A TEXT-BOOK OF LEGAL MEDICINE AND TOXICOLOGY
EDITED BY
FREDERICK PETERSON, M.D.
President of the l^ew York State Commission in I^unacy ; Clinical Professor
of Psychiatry, Columbia University, New York ; General
Consultant to the Craig Colony for Epileptics,
Sonyea, New York
WALTER S. HAINES, M.D.
Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College,
Chicago ; Professorial lyccturer on Toxicology in
the University of Chicago
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Containin0 about tsoo l&aocj?, JFuH)? 3inu?tra«b
VOLUME II
PHILADELPHIA. NEW YORK, AND LONDON
W. B. SAUNDERS & COMPANY 1904 .
Copyright, 1904, by W. B. Saunders & Company.
Registered at Stationers' Hall, London, England.
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ELECTROTYPED BY PRESS OF
WESTCOTT & THOMSON. PHILADA W. B. SAUNDERS & CO.. PHILADA.
CONTRIBUTORS TO VOLUME II.
WILLIAM T. BELFIELD, M. D., Chicago.
Associate Professor of Surgery in Eush Medical College, iu Affiliation with the University of Chicago ; Professor of Gen ito- Urinary and Venereal Diseases in Chicago Policlinic.
CHARLES GILBERT CHADDOCK, M. D., St. Louis.
Professor of Diseases of the Nervous System, Marion-Sims-Beaumout College of Medicine, Medical Department of St. Louis University.
JOSEPH F. DARLING, A. M., LL.B., New York City.
EDWARD P. DAVIS, A.M., M.D., Philadelphia.
Professor of Obstetrics in the Jefferson Medical College, Philadelphia ; Visiting Obstetrician to the Jefferson and Philadelphia Hospitals.
CHARLES A. DOREMUS, A.M., M.D., Ph.D., New York City.
Formerly Professor of Chemistry and Toxicology, Medical Department, University of Buffalo ; Member of the Medico-Legal Society ; Associate Member of the Massa- chusetts Medico-Legal Society.
W. A. NEWMAN DORLAND, A. M., M. D., Philadelphia.
Associate in Gynecology, Philadelphia Polyclinic ; Assistant Obstetrician to the Hospital of the University of Pennsylvania, etc.
J. T. ESKRIDGE, M. D.,i Denver.
Late Consulting Alienist and Neurologist, Arapahoe County Hospital ; late Neurolo- gist to St. Luke's Hospital, Denver, Col.
MARSHALL D. EWELL, A.M., M. D., LL. D. (Univ. of Mich.), Chicago.
Professor of Elementary Common Law and Medical Jurisprudence in the Chicago- Kent College of Lav7 ; formerly Lecturer on Medical Jurisprudence in the University of Michigan.
LEONARD FREEMAN, B. S., A. M., M. D. Denver.
Professor of Surgery, Denver and Gross Medical College ; Surgeon to Denver City and County Hospital, St. Joseph's Hospital, St. Luke's Hospital, and Jewish National Hospital, Denver, Colo.
A. L. GOLDWATER, M. D., • New York City.
Lecturer on Chemistry and Toxicology to the New York Board of Pharmacy Institute ; Instructor in Laryngology, New York School of Clinical Medicine.
1 Deceased.
3
4 CONTRIBUTORS TO VOLUME II.
WALTER S. HAINES, M. D., Chicago.
Professor of Chemistry, Pharmacy and Toxicology in Rush Medical College, in Affilia- tion with the University of Chicago ; Professorial Lecturer on Toxicology in the University of Chicago.
CHARLES HARRINGTON, M. D., Boston.
Assistant Professor of Hygiene in the Harvard Medical School ; Associate Member of the Massachusetts Medico-Legal Society.
JAMES W. HOLLAND, M. D., Philadelphia.
Professor of Medical Chemistry and Toxicology, Jefferson Medical College, Phila- delphia ; Member of the American Philosophical Society, Fellow of the College of Physicians, Philadelphia.
REID HUNT, Ph. D., M. D., Baltimore.
Associate Professor of Pharmacology and Toxicology, Johns Hopkins University, Baltimore.
WALTER JONES, Ph. D., Baltimore.
Associate Professor of Physiological Chemistry and Toxicology, Johns Hopkins University, Baltimore.
CARLOS F. MacDONALD, A. M., M. D., New York City.
Professor of Mental Diseases and Medical Jurisprudence in the University and Bellevue Hospital College, New York : Consulting Physician to Manhattan State Hospitals ; Consulting Physician to the Psychopathic Hospital and Laboratory of the New York Infirmary for Women and Children ; Ex-Superintendent of the Auburn and Binghamton State Hospitals for the Insane ; Member of the American Medico- Psychological Association, etc.
HAROLD N. MOYER, M. D., Chicago.
Assistant Professor of Medicine in Rush Medical College, in Affiliation with the University of Chicago.
OSCAR OLDBERG, Pharm. D., Chicago.
Dean of the School of Pharmacy of Northwestern University, Chicago.
ALBERT B. PRESCOTT, M. D., Ph.D., LL. D., Ann Arbor.
Director of the Chemical Laboratory, Professor of Organic Chemistry, and Dean of the School of Pharmacy in the University of Michigan.
JEROME PROBST, Ph. G., LL. B., of the Chicago Bar, Chicago.
JEROME H. SALISBURY, M. D., Chicago.
' Professor of Internal Medicine, Chicago Clinical School ; Assistant Professor of Chemistry in Rush Medical College, in Affiliation with the University of Chicago.
GEORGE KNOWLES SWINBURNE, A. B., M. D., New York City.
Surgeon to Good Samaritan Dispensary, New York City. VICTOR C. VAUGHAN, M. D., Ph. D., Sc. D., LL. D., Ann Arbor.
Dean and Professor of Hygiene and Physiological Chemistry in the Department of Medicine and Surgery of the University of Michigan.
EDWARD S. WOOD, A. M., M. D., Boston.
Professor of Chemistry in the Harvard Medical School ; Member of the Massachu- setts Medical Society ; Member of the Massachusetts Medico- Legal Society, etc.
PREFACE.
The object of the present work is to give to the medical and legal professions a fairly comprehensive survey of forensic medicine and toxi- cology in moderate compass. We believe this has not been done in any very recent work in English. A number of manuals of limited size and scope have been presented on the one hand, and on the other certain systems of legal medicine of almost encyclopedic dimensions. Both find fields of great usefulness ; but there is still left a broad ground intermediate between the two which we trust the present work will fill, and it was in this hope that the book has been planned and executed.
With few and wholly unimportant exceptions the articles composing the two volumes have been inserted without change by the editors. This has been done in order that the responsibility for statements of facts and opinions may be authoritatively placed upon the individual contributors — a matter of much moment in legal proceedings. In doing this we are aware that we have occasionally sacrificed unity of plan and harmony of views, but the advantages, especially to the legal profession, of individual responsibility we believe much more than com- pensate for these defects.
As the ordinary English weights and measures and the Fahrenheit thermometer scale are still the only ones easily understood by the ma- jority of courts and juries, we have generally used these measures, wholly or in conjunction with their equivalents in metric weights and measures and the Centigrade scale. This rule, however, has not been followed in the description of purely chemical tests and processes, as the metric system is practically universally employed in connection with them.
In the names of drugs and chemicals we have followed the nomen- clature and, with slight modifications, the spelling of the United States Pharmacopeia, believing that by adhering to so authoritative and well known a standard as this much confusion will be avoided and a not in- frequent source of perplexity to lawyers and physicians eliminated.
The work is divided, for convenience of reference, into two sections, Part I. and Part IL, the latter being devoted to Toxicology, and all other portions of Legal Medicine in which laboratory investigation is an essen- tial feature.
Our thanks are due to the many distinguished men who have aided us in the production of the work by their valuable contributions ; and we are greatly indebted to the publishers, Messrs. W. B. Saunders & Co., for the unfailing interest they have shown in the book, and for the numerous courtesies they have extended to us in its preparation.
FE^DERICK PETERSON, WALTER S. HAINES.
CONTENTS OF VOLUME II.
PART L
MALINGEKING AND THE FEIGNED DISORDERS (By J. T. Eskridge
and Leonard Freeman) 17
Historical survey, 17 — Simulated affections, 19 — Feigned affections, 19 — Fac- titious affections, 22 — Exaggerated affections, 25 — Self-produced injuries, 26 — Hysteria, 28 — Feigned mental and bodily disordere, 29 — Differential tables, real and feigned mental diseases, 32, 33 — Feigned pregnancy, 44 — Feigned menstruation, 45 — Feigned delivery, 45 — Feigned abortion, 45.
THE LEGAL ASPECTS OF PREGNANCY (By W. A. Newman Dorland) 46 Signs of pregnancy, 47 — Uterine signs, 48 — Vaginal signs, 51 — Abdominal signs, 54 — General symptoms, 56 — Diagnosis of pregnancy, 58 — Impregnation during unconsciousness, 60 — Unconscious pregnancy, 60 — Pregnancy in the dead, 61.
LEGITIMACY.— THE DETERMINATION OF SEX.— SIGNS OF DELIV- ERY (By W. A. Newman Dorland) 63.
Legitimacy, 63 — Fecundity, 64 — Supposititious children, 64 — Duration of pregnancy, 65 — Protracted gestation, 69 — Abnormally shortened labor, 72 — Paternity, 73 — Viability, 73 — Live birth, 73 — Fetal development, fourth day to term, 74-77 — Multiple pregnancy, 77 — Superfetation, 77 — Determination of sex, 78 — Hermaphroditism, 78 — Signs of delivery, 79 — Feigned delivery, 85 — Unconscious delivery, 85 — Concealment of birth, 85 — Concealed delivery, 85.
BIRTH AND LEGITIMACY (By Joseph F. Darling and A. L. Goed-
water) 87
Blackstone's definition, 87 — Genei-al rules, 87 — Continental laws on birth, 87" — Bastards, 87 — Posthumous children, 87 — Proof of paternity, 88 — Proof of legiti- macy, 88 — Proof of birth of legitimate child, 89 — Presumptions of access in, pregnancy, 89 — Competent time, 90.
ABORTION (By Edward P. Davis) 91
Definition, 91 — Criminal abortion, 91 — Statistics, 91 — By whom committed,. 92— Methods, 92— Drugs, 93— Mechanical aids, 93— Results, 93— Diagnosis,, 95 — Results, perceptible, 97 — Mortality, 97 — SepsMs, 98 — Effects of sepsis, 98 — Shock, 98 — Treatment, 98 — Opei-ation, 99 — Decrease of, 99 — Physician's re- sponsibilities, 100 — State laws, 101.
7
O CONTENTS OF VOLUME II.
PAGE
INFANTICIDE (By Edward V. Davis) 103
Definition, 103 — Diagnosis, 104 — Suspicious infantile deaths in institutions, 105 — Infanticide by niottieis, 105 — Sudden delivery in upright position, 106 — Injury to fetus during parturition, 108 — Communication of poison to child in utero, 108— Extenuating circumstances, 108 — Suffocation, from mucus, 109 — Mechanical, 109 — By carbolic acid, 110 — Statistics, 110 — Respiratory act of fetus, 111 — Physiology of respiration, 113 — Artificial respiration, 114 — Relative size of mother and child, 115 — Respii-atory tract, 115 — Umbilical cord, 115.
IMPOTENCE AND STERILITY (By Charles Gilbert Chaddock) .... 117 Sexual impotence, 117 — Sterility, 117 — Impotence in the male, 117 — Physical causes, 118 — Psychic causes, 121 — Impotence in the female, 123 — Sterility in the male, 124 — Sterility in the female, 125.
RAPE (By Charles Gilbert Chaddock) 127
Definition, 127 — Consent, 127 — Virgin state of female genitals, 128 — Venereal disease in victim, 134 — Evidence of force, 135 — Fear of threats, 136 — Uncon- sciousness, physiologic or pathologic, 136 — False accusations, 137 — Hypnotism, 138— Mental incapacity, 139— Causes, 139.
UNNATURAL SEXUAL OFFENSES (By Charles Gilbert Chaddock) . . 141 Incest, 141 — Psycho-physiology of, 141 — Indecent exposure, 143 — Pederasty, 143— Bestiality, 143— Tribadism, 143.
VENEREAL AND GENITO-URINARY DISEASES IN THEIR MEDICO- LEGAL RELATIONS (By George K. Swinburne) 145
Impotence and sterility, 145 — Causes of impotence in the male, 146 — Causes of sterility in the male, 147 — Causes of impotence and sterility in the female, 149 — Gonorrhea, 150 — Latent gonorrhea, 153 — Effects of gonorrhea in man, 153 — Effects of gonorrhea in women, 154 — Effects of gonorrhea upon offspring, 155 — Syphilis, 157 — Syphilis in women, 159 — Effects of syphilis in children, 159.
MARRIAGE AND DIVORCE (By Joseph F. Darling) 161
General consideration of marriage, 161 — Conflict of marriage laws, 162 — Con- flict of divorce laws, 162 — New York laws on matrimonial actions, 163 — Adul- tery, 164 — Bigamy, 164 — Cruelty, 164 — Grounds for matrimonial actions, 164 — Impotence or physical inability, 165 — Impotentia seminales et copulandi, 166 — Mental incapacity, insanity, 169 — Duress, 170 — Cruelty, 170 — Copula, 171 — Pregnancy, 171 — Venereal disease, 172 — Access, birth of child, 172 — Unchastity, 172 — Miscegenation, 172.
MALPRACTICE (By Marshall D. Ew^ell) 174
Civil malpractice, 174 — Voluntary services, 176— Errors of judgment, 176 — Schools of practice, 177 — Urgent operations, 179— Dentists, 179 — Sex, 179 — Contract to cure, 179— Mesmerism, 180— Coffinism, 180 — Morrisonism, 180 — Clairvoyance, 180— Christian Science, 180— Faith Healing, 180— Metaphysics, 180 — Dosage, 181 — Young's rule for dosage, 181 — Cawling's rule for dosage, 181 — Clarke's rule for dosage, 181— Criminal malpractice, 181 — Justice Willes on criminal malpi-actice, 182— Nanny Simpson case, 183 — Tassymond case, 183 — Miscellaneous cases, 184.
CONTENTS OF VOLUME II. 9
PAGE
THE MEDICOLEGAL KELATIONS OF THE EONTGEN OR X-RAYS (By
Harold N. Moyer) 185
General consideration, 185 — Radiographs as evidence, 186 — Interpretation of skiagraplis, 186 — Court decisions, 187 — X-ray burns, 189 — Hard and soft tubes, 190 — Pathology of X-ray burns, 191.
