PREGNANCY
It not infrequently happens that a medical man is called upon to make
an examination of a woman for legal purposes, in order to decide--(_a_)
The existence of an alleged pregnancy. (_b_) The possibility of a
previous pregnancy. (_c_) As to the existence of concealed pregnancy.
The following are some of the reasons why pregnancy may be feigned:
1. _By a married woman, to gratify the desire of her
husband for issue._
2. _To influence the jury in a case of breach of promise
of marriage as to the assessment of the damages._
3. _To extort money from a seducer or paramour._
4. _To produce a spurious heir to property._
5. _By a single or married woman, to stay the infliction
of capital punishment._
Pregnancy may be concealed--(_a_) In order to procure abortion. (_b_)
In order to commit infanticide. (_c_) In the married and the unmarried,
to avoid disgrace.
Besides the above, other important questions may arise with regard to
this state:
1. _Is pregnancy possible as the result of coïtus in a state of
unconsciousness?_--There appears no reason for doubting the possibility
of this occurrence.
2. _Can pregnancy occur before the appearance of the catamenia?_--That
pregnancy may occur before menstruation is undoubted; and it appears
probable that the changes in the ovaries and uterus may go on at
the regular monthly periods, and yet there may be no discharge of
blood from the uterus, which, as pointed out by Bischoff, is only a
symptomatic though usual occurrence. Hence, pregnancy is possible prior
to menstruation.
3. _What is the earliest and latest age at which pregnancy is
possible?_--In our climate (Britain), the earliest age at which
pregnancy may occur is about the eleventh or twelfth year; but the
youngest age at which this condition is reported to have occurred is
_nine_ years (Meyer). In hot climates--as in Bengal--mothers under
twelve years of age are by no means rare. Cohabitation in marriage
takes place much earlier in India than in Europe, but Chevers doubts
if menstruation naturally occurs much sooner there than elsewhere, and
Baboo Modusoodun Gupta believes that the catamenia appear sooner or
later, according to the mode of living of the females, and the sexual
excitement to which they may be subjected. Thomas mentions the case of
a girl who menstruated regularly from the age of twenty-one months, and
also of another at eight months. The limit to child-bearing appears
to be between the fiftieth and fifty-second years; but even here
considerable variation has been recorded, and women have been delivered
of children at the age of sixty. Haller even reports one at seventy. As
long as menstruation continues a woman may become pregnant; but even
the cessation of this flow for some months is no bar to conception.
4. _Is it possible for a woman to become pregnant eight weeks after
her last confinement?_--This is undoubtedly possible, but it is of rare
occurrence. It is also probable that a woman may abort at the end of
the time above mentioned. Husband knew a woman, who for several years
bore a child every ten months.
At _common law_, in cases of disputed inheritance, the following may
occur, and give rise to the necessity for medical evidence on the
subject: A woman who has just lost her husband may disappoint the
expectant heirs to an estate by alleging that she is pregnant.
At _criminal law_, pregnancy may be used as a stay to the infliction of
capital punishment.
In the first case, a jury of matrons is impanelled by a writ _de ventre
inspiciendo_, to decide the existence of pregnancy, and if the fact be
proved, to watch till such time as she be delivered.
In the second case, in England, the pregnancy must be proved, and also
whether she be _quick with child_. In Scotland the pregnancy must be
proved, but without reference to _quickening_, and the jury of matrons
is unknown in that country. In the same country, if it can be shown
that a woman is pregnant, and that her life or that of the child is
endangered by her imprisonment, she may be admitted to bail till after
delivery. A pregnant female also cannot be compelled to appear and give
evidence, if on competent authority it be shown that her delivery will
probably take place at the time fixed for the trial.
