DELIVERY. 499 DELIVERY. CHAPTER XLV. DELIVERY IN THE LIVING.-CONCEALED DELIVERY.-SIGNS OF ABORTION IN THE EARLY STAGES OF PREGNANCY.-SIGNS OF RECENT AND REMOTE DELIVERY.-FEIGNED DELIVERY.-DELIVERY IN A STATE OF UNCONSCIOUSNESS.-SIGNS OF DELIVERY IN THE DEAD.-TRUE AND FALSE COPORA LUTEA.-CHARACTERS OF THE OVUM OR EMBRYO.-MOLES.-CONCEALMENT OF BIRTH. DELIVERY is a subject which much more frequently requires medicolegal intervention than pregnancy. It will be sufficient to state that the concealment of birth, the crimes of abortion and infanticide, with questions relative to supposititious children, are closely dependent on the proof of parturition. This subject will admit of being considered under two heads: 1. As it relates to delivery in the living. 2. As it relates to delivery in the dead. In undertaking the investigation, we ought, if possibie, to ascertain, either from the female herself or from those around her, whether there was reason to suspect that she had been pregnant. If we can acquire any knowledge on this point, it will materially facilitate our inquiry; but this is not always possible. It has generally happened that previous pregnancy has been so concealed that few who saw the woman suspected her condition; then again, as the admission of her delivery may be the strongest proof of her criminality, she will perhaps resolutely deny it; and a medical practitioner has no right to extort this admission from her. From this it will be seen that a medical witness must often be prepared to prove the fact of delivery against the woman who is criminally charged. Delivery in the Living. Concealed Delivery. The signs of delivery in a living woman vary materially according to the time at which this event has taken place. In common language, if the contents of the womb are expelled before the sixth month, the woman is said to miscarry, or to have an abortion; if after the sixth month, she is said to have a premature labor. The law does not admit any such distinction; the expulsion of the ovum, fœtus, or child by criminal violence, at any period of uterogestation, is regarded as a miscarriage or abortion. It has been well observed that the signs of delivery are indistinct in proportion to the immaturity of the ovum. Thus, when it takes place at the second or third month there are scarcely any proofs which can be derived from an examination of the woman. All the ordinary signs of delivery at the full period will be absent the development of the embryo not having been sufficient to cause any prominence in the abdomen, or to give rise to those changes in the system which take place previously to the birth of a mature child; e. g. enlargement of the breasts and dilatation of the mouth of the womb. Abortion at this period (the second or third month) is generally accompanied by loss of blood, which may manifest itself by its effects on the body. This, however, can only give rise to a suspicion. At a later period of gestation there may be a discharge resembling the lochia, and the 500 SIGNS OF DELIVERY IN THE LIVING. mouth of the womb may be found enlarged and soft; but from the small size of the fœtus the outlet may present no positive evidence of delivery. The quantity of blood lost may be greater and may have a more decided effect on the system. Of course, if the ovum, fœtus, or any of its membranes be found, then the presumption of abortion will be strongly sup ported; but women who designedly conceal their condition will commonly take effectual means to prevent the examiner from obtaining evidence of this kind. Signs of Recent Delivery in the Living-The woman is weak, the countenance pale, the eyes are surrounded by livid areolæ, and there is an appearance of general indisposition. Any severe illness may, however, give rise to similar symptoms. Their sudden occurrence after a state of previous good health, especially when pregnancy is known or suspected, will create a strong suspicion. The breasts are large and full, especially about the third or fourth day after delivery; the nipples are enlarged, and the areola around them present all the characters of advanced pregnancy. If the appearances described are not well marked at the first examination, they may be seen at a later period; and in a doubtful case, when the embryo or foetus is not forthcoming, a second examination should be made before a final opinion is given. 1. The skin of the abdomen is relaxed, sometimes thrown into folds; the cuticle interrupted by light colored broken streaks (linea albicantes), passing especially from the groins and pubes towards the navel, which is more or less stretched and altered in appearance. Any disease which has caused enlargement of the abdomen may give rise to a similar appearance in the skin, so that, when taken alone, much confidence cannot be placed in these lines or streaks as proofs of delivery. The round form of the enlarged and semi-contracted womb may be felt at the lower part of the abdomen, generally lying towards one or the other side. The apparent size of this organ will depend upon the degree to which it has contracted, and therefore greatly upon the time at which an examination is made. Montgomery has pointed out the existence of a dark line extending from the pubes to the navel, with a dark areola round the latter, in cases of recent delivery; but he has found this line to exist independently of pregnancy and delivery-in one case in a girl aged 10, and in another instance in a lady laboring under an ovarian tumor. 2. The organs of generation will be found externally swollen, contused, or even lacerated, with clots of blood about them. The outlet is much dilated, the vagina relaxed, the mouth of the womb considerably open, and its margin much relaxed. The neck of the womb is shortened and scarcely perceptible; and the body of this organ is from two to four times the size which it has in the unimpregnated state. It occasionally happens that the neck of the womb is lacerated on one side during the passage of the head in primiparæ ; should a laceration or a cicatrix be found, it will much assist in proving delivery. 