LAWS RELATING TO THE INSANE (By Carlos F. MacDonald) .... 194 Arranged alphabetically ; State asylums named under each State and Terri- tory, 194-296
PART II
GENERAL PRINCIPLES OF TOXICOLOGY (By Walter S. Haines) ... 299 Definition, 299 — Classification of poisons, 301 — Conditions affecting the action of poisons, 302— Diagnosis of poisoning, 306 — Treatment of poisoning, 308 — Postmortem examination, 315 — Chendcal analysis, 318 — Separation of volatile poisons, 321 — Examination for mineral poisons, 322 — Detection of organic poisons, 330 — Separation of ptomains, 337— Separation of poisons by dialysis, 339.
INORGANIC POISONS (By James W. Holland) . . . 340
Corrosive poisons, 340 — Corrosive acids, 341 — Sulphuric acid, 342 — Nitric acid, 347 — Fumes of nitric acid, 350 — Hydrochloric acid, 350 — Nitromuriatic acid, 353 — Oxalic acid, 353 — Corrosive alkalis, 357 — Potassium hydroxid, 358 — Sodium hydroxid, 359 — Ammonium hydroxid, 360 — Irritant poisons, 363 — Phosphorus, 363 — Salts of the alkaline metals, 373 — Potassium chlorate, 373 — Potassium nitrate, 374 — Potassium bitartrate and potassium sulphate, 375 — Boric acid and borax, 375— Alum, 376 — lodin, 377 — lodism, 378 — Bromin, 379 — Bromism, 379— Chlorin, 380— The heavy metals, 380— Silver, 380— Lead, 381 — Acute lead poisoning, 382 — Chronic lead poisoning, 383 — Mercury, 389 — Acute mercurial poisoning, 391 — Mercurialism, 393 — Copper, 398 — Acute copper poisoning, 399 — Chronic copper poisoning, 400 — Bismuth, 402 — Arsenic, 404 — Arseniuretted hydrogen, 405 — Arsenic trioxid, 406 — Chronic arsenical poisoning, 412 — Arsenic-eating, 414 — Normal arsenic, 427 — Ai-senic pentoxid, 428 — Antimony, 433 — Tin, 439 — Chromium, 440 — Iron, 441 — Zinc, 442 — ^^Metals of the alkaline earths, 445 — Barium, 445.
ALKALOIDAL POISONS (By Albert B. Prescott) 447
The chemical character and constitution of the alkaloids, 447 — Identification in analysis, 448— Properties of vegetable alkaloids, 450 — General reagents for the precipitation of alkaloids, 452 — Use of general reagents for negative tests, 452 — Special chemical tests and color reactions, 453— Physiologic tests, 453 — Separation from animal tissues, 454 — Analyses for alkaloidal poisoning before death, 454 — Extraction of alkaloids from tissues not without inherent waste, 455 — Results of experimental analysis for alkaloids, 456 — Experiments to guard against fallacies in analysis, 456 — Precautions against impurities in rea- gents, 457 — Period of detection of alkaloidJal poisons, 458 — Aconite and aconi-
10 CONTENTS OF VOLUME II.
tine, 458 — Atropin and related alkaloids, 462— Cocain, 471 — Colchiciim and colcbicin, 474— Coniin and poison hemlock, 478 — Gelsemium and its alkaloids, 481 — Morphin and opium, 485 — Meconic acid, 505 — Codein, 508 — Nicotin and tobacco, 509 — Strychnin, 512 — Brucin, 523 — The veratrum alkaloids, 524 — Mushroom poisons, 527 — Muscarin, 528.
NON-ALKALOIDAL OKGANIC POISONS (By Keid Hunt and Walter
Jones) 532
Petroleum, 532— Methyl-alcohol, 534— Ethyl-alcohol, 537— Fusel oil, 544— Formaldehyd, 544 — Pamldehyd, 546— Chloral hydrate, 548— Chloroform. 553 — Bromoform, 561 — Iodoform, 562 — Sulphonal, 564— Trional and tetronal, 566 — Organic acids of the fatty acid series, 566 — Ether, 567 — Amyl nitrite, 569— Ethyl bromid, 570— Nitroglycerin, 571 — Hydrocyanic acid and the cyanids, 573 — Oil of bitter almonds, 581 — Cyanids other than hydrogen and potassium cyanids, 583 — Benzene, 587 — Naphtalin, 587 — Oil of turpentine, 589 —Oil of savin, 589— Oil of cedar, 591— Camphor, 592— Carbolic acid, 593 — Dihydroxybenzenes, 600— Guaiacol, 600— Creasote, 600 — Pyrogallol, 600 — Naphtol, 601— Salicylic acid, 603— Salol, 604— Picric acid, 604— Nitroben- zene, 606— Dinitrobenzene, 609— Anilin, 609 — Anilin and similar dyes, 611 — Acetanilid and similar compounds, 612— Phenacetin, 614 — Antipyrin, 615 — Cantharides, 616— Digitalis, 617— Strophanthus, 620— Oleander, 621— Ergot, 621— Cotton-root bark, 623— Male fern, 623— Santonin, 625— Vegetable purga- tives, 627 — Purgative oils, 627 — Croton oil, 627 — Castor oil, 628 — Anthracene purgatives, 629 — Aloes, 629 — Rhubarb, 629 — The jalapin purgatives, 630 — Jalap, 630— Colocynth, 630— Podophyllum, 630— Gamboge, 631— Elaterium, 631— Rhus toxicodendron, 632— Tansy, 635— Oil of pennyroyal, 636— Picro- toxin, 636— Cicuta, 639— Laurel, 641— Locust, 642.
GASEOUS POISONS (By Charles A. Doremus) 644
Carbon dioxid, 645 — Carbon monoxid, 648 — Poisonous gaseous mixtures, 661 — Vapor from burning charcoal and coal, 661 — Vapors from lime, brick, and cement kilns, 663 — After-damp and gases left after explosions of gun-powder, gun-cotton, etc., in mines, 664 — Water-gas, producer gas, fuel gas, 664 — Satu- i-ated hydrocarbons, 666 — Methane, 666 — Unsaturated hydrocarbons, 667 — Acetylene, 667 — Ethylene, 668 — Illuminating gas, 669 — Hydrogen sulphid, 671— Sewer air, 673— Sulphur dioxid, 674— Nitrogen monoxid, 675— Nitric oxid, 676.
FOOD-POISONING (By Charles Harrington) 678
Poisoning by vegetable foods, 678— Poisoning by ptomains, 678 — Poisoning by proteid-toxins, 680 — Treatment of food-poisoning, 689.
PTOMAINS AND OTHER BACTERIAL PRODUCTS IN THEIR RELA- TION TO TOXICOLOGY (By Victor C. Vaughan) 691
The tests for morphin, 691— Coniin, 699— Nicotin, 701— Strychnin, 702— Atropin, 703— Digitalin, 704— Veratrin, 704— Delphinin, 705— Colcbicin, 705 — Some proposed methods of separating vegetable alkaloids from putrefactive products, 707.
THE POSTMORTEM IMBIBITION OF POISONS (By Victor C. Vaughan) 708
CONTENTS OF VOLUME II. 11
PAGE
MEDICOLEGAL EXAMINATION OF BLOOD AND BLOOD-STAINS (By
Edward S. Wood) 722
Blood-stains, 723 — Methods of identifying blood-stains, 727 — Chemical tests for blood, 729 — Spectroscopic test for blood, 734— Microscopic examination of blood, 739 — Influence of disease on the red blood-cells, 749— The serum-test for blood, 750 — Conclusions, 752 — Other stains containing blood, 753 — Men- strual stains, 753 — Nasal blood-stains, 753.
MEDICOLEGAL EXAMINATION OF SEMINAL STAINS (By Edward S.
Wood) 755
Florence test, 756 — Detection of spermatozoa, 759 — Biologic test, 761.
MEDICOLEGAL EXAMINATION OF HAIES (By William T. Belfield) 763
DEATH FKOM POUNDED GLASS AND OTHER MECHANICAL IRRI- TANTS (By Walter S. Haines and Jerome H. Salisbury) .... 767
THE RESPONSIBILITIES OF PHARMACISTS AND THEIR AGENTS (By
Oscar Oldberg and Jerome Probst) 776
INDEX .787
GENERAL INDEX 806
CONTENTS OF VOLUME I,
INTRODUCTION; EXPERT EVIDENCE (By Frederick Peterson and Walter S. Haines).
THE TECHNIC OF MEDICOLEGAL POSTMORTEM EXAMINATION (By LuDwiG Hektoen).
IDENTITY (By James Ewing).
THE SIGNS OF DEATH (By James Ewing).
SUDDEN DEATH (By James Ewing).
DEATH FROM COLD, HEAT, AND STARVATION (By Allen J. Smith).
DEATH FROM ASPHYXIA (By Allen J. Smith).
DEATH AND INJURIES BY LIGHTNING AND ELECTRICITY (By Smith Ely Jelliffe).
WOUNDS (By Lewis Balch).
GUNSHOT WOUNDS; BURNS AND SCALDS (By Josiah N. Hall).
THE DESTRUCTION AND ATTEMPTED DESTRUCTION OF THE HUMAN BODY BY FIRE AND CHEMICALS (By Walter S. Haines).
RAILWAY INJURIES (By J. Chalmers DaCosta).
INJURIES AND DISORDERS OF THE NERVOUS SYSTEM FOLLOWING RAILWAY AND ALLIED ACCIDENTS (By Pearce Bailey).
THE MEDICAL JURISPRUDENCE OF LIFE INSURANCE (By S. T. Arm- strong).
THE MEDICAL JURISPRUDENCE OF ACCIDENT INSURANCE (By S. T. Armstrong).
MEDICOLEGAL ASPECTS OF VISION AND AUDITION (By Edward Jackson).
SPEECH DISORDERS (By Frank Warren Langdon).
INEBRIETY (By Graeme M. Hammond).
THE STIGMATA OF DEGENERATION (By Frederick Peterson).
INSANITY (By J. T. Eskridge).
IDIOCY, IMBECILITY, AND FEEBLE-MINDEDNESS (By Frederick Peter- son AND Smith Ely Jelliffe).
MENTAL PERVERSIONS OF THE SEXUAL INSTINCT (By Charles Gil- bert Chaddock). 13 *
PART I
(CONTINUED.)
I
MALINGERING AND THE FEIGNED DISORDERS.
From the beginning of the human race affections of a surgical nature have been simulated — by cowards, to avoid the dangers of combat ; by beggars, to excite compassion ; by rogues, to attain their ends ; and by others, for purposes as varied as they are sometimes obscure. Even children are not exempt. The little boy who suddenly acquires a lame knee and cannot attend school, and the little girl who sprains her wrist in time to avoid an hour's practice on the piano, are as certainly malingerers as is the soldier w^ho feigns contractured fingers in order to escape military service. Animals are often skilled in deception. The woodcock, in order to draw attention from her young, will simulate a broken wing ; and the painful limp of an unwilling horse will miracu- lously disappear when his head is turned toward home.
Feigned surgical affections, with the exception of such as are due to hysteria, are comparatively so rare in private practice, and real ones so common, that we are apt to be caught off our guard and do not recognize the fraudulent symptoms when they appear. Hence the necessity for the surgeon to acquire an idea not only of diseases which may be feigned, but of the motives and characters of those who are most likely to feign them. He should be familiar with every form of surgical trouble in all its varia- tions in order to avoid mistaking a real disease for one which is simulated, which is far more culpable than overlooking a simulation. It is better that many spurious affections be regarded as genuine than that one genuine case should be declared spurious. If we could pass in review the legion of unfortunate wretches whose real sufferings have given rise to neglect and maltreatment under the impression that they were feigned, we should employ more time and care before coming to conclusions in similar cases in the future. It is also well to remember that many instances of simulation occur in those who, from some cause or other, are not in good physical condition.
Opportunities for fraud in the domain of surgery are far fewer than in that of medicine. It is easier to simulate a colic, for instance, than a hernia. Nevertheless, deceptions are commonly enough met with, par- ticularly in the army and navy and in hospitals and prisons ; while pen- sion examiners and physicians to accident-insurance companies are con- stantly harrassed by the most obscure forms of fraud.
In former times feigning of surgical diseases was much more preva- lent than now^ For this there were various reasons. Beggars were more numerous and importunate ; in fact, begging assumed almost the dignity of an industry, and deception was practised as an art. Apparent
Vol. II.— 2 17
18 MALINGERING AND THE FEIGNED DISORDERS.
deformities, nauseous sores, and frightful tumors, draped by the rags of filthy mendicants, were seen in profusion on the streets, and there were even tliose who made a business of manufacturing cripples.
Most of these things, however, were mere stage tricks which required only close observation for their detection, and were calculated to deceive the passer-by rather than the surgeon.
In the army and navy there were formerly many more malingerers than there are to-day, malingering becoming so common at times that the most stringent laws were enacted for its suppression. This was particularly true when conscription was in vogue. Individuals re- sorted to all sorts of deception and self-mutilation in order to escape entering the service or to obtain a discharge. So-called ^^ epidemics '^ of incontinence of urine appeared among young men. Teeth were filed off and extracted by the wholesale in order that men should become unfitted to bite oif the ends of the old-fashioned cartridges. Many resorted to the cutting or shooting off of fingers and the severing of tendons. Simulations of hernias, hydroceles, contractures of joints, ulcers, and swellings of various kinds were often seen.
A reason for the lessened prevalence of such frauds is the marked improvement in the service. Men enter voluntarily instead of being impressed, and they are treated more like human beings and less like slaves. The food and hygienic surroundings are better, and personal liberty is greater. In fact, where much malingering is found, there is generally a cause, which should in justice be removed if possible.
Another reason is that malingering has been rendered easier of detection by such instruments of precision as the clinical thermometer, the microscope, the laryngoscope, the ophthalmoscope, etc. Surgical anesthesia is also of immense value in the diagnosis of obscure cases.
It is often better to reserve judgment for a time until opportunity can be gained to study the case in all its bearings. It may be useful to appear to believe all that is said until the patient, secure in the ap- parent success of the fraud, finally commits himself. If he can be con- vinced of the hopelessness of gaining his ends, he may sometimes be inclined to give up the deception. In order to accomplish this most effectively it is better that the examination be conducted privately, for the larger the audience, the more stubborn the subject. Sometimes the mere threat of severe treatment, such as amputation or the cautery, will effect a cure. Violent measures should, as a rule, be avoided, as they often do little good and it is always possible that the trouble may be real. A soldier has been known to walk for eighteen months with his back bent double and his fingers within two inches of the ground, in spite of the most severe treatment, rather than give in ; and, on the other hand, the writer has seen a stoker on an ocean-steamer, who refused to work on account of real weakness and pain, killed by a ducking, followed by exposure, under the impression that he was a malingerer.