Signs of Pregnancy
The diagnosis of early pregnancy in ordinary cases is by no means easy,
especially before the third or fourth month of gestation; but to the
medical jurist it is still more difficult, as he has to deal with cases
where he can scarcely expect much candour. No opinion should, however,
be given without taking into consideration the collective value of the
signs, as no one sign will afford sufficient data on which to base an
opinion. The signs furnished by auscultation are the most reliable, but
the position of the fœtus may render the sounds of the fœtal heart and
placental souffle difficult to detect.
The following may be taken as among the most important signs of
pregnancy, given in the usual order of their occurrence:
Uncertain or Accessory Signs
1. Cessation of menstruation First month.
2. Morning sickness Second month.
3. Salivation Variable.
4. Mammary sympathies Third month.
5. Enlargement of the abdomen Fourth month.
6. Quickening Fourth month.
7. Kiesteine Variable.
8. Jacquemier‘s Test Third month.
Certain or Essential Signs
1. Ballottement Fourth month.
2. Uterine souffle Second month.
3. Pulsation of the fœtal heart Fourth month.
Uncertain Signs
1. _Cessation of Menstruation._--The non-appearance of the catamenia,
though a most valuable sign, is by no means a conclusive one, as
menstruation may be arrested by diseases of various kinds; while, on
the other hand, there are many well-recorded cases of women who have
menstruated regularly during the whole period of their pregnancy.
There have been also cases in which the menses only occurred during
pregnancy; and in a few still more curious cases, women who have never
menstruated have been known to have borne several children. In cases
of concealed pregnancy, the woman may smear her linen with blood to
imitate the menstrual flow.
2. _Morning Sickness._--Nausea, often ending in vomiting, generally
occurs soon after rising in the morning, and may commence almost
immediately, but more frequently not till the expiration of the fifth
or sixth week after conception. It is not a reliable sign, and is often
very irregular in its occurrence. When present, it varies in degree,
from a feeling of nausea to the most violent vomiting, very distressing
to the patient.
3. _Salivation._--The excessive secretion of the salivary glands,
due to the irritation caused by pregnancy, was first mentioned by
Hippocrates as a sign of this condition. “It is to be distinguished
from ptyalism induced by mercury, by the absence of sponginess and
soreness of the gums, and of the peculiar fœtor, and by the presence of
pregnancy.” It is oftener absent than present.
4. _Mammary Sympathies._--As the breasts may enlarge from various
causes--such, for instance, as the distension of the uterus from
hydatids, or, as is the case with some women at each menstrual period,
when the catamenia are suspended, or after they have ceased--this is
by no means a sign on which much reliance should be placed. The change
in the colour of the nipple and areola, more apparent in women of dark
complexions, is more to be relied on as a diagnostic sign of pregnancy.
The first observable alteration, which occurs about two months after
conception, is “a soft and moist state of the integument, which appears
raised, and in a state of turgescence, giving one the idea that, if
touched by the point of the finger, it would be found emphysematous.
This state appears, however, to be caused by infiltration of the
subjacent cellular tissue, which, together with its altered colour,
gives us the idea of a part in which there is going forward a greater
degree of vital action than is in operation around it; and we not
infrequently find that the little glandular follicles, or tubercles as
they are called by Morgagni, are bedewed with a secretion sufficient to
damp and colour the woman‘s dress.”
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 characteristics: “A circle round 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 the 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 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 which lies
more immediately around the base of the nipple, is studded over and
rendered unequal by the prominence of the glandicular 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 with 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 around, presenting an
appearance as if the colour had been discharged by a shower of drops
falling on the part.” The value of the above changes in the nipple
and areola as a diagnostic sign of pregnancy is greatly lessened by a
previous pregnancy. It should also be remembered that milk may occur in
the breasts of women who are not pregnant.
