slight that it is difficult to tell whether it exists or no."...."In brunettes who have already borne children, the areola remains dark ever afterwards, so that this ceases to be a guide in all subsequent pregnancies." (Gooch, on some of the more important Diseases of Women, pp. 201 and 203.)

We had, at the moment of writing the above, a patient just recovered from her first labour, in whom the discoloration extended nearly over the whole breast: it was darker in some spots than in others, and presented a variety of shades not unlike a large bruise of some days' standing. Dr. Montgomery mentions a case where the areola was almost black, and upwards of three inches in diameter. A similar case occurred not long since.

most certainty in the first place, we frequently meet with so little discoloration during the earlier months as to be altogether inappreciable; we have also already shown that if the patient be a brunette, and has already had children, the colour of the areola cannot be trusted to, as it never entirely disappears after her first pregnancy. On the other hand, we occasionally meet with a considerable change of colour in the unimpregnated state, arising from uterine irritation, as in dysmenorrhoea, &c. Where, however, this is accompanied by the other changes above enumerated, there can be, we apprehend, no doubt as to the existence of the pregnancy. Dr. Smellie, and also, Dr. W. Hunter both considered the areola as proof positive of pregnancy. The latter one decided upon a case of pregnancy under very extraordinary circumstances; the body of a young female was brought into the dissecting room, which at the first glance he pronounced to be pregnant, but the accuracy of his diagnosis was not a little doubted when it was ascertained that a perfect hymen was present: to decide the point he had the abdomen opened when the uterus was found to contain a small fœtus.

Movements of the fœtus. The sensation to the mother, of the child moving in the uterus, cannot be looked upon as a certain sign of pregnancy, for even women who have had large families of children are frequently deceived in this respect by the movement of flatus in the intestines, by occasional spasmodic twitchings of the abdominal muscles, &c. ; but when the motion of the child can be distinctly felt by the hand of an experienced practitioner, it will no longer admit of any doubt: this, however, is a symptom which can seldom be made use of before the middle of the sixth or seventh month.

Quickening. This leads us to the subject of quickening as a symptom of pregnancy. The very vagueness of the term quickening is of itself a sufficient objection to its use as a source of information on these points. Strictly speaking, it refers to that moment of pregnancy when the woman is supposed to have become quick with child, or in other words, when the foetus becomes endued with life, "an error," as Dr. Montgomery observes, "which the continued use of the term was obviously calculated to foster and prolong" (p. 75.) As far as we can understand, the word "quickening" at the present day refers to two different events during pregnancy: the one is when the motion of the child first becomes perceptible to the mother; the other consists of those effects which are frequently observed when the uterus quits the pelvis, and rises into the abdominal cavity, viz. fainting, sickness, &c.; in either case it will be evident that no correct conclusion can be formed by this means. It may safely be asserted that until the last twenty years we possessed only three diagnostic marks of pregnancy, viz. the appearance of the areola, a series of changes but little understood; the being able to feel the movements of the child through the abdominal parietes, and the head of it per vaginam. Hence Dr. W. Hunter, in describing the uncertainty of the signs of pregnancy, says, "I find I cannot determine at four months, I am afraid of myself at five months, but when six or seven months are over, I urge an examination."

In the primipara, the changes which pregnancy produces upon the os and cervix uteri are generally sufficient to lead to an accurate conclusion.

The round dimple-like depression which the os uteri forms, the soft cushiony state of the cervix, are changes which we consider as peculiarly the effects of pregnancy, but their distinctness and certainty ceases when the patient has had several children; the irregular shape of the os uteri, its thickened edges, hard here and there, and the os tincæ, itself more or less open, the cervix scarcely, if at all, shortened, even at a late period of gestation, tend not a little to perplex the diagnosis furnished by this mode of examination; and where disease is complicated with pregnancy, the difficulty is greatly increased, and not unfrequently so much, that scarcely a single satisfactory point will be obtained.