The simulator is apt to give an incorrect history of his disease, or couple with it some ridiculous symptom, especially if such things be cleverly suggested by the examiner. Care is requisite, however, in
SIMULATED AFFECTIONS. 19
this connection. I once saw an old, deformed leper on the island of Molokai who earnestly claimed that on wet days he felt the bacilli of leprosy enter the tips of his right fingers, crawl slowly up the arm, around his neck, and down the left arm. In spite of his foolish state- ment there could be no question as to the reality of the disease.
It is often best not to treat actively a simulated surgical disease — ignore it as far as possible. Especially is this true of hysteria. It is a fact, however, that those who are feigning are often averse to treat- ment, especially if severe, while the possessor of a real and troublesome affection grasps eagerly at anything that offers relief.
It is difficult to classify simulated surgical lesions. Although many attempts have been made, none of them seems to be entirely satis- factory. According to the writer's view, hysteric diseases should stand in a group apart, although they are seldom so placed. Hysteria is really a form of disease ; and although its manifestations are not gen- uine diseases, they are, strictly speaking, not simulated. Individ- uals are hysteric not because they wish to be, but because they cannot help it. A working classification, differing somewhat from that which is generally accepted, is as follows :
A. Simulated Affections (abnormal conditions which are not real),
1. Feigned Affections. — Those which are entirely fictitious,,
whether they are known lesions or inventions of the imagination.
2. Factitious Affections. — Those which have been produced by
the patient, but which are claimed to be due to disease.
3. Exaggerated Affections. — Whether the exaggeration be wholly
assumed, or whether the existing condition be really exag- gerated by voluntary means.
B. Self-produced Affections (Injuries, Etc.). — These are what
they appear to be, the only fraud being in the assertion of the individual as to their causes.
C. Hysteric Affections.
SIMULATED AFFECTIONS*
I. Feigned Affections. — Pain and Tenderness. — These are purely subjective symptoms, for the existence of which the surgeon must, for the most part, accept the assertions of the patient. Hence simulation is easy and the fraud difficult to detect. Old deformities, scars, injuries, etc., offer an excellent basis for fictitious pains, and enable their possessors to live in comfort in our charity-hospitals. And yet we are compelled to believe these impostors until we can prove them to be frauds. The most flagrant examples of this form of feigning are met with among applicants for pensions and for ii^urance, and among those injured in accidents and assaults, where damages are desired.
The general appearance of the patient is of importance. Those who have much pain will soon show the characteristic eifects of suffer-
20 MALINGERING AND THE FEIGNED DISORDERS.
ing and loss of sleep. If the admiDistration of a small dose of mor- phin, without the patient\s knowledge, readily produces sleep, much pain cannot be present. Pressure on the sore spot during natural sleep may easily expose a fraud. It is often possible so to divert the patient's attention by examining other portions of his body, by plying judicious questions, etc., that the alleged tender and painful part may be quite roughly handled. A system of espionage is as valuable here as it is in the detection of other feigned diseases. The relation of the cause to the alleged eifect should be taken into consideration, a mere scratch on the body of a malingerer often giving rise to the most severe apparent suffering.
Concussion of the Brain. — This is often feigned by those who wish to exaggerate the effects of a blow or pretend that they have received one. It is a favorite trick of boxers in order to escape further punish- ment. In real concussion there are a pale, moist skin, feeble pulse, super- ficial respiration, and perhaps nausea, which are not present when con- cussion is feigned.
Wry=neck. — This is not commonly simulated, and can easily be detected. When fraud is attempted, the sternomastoid muscle of the side opposite to which the head is turned is tense, especially when efforts are made by the surgeon to correct the deformity. The eyes can be moved toward the side from which the head is rotated with difficulty only, while in the real disease this has been rendered easy by habit. The close observer will also notice in true torticollis an asymmetry of feature which it is impossible to simulate. Like other fraudulent con- tractures, wry-neck is apt to be forgotten when the patient is drunk or excited, and the muscles, of course, become relaxed during sleep or when under an anesthetic.
Lateral Curvature of tlie Spine. — Although this subject will be considered under Railway Spine, a few words will be in place here. In true scoliosis the vertebrae are rotated on their longitudinal axes, so as to bulge out the ribs on the convex side and wing the scapula. A sec- ondary curve is likewise present, which serves to bring the body into the line of gravity. In feigned scoliosis, which occurs almost invaria- bly in the dorsolumbar region, the spine is not twisted on its axis, but merely bent to one side, and there is no compensatory curve, no bulging of the ribs, etc., although there is a marked wrinkling of the skin which has not had time to adjust itself to the new position.
Non-hysteric Contractures of Joints. — Contractures are so easily imitated, and are apparently so disabling, that they are often seen among those who wish to deceive. Injury, rheumatism, neuralgia, or some obscure nervous affection may be assigned as a cause. Atrophy of adjacent muscles and swelling of the joint may be produced by pro- longed tight bandaging, while local irritating applications may counter- feit inflammatory changes. The suspicions of the surgeon should be aroused when the joint exhibits no pathologic changes ; or when the nature or extent of the injury or disease appears to be inadequate to have produced the apparent effect. A scar, for instance, intentionally
SIMULATED AFFECTIONS. 21
or accidentally produced, may be found on closer inspection to be but skin deep. The presence of a nervous trouble may often be excluded by the absence of characteristic symptoms. Contractured muscles, which frequently exist, may have no relation whatever to the seat of a supposed or actual neuralgic pain. »
The fact must not be lost sight of, however, that trivial injuries, such as a slight wTench or bruise, at times precede serious tubercular joint-disease, which may manifest itself at first by muscular con- tractures alone. This is particularly true of deeper seated joints, such as the hip. When coxitis has existed for some time, its dis- crimination from feigned disease should be easy. Patients may simu- late contractures to a certain extent, but not the absolute fixation of the joint, the muscular atrophy, the dropping and obliteration of the glu- teal fold, the worn and peevish expression, etc. Those bent on decep- tion sometimes betray themselves by the incongruity of their symptoms — by complaining of pain, for instance, when the knee is struck, but not when the blow is delivered against the heel. Pain in the knee, so common in real disease, is often neglected in the simulated form.
In the more superficial joints the presence of definite spots of tender- ness is strongly indicative of tubercular foci, in contradistinction to a general sensitiveness of the part.
When contracture is said to be due to causes which have produced real shortening of the muscles, binding of ligaments, or union between the joint-surfaces, the fraud is easy of detection, as movement is sud- denly checked during manipulation without evidence of voluntary mus- cular action, while an anesthetic quickly clears up any obscurity in diagnosis. Hence these forms of ankylosis can hardly be successfully feigned, and it is practically only the acute muscular variety which calls for serious investigation. General anesthesia is here of little use, as it merely demonstrates that the contractures are purely muscular, without indicating either the presence or the absence of real disease.
Simulated contractures are apt to increase when under direct obser- vation, and the muscles are always tense, while in real joint-deformities they may be lax. Investigations made while the subject is asleep, drunk, or excited, or when imagining himself alone, are often of value. Suddenly pushing the patient oif his balance, so that the affected limb must be straightened in order to prevent a fall, has assisted the writer in demonstrating fraud. Arousing men from their slumbers with an alarm of fire, supported by a smell of smoke, has been known to effect astonishing cures. Some of the older army surgeons ordered the sus- pected individual to balance himself on his sound leg on a high pedestal. In order to prevent falling as the muscles began to tire, the contracted leg would be put down alongside its fellow.
A weight suspended by a cord will quickly straighten simulated contractures, but it must not be overlooked that recent contractures from disease may also be overcome in tfiis manner, although less promptly.
An Esmarch strap wound around the limb above the affected joint,
22 MALINGERING AND THE FEIGNED DISORDERS.
SO as to compress nerves and muscles tightly, will often serve to relax the part and expose an impostor.
The application of the thermocautery, while not out of place in many forms of real joint-disease, often rapidly effects a cure in fraudulent affections.
Hernia, Hydrocele, Varicocele. — There was a time when these diseases were frequently feigned by the injection of air or fluids beneath the scrotal or inguinal tissues, but such deceptions are seldom, if ever, met with at present. The feel of the part, the emphysematous crack- ling, and the absence of the well-known and characteristic signs of the trouble in question should establish a diagnosis at once, provided that the examination is at all thorough. Some men possess the power of drawing their testicles into the external abdominal rings, so as to present the appearance of hernia to a superficial observer. This may frequently be seen in children.
That which is most often feigned in hernia is pain, and the fraud is difficult to detect, unless the symptoms are grossly exaggerated. It should be borne in mind, however, that the pain and discomfort of a hernia are more commonly located nearer the umbilicus, at the attach- ment of the mesentery, than at the seat of the rupture.
Fistula in Ano and Fistula in Perineo. — These forms of fistula have been simulated, though not often, by cauterizing artificially pro- duced wounds. The appearance of the part, together with the careful use of a probe, should settle such a question at once. In the case of the urethra, the absence of a stricture and of leakage of urine will be conclusive.
Hemorrhoids and Prolapsus Ani. — That these diseases should have been successfully feigned by inserting intestines and inflated bladders of animals into the anus seems almost incredible, and yet such instances have been recorded. Careful inspection must detect the deception at once.
Incontinence of Urine. — The simulation of incontinence was at one time so popular among soldiers that so-called " epidemics " resulted. In the genuine disease urine constantly dribbles from the urethra, instead of being emitted at intervals in a stream with more or less force. There is also no effort of expulsion, while in the feigned form, if the patient be stripped, the surgeon will observe contraction of the abdominal muscles. If the individual, while voiding urine, be sud- denly commanded to stop and does so, it is certain that he possesses at least fair control of his bladder.
Most authors state that an infallible test for incontinence consists in the passage of a catheter at some odd moment when the patient is not suspecting such a manoeuver, — on waking from a long sleep, for instance, — and if more or less urine be found, the trouble is fraudulent. Such advice is misleading. When there is an enlarged prostate, there is often a quantity of residual urine, and also, at times, incontinence.
Another test formerly employed by army surgeons consisted in tying a cord about the penis. In case of real trouble the penis soon swelled
SIMULATED AFFECTIONS. 23
from accumulated urine. Fouder^ once had occasion to tie up a large number of soldiers in this ridiculous manner.
The fact that in real incontinence the glans and meatus are pale and sodden in appearance is usually dwelt upon. Although this is generally true, it is not a reliable diagnostic point. Neither is it of much impor- tance that the clothing may smell of decomposed urine. Positive indi- cations against malingering would be the presence of a stricture, an enlarged prostate, ammoniacal urine with bacteria and pus, or symptoms of some nervous affection with vesical paralysis.
Urinary Calculi and Gravel. — Hysteric patients, and occasionally others, sometimes pretend to have passed stones and gravel, which they exhibit in proof of their statements. If the suspicions of the surgeon have been aroused, he can easily detect the fraud by a chemical exami- nation of the stones, which are usually but ordinary pebbles.
Hematuria. — Blood has often been mixed with the urine in order to feign this symptom. But if the patient is requested to urinate in the presence of the surgeon, or if a microscopic examination is made, there can be little difficulty in exposing the deception. The blood of a fowl may be recognized by the oval shape of its corpuscles. The Indian fig is said to color the urine blood- red, while the use of can- tharides produces actual hematuria.
Ecchymoses and Contusions. — These are often feigned by staining the skin, but close inspection will usually reveal the fraud without difficulty. Sometimes the stain may be washed or rubbed away. The well-known changes in color of a contusion should be looked for after sufficient time has elapsed. A true bruise is deepest in color at its center.
3. Factitious Affections. — Ulcers. — The feigning of ulcers is a very ancient and very common trick, practised by the hysteric as well as by beggars, malingerers, and others. All sorts of mechanical and chemical irritants have been employed in their production. A favorite method has always been to bind a copper coin tightly against the shin. The metal was erroneously supposed to be the active agent, while in reality it is the pressure. After erosion of the surface has once been obtained it is easy to keep up the ulceration by mechanical irritation. Such ulcers, of course, refuse to yield to ordinary treatment. When they are falsely said to be of long standing, the cheat may be detected by noting the absence of callous margins, of edema, and of ecchy- mosis.
It may be necessary to incase a limb bearing an ulcer in plaster-of- Paris in such a manner that the patient cannot obtain access to the part. Ordinary bandaging, even if the bandages are sealed, does not always answer. Individuals have been known to keep up the irritation by inserting pins through the dressings. At one time factitious ulcers became so prevalent in the English army that it became necessary to lock up the affected limbs in wooden boots hi order to circumvent the malingerers.
Beggars may sometimes succeed in deceiving the public by fastening
24 MALINGERING AND THE FEIGNED DISORDERS.
pieces of liver, etc., to their shins, but physicians could never be misled in this manner.
Tumors. — It is not easy to simulate a tumor, although it has been done. It must be a stupid surgeon, or a careless one, who is deceived into regarding as a cancer a piece of cow^s liver glued to a breast, or a sponge saturated with red fluid and inserted into the bowel. Such frauds have been practised successfully, however, by beggars, and for the purpose of giving color to miraculous cures.
It is otherwise, however, with certain muscular contractures, which may closely resemble tumors. Some people have such control over the recti muscles that they can contract each segment at will, leaving the others unaltered. A few years ago a colored man traveled about the country, from one medical college to another, who possessed this power. By throwing the muscular swelling against the aorta, an apparent pulsa- tion was produced, the exhibitor asserting that he had ^^ thrown his heart into his abdomen.^^ So-called ^' phantom tumors " of the abdo- men are far less common than formerly, for many of them, such as in- termittent hydronephrosis, have been found to be real. A few, how- ever, still occur, most of which have a hysteric basis. They are variously due to local intestinal paresis with unequal gaseous distention, to muscular contractures of the abdominal walls, etc. In their detec- tion the recognition of the hysteric state, combined with local symptoms, is usually sufficient. Gaseous tumors are tympanitic, and muscular contraction can be felt to be external to the abdominal cavity.
The situation of such a tumor as regards some muscle, together with the fact that the contraction cannot be long maintained, especially dur- ing sleep and anesthesia, should prevent a mistake in diagnosis.
Patients may claim that swellings, due to injuries or to more or less acute inflammatory processes, are tumors. When an untruthful history is cleverly given, the diagnosis may be rendered obscure. The main point lies in suspecting, from the circumstances or from the character of the patient, that something is wrong, when a little time, coupled with intelligent observation, will serve to clear up a doubtful case.