5. _Enlargement of the Abdomen._--For the first four months of
pregnancy the entire uterus is contained in the cavity of the pelvis;
it then gradually rises, so that at about the fifth month it is midway
between the pubes and umbilicus, which latter it reaches at the end
of the sixth month; during the seventh month it may be felt half-way
between the umbilicus and ensiform cartilage; at the end of the
eighth month it is level with the cartilage, now quite filling the
abdomen. Still increasing in size during the ninth month it does not
ascend higher, the abdominal walls yielding to its increased weight,
allowing it to fall somewhat forward. A caution is necessary with
regard to this sign. The abdomen may enlarge from causes other than
pregnancy. Pregnancy and ascites, or ovarian dropsy, may coexist in
the same patient, and the diagnosis be rendered anything but easy. The
enlargement of the abdomen may lead to unfounded suspicions detrimental
to the happiness and health of the unfortunate object of them.
6. _Condition of the Cervix Uteri._--The cervix softens during
pregnancy, and the softening is present as early as the second or third
week. It is an important sign. Hejar‘s sign or the softening at the
junction of cervix and body and the lower uterine segment is valuable,
but not always easily elicited. It is of most value from the second
to the fifth months. At the sixth month it loses one-fourth of its
length; at the seventh it is only half of its original length; at the
eighth it loses another quarter; and at the ninth the neck is entirely
obliterated. This shortening is more apparent than real, and its
occurrence is denied by the late Dr. J. M. Duncan, except during the
last few days of pregnancy.
7. _Quickening._--The period at which quickening occurs varies from
the fourth to the fifth month; and the term is understood to imply the
first perception of the movements of the fœtus experienced by the
mother. Nervous women, anxious to have children, sometimes complain of
sensations which they ascribe to quickening, pregnancy being absent.
Pregnancy may occur without quickening.
8. _Kiesteine._--This is no test of pregnancy, as it may be found in
women not pregnant.
9. _Jacquemier‘s Test._--A violet or port-wine colour of the vagina and
inner surface of the vulva, due to venous congestion of the parts from
pressure of the gravid uterus.
A flattening of the upper wall of the vagina, produced by the
enlargement and anteversion of the uterus, which, forcing the os
towards the sacrum, makes the anterior wall of the vagina tense, has
been added by Dr. Barnes as a sign of pregnancy.
Certain Signs
1. _Ballottement._--This test of pregnancy is applied by causing the
patient to stand upright; the finger of the right hand is then passed
into the vagina and placed in the anterior fornix, the other hand
being placed lightly over the abdomen in order to steady the uterine
tumour. If the finger be now jerked upwards against the head of the
child, it will be felt to float upwards in the liquor amnii, and then
by its own weight gradually to return to its former position. Tumours
in the uterus, attached to its walls by a pedicle, may give the same
sensation. Scanty supply of liquor amnii, or malposition of the child,
may sometimes prevent the adoption of the test.
2. _Uterine Souffle._--Under this head are included the placental
bruit, and the pulsations of the umbilical cord. Both these sounds
require a skilled auscultator to detect them. The uterine murmur, or
_bruit placentaire_, is heard best at the lower and lateral portions
of the uterus, just above Poupart‘s ligament. It is isochronous with
the pulse of the mother, and is heard most distinctly about the fourth
or fifth month of utero-gestation; in some cases, however, it may be
heard as early as the tenth week. The sound is intermittent, and varies
in character, being sometimes hissing, whirring, or cooing, at others
rasping.
3. _Pulsation of the Fœtal Heart._--The sounds of the fœtal heart
were first noticed by Mayar in 1818, and those of the placenta,
or _placental souffle_, by Kergaradec in 1822. The sound of the
fœtal heart is composed of a rapid succession of short, regular
double pulsations, differing from that of the adult heart in rhythm
and frequency. It can be heard more or less over the whole of the
abdomen about the middle of the fourth month, and is not unlike the
muffled ticking of a watch. In frequency it varies from 100 to 140.
The auscultator should be careful not to hang his head down, or he
may be apt to mistake the throbbing of his own arteries for sounds
communicated from the patient.
4. _Intermittent Contraction of the Uterus._--From the fourth to the
tenth month of pregnancy, the uterus may be felt by the palpating
hand to alternately contract and relax; the period of contraction and
relaxation varies. It is present in pregnancy whether the fœtus be
alive or dead.