3. The Presence of the Lochia (from aóxos, childbirth).—This is a discharge, at first of a sero-sanguineous liquid, but which afterwards appears as a brown or green colored serum. It commences soon after delivery, and continues from a week to a fortnight, or even longer; it may be absent after the third day. The discharge has so peculiar an odor that some have regarded this alone as furnishing strong evidence of recent delivery. The signs which have been here enumerated are found only when no delay has taken place in making the examination and the woman has been recently delivered. In some strong and vigorous women, the body re SIGNS OF REMOTE DELIVERY. 501 sumes its natural state within a few days, and the traces of parturition may have wholly disappeared or have become so ambiguous as to furnish no satisfactory evidence. In others, again, proofs of delivery will be obtainable for a fortnight or three weeks afterwards. In most cases, however, it is difficult, if not impossible, to say, after the lapse of eight or ten days, that delivery has certainly taken place, the signs having commonly by that time disappeared. In all cases, the earlier the period at which an examination is made the more satisfactory will be the evidence obtained. Montgomery once examined a woman five days after her delivery at the fill time, and he was particularly struck with the degree to which the pirts had become restored to their ordinary condition, especially the mouth sad neck of the womb, which hardly differed from their natural and unimpregnated form. This inquiry becomes of considerable importance in a case of alleged child-murder. When the body of a child is not found until after two or three weeks from the time of its birth, and the suspected woman denies that she has been delivered of a child, she will probably not deny her pregnancy, but may assert that she has had an abortion at an early period. (See a case in Vierteljahrsschr. für Gerichtl. Med., 1863, p. 275.) In cases of abortion at an earlier period, the placenta is not always di-charred at the time at which the embryo or foetus is expelled from the womb. (Med. Times and Gaz., 1859, i. p. 278.) A microscopical examination of the discharges might reveal placental or chorionic structures. In a case which occurred to Paxton, all the usual signs of delivery were present in a woman æt. 20; she had evidently lost much blood, and was mach reduced. From the state of the organs, Paxton considered that she had been delivered of a child within three days. There was no lochial discharge at the date of examination. The woman had previously denied her pregnancy when charged with concealment of it, but after the medical examination she altered her statement, and said that she had not only been pregnant, but was so at that time. On a further examination, the womb was found to contain a foetus advanced to about the sixth month, and in three months more she was delivered of a child. What caused the appearances of delivery, the condition of the breasts, etc.? Either she had shortly before been delivered of a child or of a blighted ovum or fœtus. Neither foetus nor placenta was ever seen or could be found, but the woman had had ample opportunity to dispose of them. This may have been a case of twin conception or of superfotation. It shows that, in charges of concealment of pregnancy or delivery, it must not be inferred, when the appearances of delivery clearly exist, that the womb is empty. This organ should always be examined in order to determine whether it contains another foetus. Signs of Delivery at a Remote Period.-A question may arise whether it is in the power of a medical practitioner to determine the period at which delivery took place, i. e. how long a time has elapsed. This becomes necessary when, in cases of concealed birth, abortion, or infanticide some time after suspected parturition), a child is found, and it is required to determine whether the time which has elapsed since the birth of the child, either dead or living, corresponds with the supposed delivery of a suspected woman. An opinion may be given within eight or ten days after delivery, from the state of the breasts, of the discharges (lochia), and of the mouth of the womb; but it becomes difficult after the sixth day; and when the tenth or twelfth day has passed it is still more difficult. After two or three months, it may be regarded as impossible to assign the date of delivery with any degree of precision. (See Devergie, Méd. Lég., vol. 1, p. 446.) 502 FEIGNED DELIVERY. In a case of pretended delivery, contested legitimacy, or disputed chastity, a medical jurist may be required to say whether a woman has, at any antecedent period of her life, been delivered of a child. This question, it must be remarked, can be raised only in respect to delivery at the full period, since there is no doubt that abortion in the early stages of pregnancy may take place and leave no traces of such an event discoverable in after-life. Indeed, a few days or weeks are sometimes sufficient to obliterate all evidence of the fact. With respect to delivery at the full term, certain signs have been mentioned, which by some are considered indelible. These are shining streaks on the skin of the abdomen, a brown mark reaching from the navel to the pubes, and the state of the mouth of the womb, which is said never to close so effectually as in the virgin. In regard to the appearance of the skin of the abdonien, it may be remarked that any morbid causes giving rise to a distention of the cavity-as ovarian enlargement or dropsy-will produce the same effect; so, also, to a certain extent, extreme emaciation from a state of obesity. (See Med. Times and Gaz., 1861, i. p. 450, on False Cicatrices.) Then, again, these marks on the skin are not always persistent throughout life. Besides, a woman, according to the statements of good observers, may be not only once, but repeatedly delivered, without having these marks produced. (Med. Times and Gaz., 1860, i. p. 583; also Ann. d'Hyg., 1873, t. 2, p. 139.) With regard to the state of the mouth of the womb, it is liable to vary in different women and