Diffuse swellings and localized tumors of the breast, due to hysteria, are described by Tourette. Marked hyperesthesia combined with other hysteric manifestations renders a diagnosis possible, although confusion is sometimes produced by edema and consequent ulceration. Pressure upon the tumor may cause a hysteric attack. Operations have been undertaken with the idea that a malignant tumor was present.
Dislocations. — Dislocations are very difficult to feign. Rarely, how- ever, individuals are met with who possess the power of dislocating their joints at will ; and there are others whose bones are so loosely ar- ticulated, perhaps through previous injury, that but slight force is re- quired to throw them out of place. Such persons may utilize their anomalous construction in exhibiting before medical students, in gaining admittance to hospitals or in obtaining money from insurance companies or mutual-benefit associations.
If the dislocation is claimed to be recent, the absence of swelling.
SIMULATED AFFECTIONS. 25
ecchymosis, etc., would expose the fraud. When the affection is said to be of long standing, diagnosis is more difficult. In those who dis- locate their joints at will, however, the luxations are always intracapsu- lar, and hence not so complete as those which have been produced by violence and in which the capsule has been ruptured. Observation of the patient for a length of time, particularly when he is not aware that he is being watched, will expose the fraud, as it cannot be kept up in- definitely. It is often impossible to reduce old dislocations, while the form under discussion can be easily replaced. The joints which are most commonly dislocated at will are the shoulder and hip.
Fractures. — Patients have been known to move a broken bone con- tinually in order to retard or prevent union, and they sometimes remove the splints and twist the parts out of shape. This is usually done in order to obtain grounds for a malpractice suit. Many reputable phy- sicians who have done everything in a case that it was possible to do have been seriously annoyed in this manner.
A favorite trick of " hospital birds '' is to complain of pain and tenderness at the site of some old fracture. In the absence of redness or swelling suspicion may be entertained of the genuineness of the trouble, especially if the individual overdoes his part, which is apt to be the case. The writer has seen an old ununited fracture of both bones of the forearm successfully passed off as recent, the member being carefully put up in splints by a hospital physician.
Gonorrhea. — An apparent gonorrhea may be produced by applying caustics to the prepuce, or by injecting irritating solutions within the urethra. The absence of the gonococcus upon microscopic examination, although not conclusive, is certainly suggestive. Sealing up the penis in such a manner as to prevent the application of irritants will rapidly effect a cure.
Swelled, discolored, and inflamed limbs may be caused by liga- tures, perhaps very small ones, which should be looked for if the case is suspicious. It is said that acute swelling of the face and head, and even elephantiasis of the leg, have been simulated by this means.
That varicose veins can be produced by ligatures is perhaps possible, but the fraud is certainly uncommon, although varicose veins which already exist may thus be exaggerated in size.
It should be remembered that atrophy of a limb can be brought about by tight bandaging ; and that various deformities have been caused in this or similar ways, particularly in ancient times. The feet of Chinese women and the flat skulls of certain Indians bear testimony to this fact.
3. l^xSLggetsded Affections. — It is with exaggerated diseases that the surgeon is most often brought in contact. A slight sprain is magnified into a serious injury by the holder of a policy in an accident- insurance company ; an old and painless hernia becomas an unbearable burden to the owner who desires admission 'into a hospital ; a wound, long since almost forgotten, is nursed into violent activity by the appli- cant for a pension. There is no end to the exaggeration of symptoms
26 MALINGERING AND THE FEIGNED DISORDERS.
in connection with broken bones, deformed joints, injuries, tumors, ulcers, inflammations, etc. The physician must be continually on his guard, in high life as well as in low, among ladies and gentlemen as well as among beggars and rogues.
Exaggeration can usually be detected by observing the rules and principles elsewhere given in this article, although there are many cases which are manifestly never discovered. We are all prone to exagger- ate our ailments at times, and we are seldom caught in the act.
SELF-PRODUCED INJURIES,
Self-inflicted wounds are not feigned diseases, although they are often considered under this heading. The wound itself is real enough, and is exactly what it appears to be, the only uncertainty being as to how it was made and who made it. It is a mere question of truth and untruth, in which there is no simulation of something which does not exist, as there is in the case of a wound which is produced by the patient and which he pretends is a chronic ulcer. Self-mutilations most frequently occur in connection with the military or naval service, par- ticularly the former. At one time it was not uncommon for men to disable themselves in various ways in order to avoid being impressed into the army or navy. In Egypt, for instance, it was said to have been difficult to find a thoroughly able-bodied young man. Self-muti- lations are now met with particularly in battle, where a comparatively slight wound made by the soldier himself may send him to the hospital and save him a more severe one made by the enemy.
Individuals who have attempted suicide and failed are at times tempted, through shame, to assert that the wounds were made by others. Through motives of revenge, in order to make others regret some real or fancied ill-treatment, self-injuries may be inflicted. Even children have frequently been known to practise this deception.
Various other instances may arise where it is of supposed advantage to simulate injuries. For instance, a gentleman who desired to be favorably considered financially by a relative pretended to have been wounded in an attempt to shield the relative from an assault. A colored cadet at West Point, who had failed in his studies, attempted to enlist sympathy by inflicting superficial injuries upon himself and bind- ing himself to his bed, as though he had been roughly handled by his fellow-students. We not uncommonly read of bank-officials or of men in whose care valuables have been intrusted being found wounded and gagged, and the valuables gone. Sometimes it has been shown that these men have purposely injured themselves. It is not impossible, with a little practice, for a man to bind himself apparently quite securely. People who are hysteric, especially women, often injure themselves, with the idea, perhaps, of gaining notoriety and sympathy.
In detecting these various impositions it is of importance to discover a motive of sufficient weight, and to consider whether it was likely for the injury to have been produced in the manner or degree pretended.
SELF-PRODUCED INJURIES. 27
It would scarcely be thought possible, for instance, that a man could stab or shoot himself in the center of the back ; or that he would pro- duce a fracture of the skull, or sever an important artery, unless he were attempting suicide.
Self-inflicted wounds, except suicidal ones, are nearly always super- ficial and comparatively trivial, while the apparent symptoms which accompany them are usually out of all proportion to the cause. It is very frequently the left side of the body which is injured, because most people are right-handed (Dr. J. N. Hall, of Denver, has called par- ticular attention to this point). One who cuts his throat begins with vigor on the left side, but pain and faintness often cause him to lessen the pressure on the knife before the right side is reached. A man who is assaulted usually grasps the assassin^s knife and receives one or more cuts across the hands in consequence, while the hands of the man who injures himself are intact.
Fraud may at times be detected by noticing the discrepancy between the injury and the assigned cause. A soldier who says his fingers were blown off by a gun, and whose stumps are, nevertheless, evidently severed by some sharp instrument, is open to the gravest suspicion.
In gunshot injuries the presence of powder-stains, burns, or scorched clothing would prove the falsehood of the statement that the injury was inflicted by some one at a distance, although individuals have been known to wrap a cloth about the part before shooting themselves. It should be noticed whether the bullet fits the patient's own weapon or not. If the pretender be requested to place himself in the position in which he was when injured, he is often unable to do so. It is a curious and confusing fact, that should be remembered, however, that when the barrel of a firearm, at least one of small caliber, is held very close to the body, the bullet may not penetrate the skin at all, or at least the damage may be greatly lessened. It is also true in such a case that powder-grains are not apt to enter the skin, only a superficial blacken- ing and scorching of the cuticle resulting.
Women have been known to bruise and lacerate themselves, generally to a moderate extent, in order to give color to their stories of attempted assaults upon their virtue.
Some persons, generally hysteric women, exhibit a curious tendency to mutilate themselves by inserting various substances beneath the skin. Hundreds of needles have been removed from beneath the cuticle of such individuals in the course of a few weeks or months. The number of needles, together with the fact that most of them are found on the left side of the body, should excite suspicion. The account of an inter- esting case went the rounds of the medical journals a few years ago. A woman, apparently in good health, was continually troubled with the exfoliation and extrusion of pieces of bone from the left forearm. Hundreds of pieces of bone were obtained and preserved. A careful examination of the specimens later on, hcfwever, showed them to be chicken-bones.
28 MALINGERING AND THE FEIGNED DISORDERS.
HYSTERIA.
Any of the diseases and symptoms which have been mentioned, as well as many others, may be simulated by the hysteric, and the means of diagnosis are often the same. Ulcers or lateral curvature of the spine, for instance, are just as apt to be feigned by those who are hys- teric as by those who are malingering. The general symptoms of hysteria, however, can usually be depended upon to help out in the diagnosis ; although we should by no means consider that, because a woman has a lump in her throat and is subject to " spells,'' all the manifestations of disease which she presents are necessarily hysteric.
The subject of hysteric joints, however, is of sufficient importance to merit special consideration. The resemblance to real disease is at times so great that the most noted surgeons have gone so far as to per- form an arthrotomy upon a perfectly normal joint. The general symp- toms of hysteria are usually present, although they may be so obscure as readily to be overlooked. Patients with hysteric joints are often so sweet, good, and long-suffering that this alone may arouse the suspicions of the watchful physician. Hyperesthesia of the affected region is very characteristic. The sufferer complains of pain as soon as the skin is lightly touched, and even before ; but if the attention is strongly attracted in some other direction, the joint may often be quite firmly pressed without exciting discomfort. There is, in the great majority of instances, no physical evidence of disease on inspection, palpa- tion, or measurement ; but occasionally a truly perplexing case is encountered in which a certain amount of heat, redness, and swelling exists. The reflexes remain equal on opposite sides of the body, although they may be exaggerated. A genuine hysteric hydrops has rarely been described. The diagnosis must be based upon the presence of other evidences of hysteria, together with local hyperesthesia and the exclusion of all forms of real disease. The absence of fever and other constitu- tional disturbances which accompany actual inflammation is always suggestive.
Hysteric contractures are sometimes met with, and may be confus- ing in respect to diagnosis. Although any joint may be affected, the most common situation is the tarsus, the foot assuming the position of equinovarus. Here, again, the hysteric temperament is in evidence, and the causes are inadequate to the effect. The writer has seen a woman, for instance, who slightly sprained her ankle during a quarrel with her husband, shortly after the injury suddenly acquire a strongly marked equinovarus, which was maintained for many weeks. Her disposition was resigned and sweet throughout, and the sympathy of friends was strongly elicited. Ten days' isolation completed a rapid cure.
Another case which was seen in a medical clinic in Berlin was one in which there was such marked flexion of the knee-joint that the
FEIGNED MENTAL AND BODILY DISORDERS. 29
patient, a little girl, was compelled to walk with a strong limp upon the tip of her toe. This condition had existed for several years. Sta- tioning himself on the opposite side of the room, the clinician took his watch in his hand, fixed his eyes upon the patient, and told her that in five minutes she would place her heel on the floor and walk without a limp, which she did.
The treatment of these cases consists, first of all, in the treatment of the general hysteric condition — in appropriate foods and tonics, in change of surroundings and conditions, and in change of mental atmos- phere, if this be possible. Isolation from sympathizing friends is of the utmost importance, and should be tried in every obstinate case. Little, if any, attention should be given tiie aflected joint itself — all forms of corrective apparatus, local applications, etc., only seem to make matters worse by keeping the attention concentrated upon the affected part. Sometimes, however, a well-planned bogus operation is of great benefit, as happened in the experience of a surgeon of the writer\s acquaintance, who removed an imaginary frog from a woman's stomach by means of a fictitious gastrotomy, performed through a skin-deep laparotomy. A prominent surgeon of New York cured a hysteric tumor of the brain by making an incision in the scalp only, although he was subsequently sued for obtaining money under false pretenses. To what extent such means are justifiable in attempts to cure is a question which every one must decide for himself, accord- ing to the circumstances of the situation. The electric brush and the thermocautery are resorted to in hospitals and institutions of various kinds, and at least a temporary cure is often effected by their use. In private practice they will usually not be tolerated, and considering that the results are mostly but temporary, it is questionable if we are in general justified in using such painful means. Hypnotic suggestion may be of the greatest value.
FEIGNED MENTAL AND BODILY DISORDERS*
Feigned disease is not a product of modern civilization. Sacred and profane histories contain references to cases of feigning, both of mental and bodily diseases. The instruments of precision and the more inti- mate knowledge of diseased processes of the present day enable us to detect without much difficulty simulation by the ignorant and unskilled. Fortunately for the medical expert, feigning disease is largely limited to this class. But it occasionally happens that persons of experience and great intelligence, and even physicians skilled in the knowledge of dis- ease, adopt dishonest methods to escape condign punishment or to ob- tain undue advantage.
Feigning Mental Disorders. — Insanity is most frequently feigned by those who have committed some criminal act ; occasionally by others who have entered into some legal contract, the results of which they wish to avoid on the theory of irresponsibility ; less often by en-
30 MALINGERING AND THE FEIGNED DISORDERS.
terprising newspaper-reporters in order that they may be sent to an insane asylum and have an opportunity to write up the management ; and, least frequently of all, by the hysteric for the purpose of gaining sympathy and notoriety.