Pregnancy may be simulated by ascites, by fibrous tumours of the
uterus, by ovarian dropsy, and by enlargement of the uterus from
retention of the catamenia due to an imperforate hymen, &c. The breasts
may also become affected by uterine tumours.
Diagnosis of Pregnancy
1. _Pseudo-Pregnancy._--In the examination of cases of alleged
pregnancy, the medical jurist should bear in mind the possibility of
enlargement of the uterus and abdomen from the presence of tumours. The
probable occurrence of _pseudo-pregnancy_ should also be considered.
Tumours and pseudo-pregnancy may occur in the married and unmarried;
and as the latter is not infrequently accompanied with many of the
signs and symptoms of pregnancy, an early diagnosis is of the utmost
importance.
The diagnosis will consist in--
(_a_) A careful examination of all the symptoms
present, when, in most cases, a break in their order of
sequence may be observed, or certain signs may be added
which do not occur in true pregnancy.
(_b_) Presence or absence of the hymen.
(_c_) If the patient be placed well under the
influence of chloroform, the tumour, if the result of
pseudo-pregnancy, will subside, gradually returning
as the effects of the anæsthetic pass off. Whilst the
patient is under the influence of the anæsthetic, the
hand may be pressed on the abdomen at each expiration,
and there retained, the pressure being continued during
the inspirations.
2. _Dropsy._--Use of the stethoscope; examination of the breasts for
milk, and the urine for albumen.
3. _Fibrous Tumours._--Absence of fœtal movements and other signs of
pregnancy.
4. _Ovarian Dropsy._--Tumour on one side of the abdomen; breasts
unaffected, and auscultation giving negative results.
5. _Retention of the Catamenia._--On examination, the hymen found
perfect and bulging. This condition cured by a crucial incision.
DELIVERY
This subject is best discussed under three heads: (1) Signs of Recent
Delivery in the Living. (2) Signs of Recent Delivery in the Dead. (3)
Signs of Previous Delivery.
1. Signs of Recent Delivery in the Living
(_a_) Transitory Signs; (_b_) Persistent Signs of Delivery
(_a_) Transitory Signs of Delivery
1. _General Indisposition._--The face is pale or flushed; the eyes
sunken, and surrounded by a dark areola; there is considerable
debility, and a tendency to faint; the skin is warm and moist, and the
pulse quick. It must be borne in mind that a woman who is anxious to
conceal her recent delivery may, by an effort of the will, to a great
extent hide her real condition.
2. _The Breasts._--The breasts feel firm and “knotty,” and on
pressure yield a small quantity of _colostrum_ or milk, which may be
distinguished by the aid of a microscope.
3. _The Abdomen._--The skin of the abdomen shows signs of recent
distension; it is relaxed, and more or less thrown into folds, the
lower part marked by irregular broken streaks of a pinkish tint,
becoming white and silvery as time goes on.
4. _The Lochia, or the “Cleansings.”_--These consist in a discharge
from the uterus, which, for the first three or four days after
delivery, is more or less bloody. During the succeeding four or five
days it acquires a dirty-greenish colour--“green waters,” with a
peculiar sour, rancid odour. In a few days this is succeeded by a
yellowish, milky-looking mucous discharge, which may continue for four
or five weeks.
5. _External Parts of Generation._--The labia and vagina bear distinct
marks of injury and distension.
6. _The Uterus._--The uterus is enlarged, and may be felt by the hand
for two or three days after delivery, as a round ball, just above
the pubes. The orifice of the uterus, if examined a few hours after
delivery, appears as a continuation of the vagina. This condition
completely disappears in about a week after delivery.
7. _After-pains._--These are of no use from a diagnostic point of view,
as we have no means of testing their presence or absence.
(_b_) Persistent Signs of Delivery
1. _Entire obliteration of the hymen._--This is no proof of actual
delivery.