*

Auscultation. Of late years, an immense advance has been made in the diagnosis of pregnancy, by means of the stethoscope. M. Major of Geneva, in 1819, observed the interesting fact that he could hear the pulsations of the fœtal heart through the parietes of the mother's uterus and abdomen: he appears, however, to have carried his researches no farther; and little attention was excited to the circumstance until three years afterwards, when a masterly essay on the subject was read before the Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.† In this interesting memoir, the author has described two sounds, which are perfectly distinct from each other in point of character. One of them consists of single pulsations, synchronous with those of the mother's heart, accompanied with the deep whizzing rushing sound, which may be heard over a large portion of the uterus at once; the other of sharp, distinct, double pulsations, producing a ticking sound, and following a rhythm, which is not synchronous with that of the maternal circulation. Kergaradec supposed that the former sound was produced by the circulation of the blood in the spongy structure of the placenta, and hence called it the souffle placentaire; later observations‡ have, however, shown that it is not connected with the placenta, but depends upon the increased vascularity and peculiar arrangement of the uterine vessels during the gravid state. The other sound is produced by the pulsations of the foetal heart. Uterine souffle. The uterine sound, or souffle, may invariably be heard in one or other of the inguinal regions, and usually over a considerable portion of the uterus, extending anteriorly or along the sides of the organ; and according to the observations of Professor Naegelé, jun., there is no part of the uterus, capable of being osculated, in which this sound may not be heard. He considers that the souffle, which is so uniformly heard in the lower parts of the uterus, especially in the inguinal regions, seems to be produced by the uterine arteries before they enter the uterus; these vessels, as soon as they arrive at the broad ligament, assume a different character, become larger than they were on branching off from their original trunk, and are much contorted before entering the parietes of the Dubois first pointed out the similarity which exists between the

uterus.

Bibliothèque Universelle, t. ix. p. 248; also in the Isis for 1819, part iv. p. 542. t "Memoir sur l'Auscultation appliquée à l'étude de la Grossesse, ou Recherches sur deux nouveaux Signes propres à faire reconnaitre plusieurs Circonstances de l'Etat de Gestation; lu à l'Academie Royale de Médicine dans la Séance Générale du 26 Decembre, 1821. Par J. A. Lejumeau de Kergaradec.

Dr. Evory Kennedy, Observations on Obstetric Auscultation, &c. 1833.

§ H. F. Naegelé, Die Geburtshilfliche Auscultation, 1838; also Dr. Corrigan, Lancet.

sound heard in the gravid uterus, and that of aneurismal varix, where there is a direct passage of blood from an artery into a vein; the sound in this latter condition is produced by the current of blood rapidly issuing from the dilated artery, and mixing with the slower flowing stream of the dilated vein. The circulation of blood in the dilated arteries of the uterus presents a considerable resemblance, in many respects, to that of the abovementioned disease.

That the uterine sound is not confined to that part of the uterus where the placenta is attached, as was supposed by Professor Hohl,* is proved by the fact that we can frequently hear it in two different and sometimes opposite parts of the uterus at the same time, which, if his opinion be correct, would indicate the presence of twins; and as yet the result of labour has proved that the uterus has contained but one child, and that the placenta had neither been attached in the one or other of these situations. The very circumstance which we have already mentioned, of this sound being invariably heard in one, if not in both, of the inguinal regions, shows that it is independent of the vicinity of the placenta; nevertheless, it must be allowed, that as the uterine vessels undergo the greatest degree of development at this part, the sound will usually be at least as distinct here as in any other portion of the uterus.