In all cases of feigned insanity there is a motive for simulation. This should never be lost sight of by the physician in investigating every case of alleged mental disorder, and when no motive for feigning is revealed by a careful inquiry into the history and acts of the indi- vidual, no suspicion of feigning is justifiable. On the other hand, the acts of many insane, before they are apprehended and sent to an asylum, are constantly bringing them into collision with the law. A motive for feigning then, in a case of alleged insanity, is no proof of simulation. It should be borne in mind that some insane persons feign a different form of insanity from that from which they are really suffering, so that the detection of simulation of a mental disorder by a person alleged to be insane does not justify the conclusion that he is sane. Under these cir- cumstances such a conclusion should be arrived at only after a most search- ing investigation has failed to detect any form of mental aberration. While it is true, as many have asserted, that in criminal cases insanity is rarely assumed until after the commission of the crime and the ap- prehension of the criminal, yet we must remember in epileptic, alcoholic, and traumatic amnesia that the individual cannot claim innocence until he is accused of acts of which he has no knowledge. Such a person's in- sanity, if it is due to epilepsy or alcoholic indulgence, may have existed previously, but attention has not been attracted by it if no overt act has been committed before. Taylor states that a person does not feign to avoid suspicion. This is true in the vast majority of cases, but if a criminal felt sure that circumstances were such that he ultimately would be suspected of a crime of which he was guilty, he might feign insanity before he was accused. Feigned insanity is almost always sudden in its onset, while mania, melancholia, paranoia, and de- mentia, the forms of insanity most frequently simulated, develop gradu- ally. Second attacks of mania may not be preceded by the usual pro- dromal symptoms that occur before the first attack. Temporary mani- acal frenzy, epileptic mania, and explosive maniacal attacks in paretic dementia come on suddenly. The first is extremely rare, and is attended by symptoms quite characteristic of the disorder ; the second is associ- ated with epilepsy ; and the third is only one feature of a chronic and distinct form of insanity. Great mental or physical shock may be the apparent cause of a suddenly developed mania. The simulator over- acts the symptoms with which he is acquainted of the form of insanity that he tries to feign, leaves out other symptoms that should be present, and adds some that have no place in the particular form of insanity which he endeavors to simulate. A person feigning insanity usually makes the symptoms sufficiently obtrusive to attract attention when he is observed, and may be quiet when unobserved. The simulator does not, as a rule, endeavor to prove his sanity, but in some cases when this
FEIGNED MENTAL AND BODILY DISORDERS. 31
has been attempted it has been done in so absurd a manner as to be strong evidence of sanity. An insane person who is depressed and sus- picious or the subject of delusions of persecution frequently regards his relatives and best friends as his enemies. This is not invariably the case, however. The incoherent raving maniac manifests somatic signs of his disorder that cannot be simulated. In the milder cases the ex- pressed ideas in the delusions and the surrounding circumstances bear a certain relation to each other. The ignorant almost always feign some amnesia and a degree of dementia with all forms of insanity that they attempt to simulate. Such symptoms are foreign to ordinary mania, melancholia, and paranoia. Complete amnesia is rare and limited to periods of great excitement in the simple forms of insanity, to epilepsy, alcoholic insanity, mental disturbance from blows to the head, and to the various forms of dementia. Simulators rarely present elaborate and systematized delusions, such as are found in paranoia.
The ruse of casually remarking to some one in the hearing of the subject after the examination is completed that if certain symptoms were present there would be no doubt of the existence of insanity, rarely succeeds except with the ignorant. With this class such a suggestion may result in the presence of the absent symptoms on the physician's next visit. If the subject whose mental condition is under investiga- tion is weak-minded, the feigning of symptoms suggested by the phy- sician would not prove the sanity of the individual. It is not infrequent in large asylums for the insane to find some of the weak-minded lunatics assuming the delusions and developing some of the symptoms of the less feeble-minded insane.
The simulator is worse when under examination and when in the presence of those whom he desires to impress with the genuineness of his insanity.
No rules can be given by following which, in the examination of a person alleged to be insane, feigned insanity can invariably be detected. Each case forms a subject for special study and investigation. An experienced, skilled, and well-trained observer will rarely fail to de- tect simulation if sufficient time is allowed for a thorough study of the case. The previous character of the subject should be ascertained. If there is a possible motive for feigning, this should not be ignored. A thorough examination into the physical and mental condition of the subject should be made. If he will write, it will often facilitate matters by getting him to write his history and all the circumstances connected with his arrest, indictment, and imprisonment. Frequently repeated visits by the examiner are necessary. Sometimes prolonged observation of the simulator may enable one to detect feigning. Under such cir- cumstances a shrewd attendant who will watch the subject when he thinks he is not observed, and who will, from time to time, after he has succeeded in obtaining his confidence, engage him in conversation, can best play the detective. The physician will b^st succeed in his investi- gation by making himself and the object of his visits known. He should not act the part of a spy.
32
MALINGERING AND THE FEIGNED DISOKDERS.
Mania.
1. Gradual in onset, with a prodromal
period of depression.^
2. If a crime is committed, the insanity-
is exhibited before the commission of such an act.
3. If the patient is wildly incoherent,
there are pronounced somatic signs of such a mental state.
4. In the milder forms there is a rela-
tion between the expressed ideas and surrounding circumstances.
5. The excited mental state and muscu-
lar restlessness may continue for days, with only short periods of comparative quietness, and no sleep may be obtained during this time either night or day.
6. The facial expression and the mental
exaltation correspond ; there is no dementia, and the memory in the quiet periods is found to be quite good, with rapid and irregular speech.
Feigned Mania.
1. Sudden in its onset.
2. If a crime is committed, the insanity
is not assumed until after its com- mission, and usually not until the subject is arrested and indicted.
3. No somatic signs except those that
attend forced physical exertion.
4. No constant relation between the
expressed ideas and the surround- ings of the subject. 6. Becomes exhausted and falls to sleep at night. In fact, the simulator often sleeps soundly all night.
6. The facial expression and the feigned mental exaltation do not corres- pond, and therefore give to the simulated psychosis an appearance of unreality ; a partial demented condition is assumed, and memory in the quiet periods appears poor, with slow and measured speech.
Feigned Melancholia.
1. Sudden in its onset. A rather fre- quent form of insanity feigned by the criminal, but the symptoms had not existed previous to the com- mission of the criminal act.
2. No somatic signs.
3. The simulator often puts on flesh in prison ; loss of memory and demen- tia often feigned.
4. Shows no disposition to treat friends and relatives as enemies.
5. Facial expression normal.
Feigned Temporary Maniacal Frenzy.
1. The outbreak is sudden, and no evi- dence of mental disturbance is observed until after the criminal act is committed.
2. The subject frequently makes an attempt to escape, and often talks to the authorities if arrested a few minutes or an hour or so after the crime has been committed; is not violently incoherent immediately after the commission of the crime,
and does not pass into a deep, stuporous sleep.
^ Mania may begin comparatively suddenly in those who have suifered from a previous attack of this disorder, or when it is* caused by some profound mental or physical shock.
Melancholia.
1. Gradual (weeks or months) in its
onset. Crimes are rarely com- mitted by melancholiacs, but when they are, the insanity had pre- viously existed.
2. In the violent and agitated forms
somatic signs are prominent.
3. In the quiet forms loss of flesh
usually occurs and memory is pre- served ; no dementia.
4. The friends and relatives are often
regarded as his enemies.
5. Facial expression is painfully sad.
Temporary Maniacal Frenzy.
1. The outbreak is sudden, but it is pre-
ceded by a period of mental or physical depression.
2. The patient is in a condition of mani-
acal excitement or melancholiac frenzy, and is destructive, violent, and incoherent usually for a few hours, when he falls into a deep sleep.
FEIGNED MENTAL AND BODILY DISORDERS.
33
3. On awakening, he is rational, but feels exhausted. The mind is clear, remembers everything up to the time when he became incoherent, but nothing more.
3. Frequently feigns to have forgotten the altercation or any of his actions and those of his victim immediately preceding the criminal act.
Paretic Dementia.
1. Developed gradually.
2. The speech defect and the moral and
mental failure are so characteristic that this form of insanity is rarely attempted to be feigned by the ignorant.
Feigned Paretic Dementia.
1. Assumed after the offense has been
committed.
2. The eye symptoms cannot be feigned,
but these may be absent. Unless the simulator is an expert in in- sanity he will be detected if he is requested to read a manuscript con- taining the words " truly rural," " national intelligencer," " artil- lery," " stethoscope," etc.
Paranoia. 1. Delusions elaborately systematized.
2. Is quiet and frequently unobtrusive
in regard to his delusions if not contradicted.
3. If his delusions are denied and ridi-
culed, he becomes angry and some- times violent.
4. Is not cautious in his speech, espe-
cially if excited.
Feigned Paranoia.
1. Delusions maintained by a very poor
process of reasoning, even if the premises were correct.
2. Seeks to make his delusions promi-
nent, so that they will attract at- tention.
3. Bears opposition and even ridicule
without becoming demonstrative.
4. Shows a disposition to weigh the
effect of his words.
Amnesia is found in epilepsy, dementia, alcoholism, and may follow traumatism to the head, and during this mental state apparently intel- ligent acts may be performed of which the subject has only an indistinct memory afterward, or all knowledge of them may be entirely obliterated.
Amnesia.
1. In amnesia from all forms of demen- tia recent events are less readily recalled than those of a former date, especially those in connection with the subject's childhood and youth.
2. In all forms of temporary incomplete amnesia the things that are remem- bered will be those that would naturally have made the most im- pression on the subject's mind at the time of their occurrence. If a murder has been committed, the quarrel, the fatal shot, or some similar circumstance may be re- membered, but the minor details will be forgotten. Vol. II.— .3
Feigned Amnesia.
1. Considerable amnesia is assumed for
all periods of life, and the recent occurrences may be remembered and those of youth forgotten. May feign to remember nothing that occurred at the time of the commis- sion of the act for which he is arrested, but is able to repeat the conversations he has had in his cell from day to day.
2. The trivial things are more likely to
be recalled, and all that relates to the subject's excited state leading to the commission of the crime will be forgotten.
34 MALINGERING AND THE FEIGNED DISORDERS.
It is rare for temporary amnesia to be complete unless caused by epilepsy, a blow to the head, or some decided emotional or physical shock. Most of these excited periods are followed by a stuporous sleep. Persons who commit crimes during periods of excitement, speak about them intelligently immediately afterward, and subsequently pre- tend to have forgotten everything connected with the crime are usually feigning. Some epileptics may commit crimes during their peculiar psychic conditions that occur between the convulsive attacks. Under such circumstances the history of the patient, his former mental aber- rated states, and his actions during these must be carefully studied in each individual case.
Attempts at feigning a delirious state are usually unsuccessful, as the impostor associates it with a condition of dementia instead of a dreamy confusion.
Feigned Bpilepsy. — When epilepsy is simulated by the hysteric for the purpose of gaining sympathy, or by the impostor in order to obtain alms or to secure care and attention in a hospital, the usual tests found in the books will generally suffice to detect feigning. When, however, the simulator is an expert scoundrel and assumes epilepsy in the hope of being excused from duty in the army or of being con- sidered irresponsible if he has committed a crime, it is not always easy to distinguish the real from the feigned disease. Gowers ^ states : ^^ The simulation of an epileptic fit is, on the whole, rare, and the pre- tended fit never closely resembles a genuine seizure. In all cases the perfect reaction of the pupil to light throughout the fit will be con- clusive evidence.'^ I am reluctant to differ from an authority so eminent as the one just quoted, but a careful study of cases of feigned epilepsy by criminals has convinced me that it is possible for some sim- ulators to imitate fits that are not easily distinguished from the genuine. The results of a most careful study of feigned epilepsy will be found in an article on " Malingering '^ by Keen, Mitchell, and Morehouse.^ This paper, prepared conjointly by three skilled observers from their own observations on soldiers during the late war of the Rebellion deserves more attention than it seems heretofore to have attracted.
The epileptic, in going into a convulsion, with or without a cry, falls unconscious, often striking his face, or he may suddenly sink to the ground to save himself if he has any warning of an approaching fit. The face is at first pale, but the convulsive movements, tonic in char- acter, immediately follow the fall, the limbs and trunk muscles are fixed and rigid, respiration is arrested for a few seconds, during which the face first becomes flushed, then livid. As soon as the muscular rigidity begins to relax, clonic convulsive movements take place, and the patient breathes irregularly. The muscular disturbance is often more marked on one side of the body than on the other, and the head is frequently draAvn downward and to one side by the irregular action of the sternocleidomastoid muscles. During the clonic convulsive move-
^ Diseases of the Nervous System, second edition, vol. ii., p. 760.
2 American Journal of the Medical Sciences^ October, 1864, pp. 384-394.
FEIGNED MENTAI. AND BODILY DISORDERS. 35
ments the tongue is often bitten, and froth and mucus, tinged with blood, may ooze from the mouth, and sometimes from the nose. As the clonic convulsive movements become less frequent, the livid condi- tion of the face lessens. After the fit, which usually lasts from one to three minutes, the patient may immediately pass into a stuporous sleep, or he opens his eyes and looks around in a dazed manner, may answer questions, but soon falls into a deep sleep ; he may perform various automatic acts, or he may become maniacal. Personally, I have never witnessed the last as a termination of an epileptic fit. During the seizure the eyes may be turned or jerked in various directions, the pupils are dilated, and usually the irides are irresponsive to light ; the patient is totally unconscious and does not feel pain, but the corneal and other reflexes are not completely abolished.
Everything usually observed in an epileptic fit may be simulated by a clever malingerer except the change in the color of the face, the condition of the pupils, and the insensibility to suddenly inflicted and unexpected irritation.
Color of the Face. — A simulator, by muscular action, can produce redness of the face, and by holding his breath this color will change to a darker hue. It is very difficult voluntarily to cease breathing until the face becomes deeply cyanosed, as occurs in genuine convulsions. It is rare for a simulator to be seen sufficiently early for absence of the pale- ness of the face to be noted.
Condition of the Pupils. — In the early stage of the fit the pupils are said to be occasionally contracted. If this phenomenon is present, it must be very evanescent in character, as I have never succeeded in exposing the eyes sufficiently early to find the pupils contracted. At all events, during most of the tonic stage and throughout the clonic the pupils are dilated, and the irides will not often respond perceptibly to light. As consciousness begins to return the extreme dilatation passes away, and the pupils may alternately contract and dilate every few seconds.^ Personally, I have not seen a genuine epileptic convulsion during the height of which the irides responded to light.
Keen, Mitchell, and Morehouse, in the article on malingering pre- viously referred to, state : " We ourselves are of the opinion that when, in a fit, the pupils, largely dilated, remain impassive and motionless before a bright light, the case is almost certainly a real one. But, unfortunately, this state of things is of very rare occurrence, even in severe fits. The pupils unquestionably contract in the presence of a bright light in many such cases. Sometimes the movement is sluggish and slight ; in others, it is almost normal as to range and speed of movement.^' These observers experimentally demonstrated that violent muscular action will cause the pupils to dilate rapidly, and that so long as the muscular action is kept up, the irides will move only slightly and sluggishly to a bright light.^ From their observations they deduce the conclusion that only in those cases of epileptic fits in which the
* Gowers states that this phenomenon was first pointed out by Keynolds. 2 I have verified the accuracy of this observation.
36 MALINGERING AND THE FEIGNED DISORDERS.
irides fail absolutely to respond to light is the pupillary test of the geiiuiiioness of the convulsion of any value whatever.
Insensibility to Suddenly Inflicted Irritation. — In the uncon- sciousness from an epileptic convulsion, if the cornea is touched with the end of the finger, the eyelids may move a little ; if the supra-orbital nerves are iirmly pressed upon with the thumbs, the skin of the fore- head may slightly corrugate ; or if a pin be thrust into a limb, it may be flexed, but no purposive movements will be made to get rid of the irritant. In feigned epilepsy, if suddenly and unexpectedly acute pain be caused, an intelligent effort will at flrst be made by the simulator to avoid the irritant.