2. _Destruction of the fourchette._
3. _The vagina dilated, and free from rugæ._
4. _Dark colour of the areola round the nipples._--This varies among
women; and cases are known where there was no areola either during
pregnancy or after delivery.
5. _Skin of Abdomen._--Due to the great distension of the abdomen, the
skin appears streaked with silvery lines varying in breadth. These
markings in some cases may be scarcely perceptible, especially if the
female has worn a tight abdominal belt during her pregnancy. The same
appearance may be produced by dropsy, or the prolonged distension of
the abdominal walls, the result of other causes. Attention to the other
signs present will assist the diagnosis. After the lapse of seven to
ten days the recent delivery of a woman cannot be certainly proved by
an examination of the living woman, especially if it be known that she
had previously borne children. In primiparæ the pink-coloured streaks
on the abdomen, and the transverse condition of the os uteri, may
strongly point to recent delivery.
2. Signs of Recent Delivery in the Dead
Should the woman die immediately after delivery, the external parts
will present the same appearance as just described in the living. On
opening the abdomen, the uterus will be found fat and flabby, between
nine and twelve inches long, and with the os uteri wide open. The
cavity of the uterus may contain large bloody coagula, and its inner
surface be lined by the decidua. The attachment of the placenta is
easily detected by its dark colour, and by the semi-lunar openings of
the arteries and veins on the surface of the uterus.
Of course all the appearances just described will be greatly modified
by the time that has elapsed between delivery and death.
_Delivery after Death._--The fœtus has been known to have been expelled
from the uterus by the force of the gases generated by putrefaction.
Dr. Aveling, in a paper published in the _Obstetric Transactions_,
1873, arrives at the conclusion that _post-mortem_ delivery is possible
even where no symptoms of parturition were noticed before death. He
also thinks that the child may live _in utero_ for some hours after the
death of the mother.
Table showing the Size of the Uterus at Different
Periods after Delivery
_Two to Three Days._--7 inches long and 4 inches wide.
_Seven Days._--Between 5 and 6 inches long and 2 inches wide.
_Fourteen Days._--From 4 to 5 inches long and 1½ inches wide.
_End of Second Month._--Normal size. 2½ inches long and about
2 inches broad at the fundus.
Table giving Weight of the Uterus after Delivery
Immediately after Delivery 22 to 24 ounces.
Within a Week 18 to 21 “
End of Second Week 10 to 11 “
End of Third Week 5 to 7 “
End of Second Month normal, 9 to 10 drachms.
(Heschl.)
3. Signs of a Previous Delivery
1. _Marks on the abdomen_, consisting in shining silvery lines, due to
the distension of the skin. These may result from distension other than
that the result of pregnancy--tumours, dropsy, &c.
2. _Marks on the breasts_, similar to those appearing on the abdomen.
These, in conjunction with the above, are important.
3. _Peculiar jagged condition of the os uteri_, felt by the finger. The
condition may be the result of disease.
4. _Marks of rupture of the fourchette or perinæum._
5. _Dark colour of the areola round the nipple._
6. _Negative evidence_, from absence of any of the above.
=Can a Woman be delivered unconsciously?=--This question may arise in
cases of infanticide. Setting aside cases of epilepsy (in a fit of
which disease Husband once attended a woman who was confined during
the fit without being aware that she had been delivered), cases of
apoplexy, coma, and narcosis from chloroform, opium, &c., it may be
stated that delivery is possible during profound sleep. Husband once
attended a woman who informed him that “she always had her pains during
her sleep,” and only woke up just as the head came into the world. When
it is borne in mind how easily some women pass through labour, it is
quite possible that, after a busy day, sleep may be so profound as not
to be disturbed by the pains of labour. In primiparæ the occurrence
is more problematical. Women have often declared that they have been
unconsciously delivered whilst at stool. This is also possible, but the
circumstances of the case must be severely sifted.