CHAPTER XII
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.
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