The test of a genuine fit which Keen, Mitchell, and Morehouse re- garded of the most value is etherization. According to these observers, if ether is administered to a patient in an epileptic convulsion the violence of the muscular spasm is at first increased, but the subject passes into a profound comatose state without showing any of the cerebral excitement witnessed ordinarily in the administration of ether. Further, when these subjects are recovering from the effect of the anesthetic, they may have convulsive movements before complete consciousness returns. In feigned epilepsy the subject will laugh and talk during the cerebral excitement caused by the administration of ether, just as is generally observed. These writers add :
^^ When ether is used during the state of comatoid sleep which fol- lows many fits, there is also an absence of all manifestations of excite- ment, and the sleep only becomes more intense.
" It appears to us that the ether-test as proposed by us is the most valuable and certain of all the means hitherto employed to unmask cases of feigned epilepsy.''
The ether-test for determining the genuineness of an apparent epi- leptic fit would be more valuable and reliable if all persons who are not subject to epileptic attacks manifested unequivocal evidences of cerebral excitement before passing into a deep ether coma. It is not an uncom- mon experience, however, to have patients become deeply narcotized from ether without laughing or talking or manifesting very decided signs of cerebral excitement.
We have seen that the majority who attempt to feign a fit do it so bunglingly that the fraud is easily detected. It is only the expert simu- lator whose cleverness at deception often puzzles the most skilled phy- sician. There is probably no one means by which feigning of a fit can invariably be exposed. What, then, should be the rule of procedure in cases where feigning is suspected, but cannot positively be detected by the ordinary means resorted to for this purpose ?
" We should observe, first, the patient's face and mental condition, to see if they have been influenced as yet by the disease. Next, we should obtain his personal character as nearly as possible, and all the particulars of the origin of his malady and of his general health, to see if there were any contraindications developed. We should observe where and how he was attacked by the fit. One of our patients, whom
FEIGNED MENTAL AND BODILY DISOKDERS. 37
we had suspected, set our suspicions at rest when we learned that he unquestionably had a fit in his sleep. ^ We should then observe one or more of the attacks, and never should we decide without doing so. If we can discover any true signs of real consciousness or sensation, un- questionably the man must be a malingerer. Hence, if he grows worse when visitors are present ; if he opens his eyes, evidently to see what is going on ; if he does not fall oif the bed when not held, but struggles sufficiently to do so when he is held ; or if he exhibits pain, not reflex movements from irritants purposely applied or from self-inflicted in- juries ; or if he should suddenly recover when severe measures are proposed in his hearing — we should class him as a malingerer. Per- fectly immobile pupils, especially in the absence of violent spasms, we should regard as an evidence of real epilepsy, but only when they were thoroughly and carefully observed during the spasm itself, which is often impossible. A genuine epileptic will usually keep his hands open if they are forcibly unlocked, while a malingerer rarely does so.''^
Severe pressure with the thumbs on the supra-orbital nerves during a genuine spasm never causes any purposive movements ; simply a slight corrugation of the skin of the forehead. So much pain may be caused by this method that it is difficult for a simulator to prevent attempting, at least, purposive movements directed toward getting rid of his tormentor. I have never met with a case of feigning in which this test has completely failed. Irritation of the cornea is hard to bear by the simulator without showing some signs of pain. Very few simu- lators can bear, without giving some expression of suffering, a strong galvanic or faradic current applied to the dry and powdered skin by means of a dry wire-brush, especially if they do not know beforehand that the skin is going to be severely irritated. Various states of feigned unconsciousness may be exposed in this manner.
Since accident-insurance policies are so commonly carried by all classes of persons, feigned and exaggerated disease and suffering have become common. The ease with which jurors, and often physicians, are deceived by the actions and statements of persons who have sustained only slight injuries is another incentive for the dishonest to magnify their suffering or to simulate some disease the existence of which would entitle them to liberal compensation.
F'eig'ned Headache. — Of all symptoms of disease, headache is the easiest to feign, and its existence may be impossible to disprove when this symptom is assumed by a clever simulator. In the alleged presence of this symptom, as in that of any other of the nervous sys- tem, all the organs of the body should be subjected to a most thorough and searching examination. In the absence of an apparent cause it does not prove that the headache is feigned. We all know how fre- quent it is for the physician to meet with persistent and distressing headache in persons in whom there can be no suspicion of feigning, and
1 Too much stress must not be laid on the occurrence of a fit during sleep, as the latter may be feigned.
2 Keen, Mitchell, and Morehouse, Amer. Jour. Med. Sci., October, 1864, p. 389.
38 MALINGERING AND THE FEIGNED DISORDERS.
yet no probable cause for the cephalalgia is detected. The character and seat of a feigned headache may often be changed at will by sug- gestions skilfully made to others in the hearing of the simulator. Fail- ing this, I know of no means by which one can say with positiveness that no headache exists. On having the patient watched, and finding that he acts differently when he thinks he is not observed by the phy- sician, fraud may be suspected.
Vertigo, when feigned, is equally as difficult to detect as is head- ache.
Pain and Tenderness. — These may be complained of in any portion of the body. The most common sites for feigned pain are in the spine, back, hips, or legs. Real pain in the spine will be attended with some rigidity of the spinal muscles, and the gait and carriage of the patient will be in keeping with the severity of the pain, and will not be changed as soon as the patient thinks he is not under observa- tion. Pain in the nerves of the legs or radiating from the spine down the nerves will follow the course of these nerves. Simulated tenderness may often be detected by pressing on the alleged tender spot while the patient's attention is absorbed in some subject of conversation. It must be remembered that real pain in the spine and nerves often exists, and is exaggerated by the patient's attention being concentrated on his suffering. Great care is always necessary, lest by a superficial exami- nation and a hasty conclusion injustice to an actual sufferer is done. Many mistakes of this kind have been made by men of experience and skill. It may be accepted that the greater the examiner's knowledge of the functions and diseases of the parts, and the greater the thorough- ness and patience displayed in the examination, the less frequently will real disease go undetected and the less the chances of the simulator will be of escaping exposure.^
Paralysis of motion may involve one limb or part of a limb, one entire side of the body, both legs, rarely both arms, or nearly all the voluntary muscles may be affected. The sphincters of the bladder and rectum and nearly all the muscles supplied by the cranial nerves may be paralyzed. The paralysis may be organic, feigned, or hysteric. The first question to decide is whether the loss of power is due to organic changes in the muscles or nervous system. If it is due to disease of the muscles, it is either acute or chronic. The acute variety is attended by inflammation, tenderness, pain, and swelling in the affected muscles. The chronic form is attended by wasting of groups of muscles-^progressive muscular atrophy of the idiopathic variety. This cannot be successfully feigned.
A lesion in the nerves, cord, or brain may give rise to paralysis.
1 The so-called " Mannkopf plan ' ' may be utilized : If pain and tenderness are real, pressure upon the painful parts increases the rapidity of the heart's action. In simu- lation the pulse would not change. This scheme is not to be wholly trusted, however, as in exceptional instances an increase of real pain is not followed by a more frequent pulse ; while, on the contrary, the pulse may increase during the experiment in a case of simulation. — Editor.
\
FEIGNED MENTAL AND BODILY DISORDERS. 39
If the paralysis is caused by trouble in one nerve or a plexus of nerves, the loss of motion will be limited to the muscles supplied by these nerves. The character of the paralysis, the changes in sensation, the trophic disturbances, and the electric reactions will suffice to determine whether the loss of motion is due to disease of the nerves. Multiple neuritis is bilateral, usually symmetric, aifects the parts most at the distal portions of the limbs, is attended commonly by sensory and motor defects, alterations from the normal in the reflexes, trophic disturbances, and electric changes. If the paralysis is due to a lesion in the anterior horns of the cord, there will be no pronounced sensory disturbance, the muscles will be flaccid, atrophy early, and present electric changes. If a group of muscles only is involved, it will be those concerned in the performance of definite associated movements, instead of all those supplied by individual nerves. In paralysis from myelitis, both motion and sensation will be, to a greater or less degree, aff*ected from a point on a level with the height of the spinal lesion downward. If the lesion is in the lumbar region, the sphincters of the bladder and rectum will be paralyzed and the urine will dribble away as it reaches the bladder. An examination of the rectum by the finger will readily detect the paralysis of the rectal sphincter. Muscular wasting will occur, electric changes may be detected, a sacral bed-sore will probably form, and the deep reflexes will be abolished. If the spinal-cord lesion is above the lumbar region and sufficient to paralyze the parts innervated by nerves given off" below the seat of the myelitis, the reflexes on a level with the lesion will be abolished, the deep reflexes in the parts below will be increased, there will be little tendency to the formation of bed-sores if cleanliness is maintained, electric and trophic changes in the parts below the level of the lesion will be slight, and while voluntary control of the bladder and bowel is lost, the sphincters are not paralyzed. If the urine dribbles, it is because the bladder is full and the incontinence is that of overflow. No voluntary effort can be made to evacuate the bladder and bowel. Spinal paralysis, except that form due to disease of the anterior horns (poliomyelitis), is generally bilateral.
Cerebral paralysis of organic origin is, except in very rare cases, unilateral in character. The most common form is the hemiplegic — the leg, the arm, and lower side of the face on the same side. In a num- ber of instances the paralysis is monoplegic at first, the face, arm, or leg being affected. In a still smaller number of cases the paralysis is ^^ crossed,'^ the face is paralyzed on one side, and the leg and arm on the opposite side. In paralysis from organic cerebral disease the deep reflexes are often increased on both sides of the body, but to a much greater extent on the affected side. Sensory disturbance may be present or absent, depending upon the seat of the brain-lesion. Electric changes are usually absent. The greater the tendency to contractures, the more pronounced the trophic changes in the paralyzed parts.
Disturbance of sensation due to organic trouble will, when caused by lesion of one or more nerves, follow the cutaneous distribution of the nerves, and be associated with some loss of motion unless a purely
40 MALINGERING AND THE FEIGNED DISORDERS.
sensory cranial nerve is affected. If the loss of sensation is from a lesion of the cord or brain, the attendant symptoms will enable a diag- nosis to be made.
If paralysis exists and no evidence of an organic lesion is found, it is not always an easy matter to make a sharp distinction between feigned and hysteric paralysis, because few cases of hysteria are encoun- tered in which the symptoms are not exaggerated, and some may be feigned.
Space will not permit a thorough discussion of hysteric paralysis. Quite frequently the loss of motion is associated with loss of sensation. If the anesthesia is limited to the limbs, it involves the limbs up to its junction with the body, where it abruptly ends. It thus differs in its distribution from anesthesia due to an organic lesion. When the loss of sensation affects one side of the body, it involves the face, scalp, and special senses on that side. There is a condition of ^^ crossed ambly- opia," differing from the hemianopsia of organic origin. I have never met with a case of "crossed amblyopia '^ of organic origin. The reflexes are increased in hysteric paralysis, but they are usually alike on both sides of the body. In hysteric paralysis, if the patient is requested to make an attempt to contract the flexor muscles of a limb, the ex- tensors may be felt to contract at the same time. This does not occur in paralysis from organic origin. Further, hysteric paralysis is often changeable. The history of the patient will usually reveal former attacks of a hysteric nature.
Feigned paralysis presents no symptoms of an organic nature, and, on account of the ignorance of the simulator, the symptoms are greatly exaggerated and there is an absence of those stigmata so commonly found in pure hysteria. If anesthesia is feigned, it may be detected by the electric brush applied when the simulator is not expecting it. If the subject is blindfolded and a feather or cameFs-hair pencil used to mark out the area of anesthesia, the latter wdll be found to vary con- siderably from minute to minute, as it is impossible to feign cutaneous anesthesia that ends abruptly. The methods employed to detect feign- ing in general may be resorted to with advantage in the examination of suspected feigned paralysis. Some movements may take place in the paralyzed limbs from organic disease if the patient is anesthetized, but the muscular movements are purely reflex, while in feigned paralysis the movements will be equally vigorous on the two sides of the body. Hutchinson^ has show^n that a healthy limb trembles when a heavy weight is suspended from it.^
Feigned contractures are sometimes most difficult to detect.
^ Hamilton, Medical Jurisprudence^ p. 211.
2 The so-called " Babinski reflex " may be tried : In a normal adult, when the sole of the foot is tickled, the great toe bends downward or is flexed. In an organic paral- ysis of one or both legs, the great toe is extended or bent upward. In a hysteric paral- ysis of one or both legs, and in simulated paralysis (unless simulated by one cognizant of this sign), irritation of the sole of the foot would produce the same movement of the toes as in normal conditions. There are exceptions to the rule thus laid down, but the Babinski test is valuable in some 80 per cent, of all tests. — Editor.
FEIGNED MENTAL AND BODILY DISORDERS. 41
They should be investigated in the same manner as is pursued in ex- amining a case of paralysis. A thorough examination will fail to reveal any evidence of organic disease.
If the feigning is continued long enough, the contractured muscles will shorten, and some wasting of the parts will take place. Before organic changes have occurred in the muscles, if the patient is sur- prised in his sleep, the contractured muscles will be found relaxed and the limbs may be suddenly extended before the simulator recovers con- sciousness sufficiently to resist extension of the limb. A clever rogue may simulate paralysis or contraction of a limb so skilfully as to almost defy detection. Complete relaxation under an anesthetic of a limb that has been contractured for months would be in favor of feigning.
Catalepsy is extremely rare and difficult to feign. The muscles are in a wax-like condition, and gradually yield to gravity when the limb is extended at right angles with the body. If a weight is sus- pended to the limb and the latter is held rigidly in the same position, the subject is probably feigning.
Sleep may be simulated. In sleep the pupils are very small, and on awakening the subject and raising his eyelids, they will dilate at first, even in the presence of a bright light. A person may voluntarily contract his pupils by a strong effi^rt at convergence of the eyes. Ex- cluding all diseases or drugs that contract the pupil, pin-hole pupils without convergence of the eye would be in favor of the genuineness of the sleeping condition of the subject.
Feigned unconsciousness may usually be detected by using some irritating agent^ — the faradic brush suddenly applied to the skin when the simulator is not suspecting anything of the kind and is totally unprepared to nerve himself against pain will cause purposive move- ments. It is probable that the method employed and recommended by Keen, Mitchell, and Morehouse during the war of the Rebellion to de- termine the genuineness of epilepsy may be used in detecting feigned unconsciousness in general.^ These observers found, on anesthetizing a person who was feigning unconsciousness from a simulated fit, that he would invariably struggle during the stage of cerebral excitement, but no evidence of such excitement was ever manifest if the assumed un- conscious state Avas real.