to be affected by disease-so that a certain judg ment cannot always be formed from its condition. In a woman who has not borne children the mouth of the womb is in the form of a slit, the angles being bent down and giving to it the appearance of the os tinea (tench's mouth). Whitehead has observed that in a woman who has borne children the mouth becomes elongated and loses the slight bend at each of its extremities; the labia are thickened, and more nearly of equal size; the commissures are less clearly defined, and the whole of the neck is enlarged and not so compact in texture. (On Abortion, p. 195.) It must be remembered, however, that the condition of the mouth of the womb, even in the virgin, varies at each menstrual period. Should there be congenital occlusion of the vagina, or the hymen be found imperforate, this will at once negative a previous delivery; but the latter condition will not negative a previous pregnancy, since a woman may have been impregnated, and have had an abortion in an early stage of pregnancy, without a necessary destruction of the hymen. This sort of negative evidence may, however, be sometimes of great value. There is a total want of good affirmative evidence of delivery at a remote period in the living, if we except that which is furnished by the presence of cicatrices in the vagina, or of a cicatrix as a result of a lacerated perineum. It is rare, however, that any decision on this subject is required in medical jurispru dence. It might be demanded, either in a case of infanticide, when a woman was accused of having destroyed her alleged offspring some months or years before; or in a case of contested legitimacy, when a female is accused of having substituted a child of which she pretends she had been delivered at some remote period of time. Feigned Delivery.-Delivery has often been feigned by women for the purpose of extorting charity, compelling marriage, or disinheriting parties who have claims to an estate, and in other cases without any assignable motive. Of course, an imposition of this kind could not be sustained before a medical practitioner; and detection is rendered easy, because it is recent and not remote delivery which is assumed. The latter would, if pretended, UNCONSCIOUS DELIVERY. 503 he generally cleared up by an examination, as well as by circumstantial evidence. (See case, Lond. Med. Gaz., vol. xix. p. 231; also another by Capuron, Méd. Lég. des Accouchements, p. 110.) Can a Woman be delivered unconsciously?-Another important question relative to delivery in the living is whether a woman can be delivered without being conscious of it. The signs of delivery may be discovered by a practitioner; the offspring may also be found; the woman may admit the fact of her delivery, but allege that she was totally unconscious of it. The only medico-legal case in which this plea is occasionally raised is in infanticide; and as the possibility of the occurrence may be questioned, the practitioner must be provided with a knowledge of those facts which medico-legal writers have accumulated respecting it. There is no doubt That a woman may be delivered unconsciously during profound sleepwhile laboring under coma, apoplexy, asphyxia, syncope, or when suffering from the effects of narcotic poisons-e. g. the vapors of chloroform and ether, or intoxicating liquors. It is said, also, that delivery has taken piace spontaneously while a woman was in the act of dying. This, howver, has no bearing on the present question. It is in those cases where, after her recovery, a woman pleads unconsciousness of delivery that medal practitioners are chiefly consulted. Besides the cases enumerated, hysteria, when accompanied by loss of sense and motion, has been mentioned as a state in which parturition is liable to occur unconsciously. We need not be surprised at delivery taking place under these circumstances, when we consider that the contractile power of the womb is altogether independent of volition; but, unless the morbid states already mentioned are accompanied by the most profound lethargy and entire loss of sensaion, it can rarely happen that the contractions of this organ in its efforts to expel the child should not at once rouse a woman into consciousness. We ought particularly to expect this in primiparæ, i. e. in those who have never before borne children. At the same time, it must be remembered that parturition in some women, especially when the pelvis is wide and the child small, may take place with such rapidity and ease as scarcely to be accompanied with pain. It has been observed that when a woman has frequently borne children delivery sometimes takes place without effort, and without any consciousness on her part. On other occasions a woman may lie in a kind of torpor or stupor, or suffer from puerperal convulsions, and have no recollection of her delivery. The following case is possible: a woman may be deliv ered while under the influence of puerperal convulsions, which might have attacked her before labor set in; and after delivery, but before compete recovery, she might become maniacal-a not unfrequent condition_ oring which interval she may have killed or injured her child; or the ild may have been born dead or suffering from some accidental injury. She would with truth assert her entire ignorance of it. Her statement would be verified by a bitten tongue and a congested conjunctiva or face. Should albumen be found in the urine, this fact would be still more conmative. Of course, puerperal convulsions occur without these results. The statement might be disproved by finding that her actions had shown care and design in other circumstances at the time she said she was unconious. King has described the case of a woman, æt. 36, the mother of nine children. She received his assistance in her tenth labor: when summoned, she was lying calmly and placidly in bed, and was perfectly insensible. He found that the child had been expelled with the placenta. The Woman did not recover her consciousness for ten or twelve hours, and then stated that she had no recollection either of the birth of the child or of any |