The uterine souffle is the first sound which auscultation detects during pregnancy; it may be heard as early as the fifteenth or sixteenth week, but cases now and then occur where it has been even distinguished in the thirteenth or fourteenth week, and Dr. Evory Kennedy has given some very interesting examples where he was able to hear it with certainty at the twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy, op. cit. p. 80.) During these earlier periods, the sound is weaker, but extends over the whole of the uterus, from the diminutive size of which it can be heard most readily immediately above the symphysis pubis; in fact, there is every reason to suppose, that the uterine souffle might be detected at a still earlier period, if the uterus were at this time within reach of the stethoscope. As pregnancy advances, it becomes more distinct and powerful, and is occasionally so to a remarkable degree. During the latter periods of pregnancy, it frequently presents considerable modifications of tone, especially where there is general or local vascular excitement, as in cases of fever, or dispositions to hæmorrhage, where the vessels are usually distended, or where (Naegelé, op. cit. p. 86,) the placenta is situated near the os uteri, it assumes a piping, twanging sound of considerable resonance: the same is also observed where, either from the weight of the gravid uterus or any other cause, pressure has been exerted on any of the main arterial trunks: hence, as we shall show more fully when speaking of labour, a remarkable change is produced in the tone of the uterine souffle by the first contractions of that process. The causes of these modifications are not always very easily explained; we sometimes observe the souffle on the same side of the uterus vary rapidly in its degree of intensity, and occasionally even disappear for awhile, without our being able to assign any satisfactory reason for such changes.

The uterine souffle, taken by itself, although a very valuable sign of

• Die Geburtshülfliche Exploration, von Dr. A. P. Hohl.

pregnancy, can scarcely be looked upon as one which is perfectly certain and diagnostic, since a similar sound may be produced by aneurism of the abdominal aorta and its large branches; there is much reason to think that the uterus, enlarged from other causes than that of pregnancy, and pressing upon the iliac arteries, will produce a similar sound. Professor Naegelé, jun., has also shown that the sounds of the patient's heart may sometimes be heard very low in the abdomen, even as far as the ossa ilii, a circumstance which seems to have depended upon the sound being transmitted through the intestines distended with flatus. Where any of these causes of abdominal souffle have existed in connexion with suppressed catamenia, swelling of the breasts, &c., we might be liable to be deceived if we allowed ourselves to be entirely guided by this sound.

With regard to the foetal pulsations, we find them generally beating at the rate of from 130 to 150 double strokes in a minute, and the age of the fœtus appears to have no effect upon their rapidity, for even at the earliest periods at which we can detect these sounds the rate of the pulsation is the same as at the full term of pregnancy.

Although Dr. Kennedy has in a few cases detected this sound even before the expiration of the fourth month, it will not in the majority be possible until a later period. "At the fourth month it frequently requires not only close attention, but considerable perseverance, to detect the foetal heart; and at this period it has occurred to us to examine patients whom there was strong reason to suppose pregnant, and after spending a considerable time in endeavouring to detect the sound, we have been on the point of giving up the search as hopeless, when it has been suddenly discovered in the identical spot that had before perhaps been explored without success." (Kennedy, op. cit. p. 101.)

The sound of the foetal heart is usually heard at about the middle point between the scrobiculus cordis and symphysis pubis, usually at one side, and that, generally speaking, the left. The extent of surface over which the sound may be heard varies a good deal, and depends, in great measure, on the distance which intervenes between the foetus and stethoscope; hence, when the uterus is distended with a large quantity of liquor amnii, or when the uterine or abdominal parietes are very thick, it is heard over a much larger space, although with diminished intensity; on the other hand, when there is but little liquor amnii in the uterus, it is audible over a small portion only, but is remarkably distinct: this is pecularly the case during labour after rupture of the membranes. The rapidity and strength of the foetal pulsations appear to be entirely independent of the mother's circulation; violent exercise, spirituous liquors, &c., which will raise her pulse to a considerable degree, have no influence whatever on the fœtal pulse. In cases of fever, where the mother's pulse has ranged between 110° and 120°, and even higher, not the slightest change was observable in the sound of the foetal heart; even in acute inflammatory affections, in pneumonia, pleurisy, where there was severe dyspnoea, and also in tubercular phthisis; in cases where the patient has been bled; in cases of menstruation during pregnancy; and even in severe flooding, and when the mother's pulse has been greatly reduced, no perceptible change has been observed in that of the foetus. (Naegele, op. cit. p. 39.) Dr. Kennedy has observed some remarkable cases where the foetal pulse ap