Tetanus, chorea, the systemic diseases of the spinal cord or pronounced disease of the brain could not be success- fully feigned, even by a clever simulator, if the medical examiner in- vestigates the condition critically in the light of a detailed history.
Aphonia may be feigned for an indefinite period. The deception can be detected by placing the simulator under an anesthetic, preferably ether. During the stage of cerebral excitement, as the will no longer restrains the action of his vocal muscles, he talks quite distinctly. I am not aware of any reliable method for distinguishing hysteric from feigned aphonia, aside from the history and general hysteric stigmata of the former.
1 Amer. Jour. Med. Set., October, 1896.
42 MALINGERING AND THE FEIGNED DISORDERS.
Sciatica. — Under the heading pain and tenderness a few remarks are made on feigning, but as* sciatica is commonly assumed by impostors, some of the principal points in the diagnosis may be mentioned. There is pain along the course of the nerve, and often along that of its branches, and not infrequently in the areas of the final distribution of the nerve. The pain is increased by putting the limb in such a position as to make the nerve tense ; and the knee is kept slightly bent in walk- ing so as to prevent any increased tension of the nerve. Gowers gives s^ven spots of tenderness : (1) Above the hip-joint, near the posterior iliac spine ; (2) at the sciatic notch ; (3) about the middle of the thigh ; (4) behind the knee ; (5) below the head of the fibula ; (6) behind the external malleolus ; (7) on the back of the foot. It is scarcely neces- sary to say that all these points of tenderness are not present in every case. The patient, in pointing out the course of the pain, maps out the distribution of the branches of the nerve. The main nerve-trunk at the back of the thigh is often extremely tender to pressure. If the leg is extended at the knee and the thigh flexed upon the pelvis, the patient will experience pain at the sciatic notch, along the course of the nerve at the back of the thigh, at the back of the knee, and often in the heel. In feigned sciatica the pain is not definitely located along the course of the nerve and at the points of its distribution. In feigned cases the points of tenderness are not always over the body of the nerve or branches of distribution. Pain on the inner side of the thigh is not caused by disease of the sciatic nerve. It should be borne in mind that when the sciatica is due to pressure or irritation within the pelvis there may be no points of tenderness along the course of the nerve, but the pain experienced by the patient will be referred along the course of the nerve, that of its branches, and more especially to the points of distri- bution of the nerve.
Rheumatism. — DaCosta says : Chronic rheumatism is often feigned, especially by malingerers in the army and navy, and the decep- tion may be difficult of detection. They pretend to be scarcely able to walk or hobble around with a cane, and complain much of pain and stiifness in their joints. Yet there is not the least sign of deformity or real stiffness ; the pain is always stated to be the same, and their gen- eral health is excellent. Their way of using the stick, too, is charac- teristic ; they move it each time they move the seemingly crippled leg, but, as a rule, not immediately, thus not employing it as a support. Anesthetics are of great value in enabling us to decide as to the real amount of immovability of the limb.'' ^
Hysteria is sometimes feigned for the purpose of gaining sym- pathy. It is not always easy to determine whether the symptoms in a case of assumed hysteria are genuine or simulated. The deception is made all the more difficult from the fact that many hysteric subjects feign some of the symptoms. If the history of the case gives no former attacks or symptoms of hysteria and the general stigmata of the disease are absent, it is fair to presume that the subject is a malingerer. * DaCosta, Medical Diagnosis^ seventh edition, p. 812.
FEIGNED MENTAL AND BODILY DISORDERS. 43
Vomiting is not infrequently simulated by malingerers. Some persons learn to vomit apparently at wilP; others induce nausea and vomiting by irritation of the fauces. A short time ago I had a man under my care who had been injured in a mine. He had a suit pend- ing for large damages. It was reported to me by the nurses in the hospital that he vomited about an hour after each meal, and between meals he vomited almost immediately after drinking any liquid sub- stance. I expressed great concern in the presence of the patient about the gravity of his case, and requested him to drink a glass of water in my presence that I might witness his distressing symptom and be able to testify in regard to his condition. He hesitated at first, ostensibly on account of the distress that he experienced on imbibing any liquids. I was persistent, and insisted that I must observe the vomiting. He drank a glassful, about eight ounces, of water, and almost immediately I noticed that he began to retch. On placing my hand on the abdomen I found that he was voluntarily contracting the abdominal muscles and the diaphragm. These movements continued every few seconds for about two minutes, when he succeeded in ejecting from the stomach nearly all the liquid he had drank. The emesis occurred without any pallor of the face, increased flow of saliva, or any other evidence, so far as I could determine, of nausea. I at once charged him with malingering and of voluntarily inducing the emesis. I threatened that if he vomited any more I would testify against him when his case came to trial. He did not vomit again, either liquids or solids, although he remained under my observation several weeks longer. In cases of suspected feigned vomiting the patient should be watched carefully, when the deception will ordi- narily be readily detected.
Hemat emesis. — There are several ways by which a clever simu- lator may cause vomiting of blood. The mucous membrane of the nose, mouth, or fauces may be irritated until it bleeds and the blood be swallowed, or blood may be obtained from other sources and taken into the stomach. In suspected cases of fraud the supposed malingerer should be watched carefully and the exposed air-passages examined.
Suppression of Urine. — The man who feigned vomiting, an account of whose case is given above, simulated a partial suppression of urine before he learned to vomit at will. The nilrse reported that he apparently passed only about three ounces of urine in twenty-four hours. I requested that the entire quantity passed during this time should be saved in a vessel for me. The quantity was three and one- half ounces. It was normal in color, slightly acid in reaction, and had a specific gravity of 1010, and contained neither albumin nor sugar. It was quite evident from the analysis of the urine that the man was passing more than this quantity of water. His bowels had moved only once during the twenty-four hours. I asked him if he had not passed more than three ounces and a half of urine, fie declared that he had not. I left orders with the resident physician that the patient should be catheterized every four hours during the next twenty-four hours. The result was about the same — only four ounces of urine were obtained.
44 MALINGERING AND THE FEIGNED DISORDERS.
This specimen was normal in every respect. I left instructions that the catheter be employed in the same manner during the next twenty- four hours ; at the same time ordered the patient to be closely watched, and the entire quantity of liquid drank to be measured without his sus- pecting what was being done. Again the quantity of urine ])assed and drawn oif by the catheter was only three and a half ounces, ^^o one had seen him go to the water-closet or any other place in which he might urinate. It was certain that he had not gone to the toilet-room during the day. He was undressed and apparently in bed all the time. The quantity of liquid that he had drank during the twenty-four hours that he had been under such close observation was 48 ounces. It was reported that he had not perspired much. His temperature, pulse, and respiration were normal. During the time that this man was under observation in St. Luke's Hospital I had been conducting a series of observations on afebrile patients in the Arapahoe County Hospital to determine the relative quantity of urine passed to the quantity of liquid ingested. In no case, while the patients were in bed, had the quantity passed been less than two-thirds of the quantity ingested, and in most of the cases the former quantity was about three-fourths as much as the latter. Thus fortified, I boldly charged the man with lying, telling him that I had measured every drop of fluid that he had drank, and that there could be no such discrepancy. He confessed. During the day he had kept a vessel secreted back of the wardrobe, into which he had urinated, and between midnight and day, when everything was still, he had quietly gone to the water-closet and emptied the vessel.
Diarrhea and constipation are sometimes feigned, but the fraud may easily be detected by having the malingerer closely watched.
Blood-Spitting or hemoptysis, if assumed, can usually be de- tected by a careful inspection of the mucous membrane of the nose, mouth, and fauces.
Feigned asthma, according to DaCosta, is not worse at night nor much increased by exercise.
Feigned Poisoning. — An evilly disposed person might assume some of the symptoms produced by a poison and accuse an innocent person, against whom the simulator had a grudge, of administering the poison. The symptoms would be ill feigned by an ignorant person. One well versed in the action of poisons might take a cathartic and an emetic and then place a poison in the discharge from the bladder and bowels or in the vomited matter. The finding of a poison in these would be no proof that it had come from the body of the person alleged to have been poisoned, unless they had been passed into clean vessels in the presence of a physician or some other reliable witness. If the urine drawn with a catheter showed the presence of the poison, this would be conclusive evidence of its having been within the patient's body, and nothing more.
Feigned Pregnancy. — Pregnancy may be feigned to extort charity, to secure an unjust settlement of property, or to escape inflic- tion of condign punishment. The deception may be detected by skilled
FEIGNED MENTAL AND BODILY DISORDERS. 45
physicians versed in the symptoms of pregnancy. In no case should an opinion be given without a careful internal and external examination of the alleged mother. If the period of gestation has not advanced suffi- ciently to permit of a definite opinion in regard to the woman's real condition, the physician should not hesitate to ask for an extension of time, during which repeated careful observations should be made.
Feigned Menstruation. — A woman may be pregnant, yet, desiring to conceal her condition, feign menstruation by soiling her linen with blood. The chemical tests are uncertain for distinguishing ordinary blood from that found in the menstrual flow. An examina- tion of the woman to determine the presence of the results of conception will usually suffice to settle the question. It must be borne in mind that a few persons menstruate throughout the period of gestation. I have met with one woman who menstruated only during gestation and lactation. Throughout these periods her menstrual epochs occurred regularly every twenty-eight days. Suppressed menstruation could be determined only by keeping the suspected person under close observation.
Feigned Delivery. — Taylor says : " 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.'^ In most of these cases it is recent delivery that is assumed, and an examination of the alleged mother by a competent medical man would soon determine the matter.
Feigned Abortion. — If a woman charges another person with having perpetrated the crime of abortion on her, the truth or falsity of the statement may be easily demonstrated by a physical examination, if this is made soon after the crime has been committed. If the charge is made several months after the alleged commission of the crime, it should raise a suspicion of deception on the part of the woman making the charge. At so late a date it may be impossible to decide positively whether an abortion has been performed.
Feigned Strangulation. — In the few cases of simulated stran- gulation the marks of violence around the neck have been slight or entirely absent, the impostors have retained sufficient consciousness to take cognizance of everything that has occurred, the cord around the neck has not been sufficiently tight seriously to endanger life, produce cyanosis of the face, protrusion of the tongue, or congestion of the eyes, and the other circumstances surrounding the alleged attempts at murder have been such as to prove the innocence of the accused parties.
If a serious, but unsuccessful, attempt is made to commit murder by strangulation, either by means of the hands or a cord tied around the neck, the parts would not be so delicately handled as to leave no marks of violence. If a cord were tied around the neck, it would be with a firm knot, and the constriction would be so great as to endanger life unless the cord were removed within a few minutes from the time it was applied. There would, in all probability, be. evidence of a des- perate struggle, and the general circumstances would be in keeping with the acts of the attempted murder.
THE LEGAL ASPECTS OF PREGNANCY.
It is exceedingly important that the medicolegal expert be well versed in the clinical signs and manifestations of the various stages of pregnancy, since it is not at all infrequent for the question of gestation or the effects of child-bearing to arise in a certain class of cases. Thus, in civil law a physician may be called upon to testify as to the virginity of a woman or the purity of a divorced wife libelously accused of ges- tation, as proved, negatively, by the absence of the signs of pregnancy or of parturition ; he may be required to show the absence of pregnancy in cases of feigned gestation, or when a woman claims to be with child by a man recently dead, for the purpose of advancing an additional heir to a disputed title or estate, or for the purpose of substituting a child in place of the legitimate heir. The claim of pregnancy may be made in order to institute blackmail ; it may be advanced as a plea to prevent attendance upon the witness-stand in an important trial by jury ; it not infrequently is employed as a means of enforcing marriage to satisfy feelings of unrequited love or to establish a claim for financial support. It has been used as a means of holding the affections of an estranged husband desirous of offspring.
In the criminal court instances are recorded of women pleading pregnancy to bar execution. From the time of the old Roman law to the present such a claim, if verified, has been ample to postpone the carrying out of the sentence of capital punishment until the birth of the child is accomplished. In all such cases, under writ of de ventre inspi- ciendOj proof of the supposed condition is required, and is secured by careful investigation by medical experts or by the physician appointed by the court. These have rightfully supplanted the old English jury of twelve matrons who were summoned to ascertain the unfortunate woman's condition, and whose main duty was to determine whether or not the woman was quick with child. If the woman is acting bona fide y the examination w^ill not be refused ; indeed, it will probably be insisted upon by her. Refusal to permit the examination will expose her to the strong suspicion of unfair dealing. The practitioner must remember, however, that he becomes liable to legal action on her part if he force an examination against her will. It should be his duty, likewise, ta warn the patient in all cases that any suspicious appearance may be used as valuable evidence against her. Again, the existence of preg- nancy may be denied strenuously by a woman in order to avoid the stigma of illegitimacy, or to gain time for the induction of an abortion.
46
THE SIGNS OF PREGNANCY. 47
Here the effort of the physician should be to demonstrate the presence of the gestational signs.
It is important to note that a positive diagnosis of pregnancy is impossible before the sixth week, and often not until the second men- strual epoch, especially in multiparous women. After the date of the positive signs no difficulty should be experienced in proving or dis- proving the existence of pregnancy. Hence the examination should be postponed, if possible, until such a time as will elicit positive results. An error in diagnosis, whereby an innocent woman is erroneously declared by the examining physician to be pregnant, will react dis- astrously upon the so-called expert, and may prove ample ground for the institution of legal proceedings.
It is patent, therefore, that a knowledge of the signs of pregnancy is essential for a positive affirmation or denial in a given case.
THE SIGNS OF PREGNANCY*
It is customary to group the signs of pregnancy broadly under the two headings of subjective and objective, of which the latter only — those detected by the senses of the examining physician — are to be trusted implicitly, since they alone are capable of demonstration. While the subjective signs, when present, are exceedingly valuable as suggestive of pregnancy, it must be remembered that a woman may be voluntarily deceiving her physician, or that she may be herself deceived, as has been frequently noted in remarkable instances in the history of obstet- rics. Thus, a woman nearing her menopause and married late in life, or sterile since an early marriage, may readily coax herself into believing that the menstrual suppression characteristic of the so-called ^^ dodging- period ^' of the climacteric is due to an incipient gestation. Once firmly fixed in her mind, this belief can grow jpari passu with the supposed advancing pregnancy. Intestinal movements will be interpreted as fetal motions ; gaseous distention of the bowels and fat-accumulations in the abdominal walls are the progressively enlarging uterine body ; the irritable bladder of elderly women is construed to mean the irritable bladder of uterine pressure ; the breasts may be found to secrete a small amount of serous fluid, and the woman and her husband, and even the family doctor himself, may be deceived into believing that pregnancy exists. In other words, a typical pseudocyesis or phantom py^egnancy is developing.
Let it be noted here that pseudocyesis, with the one exception of abdominal enlargement, is a subjective consciousness entirely. The woman feels the sensation of quickening, the fetal movements, the pres- sure upon the bladder, the sympathetic breasts. The diagnosis of her true condition can be made by the skilled obstetrician only by giving attention to the following points : The woman's age — she is approach- ing the menopausal period when menstrual sujfpression or irregularity is the rule, and nervous manifestations are frequently exaggerated ; abdominal palpation and percussion will reveal a heavy accumulation
48 THE LEGAL ASPECTS OF PREGNANCY.
of fat in, together with a lax and pendulous condition of, the walls, and a highly resonant or tympanitic note over the entire surface ; no fetal outlines can be detected by palpation of the abdominal surface ; exami- nation of the vulvar orifice and vagina reveals the senile atrophy and probably the beginning yellow discoloration of the mucous membrane that are characteristic of advancing years ; the vagina may be more or less contracted, the cervix senile and atrophic, and the uterine body small and undergoing retrograde changes ; the appendages are also small and detected with difficulty. In order to avoid any error in diagnosis it is better in these cases to administer chloroform or ether, when the abdominal enlargement will collapse and the true condition be made patent. These cases of genuine pseudocyesis may be much more difficult to diagnosticate than feigned pregnancy in hysteric women (see Feigned Pregnancy, p. 44).
It is well, then, to note that a pregnancy may be py^esumptive, it may be probable, or it may be certain. It is presumptive when, without any expert investigation, the woman, having been exposed, legitimately or illegitimately, to the possibility of conception, presents some or all of the subjective signs of pregnancy, together with a minor degree of abdominal enlargement. It is probable if these signs steadily increase in intensity and other signs develop at proper periods, which in a typical case of gestation should be superadded to the initial symptoms. Finally, a pregnancy is certain only when there are present the so-called positive or diagnostic signs of pregnancy, variously estimated as from three to five in number. They include the fetal heart-sounds, the fetal movements, ballottement, vaginal and vulvar discoloration, and inter- mittent uterine contractions.
For convenience of reference the signs of pregnancy may be grouped under four headings : namely, the uterine, the vaginal, the abdominal, and the general.
THE UTERINE SIGNS.
Cessation of Menstruation. — This is probably the most valu- able of the subjective signs of pregnancy. If the previous history has been one of regularity, greater value is to be attributed to the irregu- larity or suppression of the function, especially if this be associated with other suspicious circumstances, as the history of sexual intercourse. It is the usual result of gestation, although it may follow other patho- logic causes, or it may be absent altogether, and the woman menstruate regularly throughout the first trimester or even the full period of preg- nancy. Other remarkable cases are those in which the normal (?) con- dition of the woman is that of amenorrhea, save during the progress of gestation, when regular menstrual discharges prevail. Again, it is pos- sible for pregnancy to occur in young girls prior to the establishment of the menstrual flow, and for rapid successive pregnancies to prevent the appearance of the menses until late in the woman's life, or even altogether. Again, cases are on record of conception having occurred some time after the woman had passed through her climacteric. These
THE SIGNS OF PREGNANCY. 49
instances all go to prove that ovulation, the essential feminine process in conception, is not at all dependent upon menstruation, although it is probable that each menstrual epoch is associated with the escape of an ovum either at its height, shortly before, or shortly after its appearance. In other words, it is not necessary for a menstrual discharge to accom- pany each escape of an ovum.
Leopold and Mironoff ^ find that menstruation is usually accompanied by ovulation, but not rarely is unattended by ovulation. It is not de- pendent upon the maturation and rupture of a Graafian follicle, but the presence of the ovary and a sufficient development of the uterine mu- cosa are necessary. Ovulation is connected with menstruation in so far as it requires for its occurrence a congestion of the sexual organ lasting several days. Ovulation occurs independently of the time of menstrua- tion, but under physiologic conditions, rarely. Usually menstruation occurs with ovulation ; less frequently it may occur without ovulation ; and least frequently ovulation may occur without any sign of blood at a regular menstrual period.
To still further complicate matters, there may be total absence of menstruation, the result of occlusion of some portion of the lower birth- canal (atresia of the cervix uteri, vagina, or vulva ; imperforate hymen), with a vast accumulation of the fluid and great distention of the uterine and abdominal cavities, thus closely simulating an advanced pregnancy, with total suppression of menstruation. The persistence of menstrua- tion during the first trimester of pregnancy, in addition to confounding the diagnosis, will be a confusing element in the determination of the duration of a given case.
The morbid conditions that are frequently associated with menstrual suppression without coincident gestation, and which are frequently over- looked by the examining physician, are incipient phthisis, chlorosis, anemia, hemorrhage from wounds or other mucous surfaces (vicarious menstruation), various forms of insanity, hysteria, sudden and de- cided change of climate, and the development of certain pelvic tumors as ovarian cysts, and occasionally uterine myomata. An important fact worth noting is that the menstrual suppression of pregnancy is gener- ally associated with a steady improvement in the body-health, which is not true of the foregoing conditions. Anxiety, as after illicit inter- course, may temporarily cause menstrual suppression.
Feigned Menstruation. — Occasionally women will feign men- struation in order to conceal an illegitimate pregnancy. This is ac- complished by staining the underclothing and napkins with other mam- malian blood, which is not readily distinguishable from the menstrual flow ; or even, as has been noted, with preserved menstrual blood. In the former case microscopic examination will generally show the absence of the typical vaginal epithelium, and such blood is much more predis- posed to coagulation than are the true blood and acid vaginal discharge.
Progressive Increase in the Si^e of ihe Uterine Body. — This is a fairly presumptive sign of pregnancy after the first trimester, 1 Arch./. Gyn., Bd. xlv., H. 31. Vol. II.— 4
60
THE LEGAL ASPECTS OF PREGNANCY.
although not an infallible one. The tumor of pregnancy, at first ovoid in 8haf)c, becomes progressively more and more pear-shaped, occupies a median position with a slight inclination to the right, is smooth in con- tour and of a soft and elastic consistency, and is freely moval)le. It is of rapid growth, occupying fixed positions at certain periods of gestation (Fig. 1). Thus, at the sec(^jnd month, the fundus is about on a level with the top of the symphysis pubis ; at the fourth month it is midway be- tween this point and the umbilicus ; at the sixtlT month it is at the um-
Fio. 1.— Abdominal enlargement of the sixth month of prcKnancy, showiiiK position of the funduw of the uterus at different weeks of geKtation,
bilicus ; at the seventh month it is midway between the umbilicus and the xiphoid cartilage ; and at the ninth month it has fallen about one inch. The percussion-note over the uterine body is dull, due to the upward and backward displacement of the bowels. Other conditions that may simulate such a tumor at an early or later period are a sub- involuted uterus, retained menses forming a hematometra, a non-nodu- lated fibrous or myomatous tumor, gaseous distention of the bowel, ascites, an ovarian cyst centrally situated, and tumefactions of the ab- dominal organs, as the liver and spleen. It is very important that an
THE SIGNS OF PREGNANCY. 51
error be not made in this diagnosis, since many a woman has had her life embittered and the physician his professional reputation injured by such ,a mistake. Legal action can readily be grounded upon such an error. Intestinal flatus will be detected by the percussion-note ; ascites and ovarian cyst, by variation in the area of dulness and the elicitation of fluctuation ; the absence of correlated signs of pregnancy will dis- tinguish other growths, while the uterine contractions may be noted in true pregnancy when the cold hand is laid upon the surface of the ab- domen. Etherization in doubtful cases will be imperative.
Braxton Hick's Sig:n. — Intermittent uterine contractions cap- able of recognition after the third montli of gestation must be regarded as an exceedingly valuable proof of gestation. No other known tumor than a uterine growth will present this phenomenon. At regular inter- vals from the fourth to the tenth month of gestation, varying from five to twenty minutes, the uterine tumor will harden and remain contracted for the space of from three-fourths to five minutes. This process is absolutely painless and is not recognized by the woman herself. The mere grasping of the uterus may cause it to appear. It is never absent in pregnancy, whether the fetus is living or dead.
The Uterine Souffle or Placental Bruit. — This is a very con- stant but non-diagnostic sign of pregnancy, since it may occasionally be detected in other uterine and ovarian tumors or conditions of marked, pelvic congestion. It is a rhythmic blowing sound occurring syn- chronously with the woman\s heart-beat, commencing about the tenth week of gestation, and persistent throughout ; it is situated low down and to one or the other side of the uterine tumor. It is produced by the rush of blood through the enlarged uterine arteries, and is generally most prominent in anemic individuals. It must not be mistaken for a similar sound, known as the cardiac SOUffle, which is produced by the passage of the blood through the foramen ovale.
The funic or umbilical souffle is a high-pitched, whistling sound synchronous with the fetal heart-beat, and heard best, although even then with difficulty, over the fetal chest. It is produced by tension of the cord with stenosis of its vessels, and has but slight value as a diag- nostic sign of pregnancy. It is claimed that it is more readily heard when the cord is wrapped around the fetal body.
Irritability of the bladder is produced early in gestation, and in the closing month by direct pressure of the uterine body upon the base of the bladder. It is, in primiparous women, a sign of much value, especially if it be associated with a history of coitus and of men^ strual suppression. It is by no means diagnostic.
VAGINAL SIGNS.
Jacquemin's Sign. — A bluish or purpjish discoloration of the vagina is a positive sign of pregnancy. In many cases of gestation I have never failed to find it present, and in some thousands of gyne- cologic cases I have not seen it accompanying any other condition than
52 THE LEGAL ASPECTS OF PREGNANCY.
pregnancy. Jacquemin originally declared it to be a certain sign in women who have no hemorrhoids, and this statement has been con- firmed by many obstetricians. It may be recognized as early as the fourth week, though it is often not well marked until the third month. Dependent as it is upon the pelvic congestion, it must increase in intensity pari passu with the advancing pregnancy. Toward the close of gestation the mucous surface of the vulva may be almost black in color. In the earlier weeks the discoloration may be first noticed beneath the urethral orifice, digital compression showing the sluggish- ness of the circulation. It is claimed that certain neoplasms may pro- duce such a discoloration, but this must be quite exceptional. The absence of the discoloration cannot be construed as an argument against the existence of pregnancy ; its presence is practically diagnostic.
The vaginal pulse is a frequent sign, and valuable as a pre- sumptive symptom of early gestation. It consists in a distinct pulsa- tion of the vaginal arteries consequent upon the high arterial tension of the pelvis. It is not invariably present, and may accompany other conditions, as fibroid tumors, extra-uterine fetation, and inflammatory pelvic conditions. Flattening of the anterior vaginal vault may like- wise be noted, and was regarded by Barnes as strongly suggestive of pregnancy. It results from backward traction by the upward-tilted cervix.
I/eukorrhea is of no special value as a means of diagnosis, even though the woman has never suffered from it prior to the supposed gestation. It is always present to a certain degree, but may be due to many other conditions. It is associated with more or less puffiness of the vaginal walls and vulvar tissues, and is directly dependent upon the increased pelvic congestion.
Softening of the cervix (GoodelPs sign) is a very suggestive symptom, especially in primiparous women. It is due to edema of the cervical tissues beginning around the os uteri, and is present as early as the second or the third week of pregnancy. As formulated by Goodell, the rule of practice is as follows : If the cervix be as hard as the tip of the nose, pregnancy presumably does not exist, but if it be as soft as the lips, the existence of gestation is probable. It is accompanied by a considerable degree of dilatability of the cervix, especially in multi- parous women. The same softening may be noted in certain pelvic inflammatory conditions, at the menstrual epochs, and accompanying the growth of soft myomata. After the fifth month the cervix will also be found to have shortened materially, and the external os points more toward the sacral hollow. By term the cervix has become fully obliter- ated, the internal os, however, remaining closed until labor begins.
Hegar^S sign, or softening and compressibility of the lower uterine segment, is regarded by many as almost diagnostic of early pregnancy. Soft uterine myomata, however, may occasionally produce such softening of this lower segment as closely to simulate the gestation sign. Bimanual palpation is necessary to elicit the change, the right hand resting upon the abdomen just above the symphysis, while the
THE SIGNS OF PKEGNANCY.
53
thumb of the left hand enters the anterior vaginal fornix and the index- finger passes far up the rectum (Fig. 2) ; approximation of the thumb and finger below while the uterus is depressed by the external hand will reveal the undue softening of the uterine tissues. Between the second and fifth months of gestation Hegar^s sign may be regarded as one of great value. Anesthesia may be required in order to detect it in some cases, and in a large number of cases it cannot be elicited.
In vaginal ballottement, or the balancing of the fetus between the fingers, we have an absolutely diagnostic sign of pregnancy, which, however, is available only from the middle of the fourth to the eighth month. It is elicited by allowing the woman to stand, or by placing her upon her back with the abdominal muscles partially relaxed and the shoulders elevated. The index- and middle fingers of the left hand are introduced into the anterior vaginal fornix, while the fundus is steadied by the right hand placed on the abdominal surface (Fig. 3). The fingers in the vagina then give a sudden impulse to the anterior uterine
Fig. 2.-
-Method of eliciting Hegar's sign of pregnancy (Sonntag).
Fig. 3.— Vaginal ballottement.
wall, when the fetus, which is displaced upward in the liquor amnii, impinges upon the abdominal hand and gently falls again upon the vaginal fingers. A double thumping is thus noted. There is no other condition that could possibly produce a similar sensation, although some claim that an extra-uterine polypus with a long pedicle will respond to the test. It is not always present, however, being absent in twin pregnancy, in absence or deficiency of the liquor amnii, and in placenta prsevia.
Uterine fluctuation is considered by Rasch as an important sign of early pregnancy, recognizable from the second month. It is elicited by placing two fingers of the left hand in the anterior vaginal fornix and steadying the fundus by the right hand placed on the abdominal wall. Gentle tapping by the external fingers, will transmit a wave to the vaginal fingers through the agency of the liquor amnii.
Varicosities in the vaginal wall and around the vulvar orifice are indicative of pelvic congestion and are usually most prominent in the
54 THE I^EGAL ASPECTS OF PREGNANCY.
congestion of pregnancy, because of the additional mechanical factor — pressure by the gravid uterus upon the pelvic veins. In association with other signs of the advancing gestation it possesses some signifi- cance.
An absolute diagnostic symptom is the detection, by the vaginal finger, of the fetal parts.
ABDOMINAL SIGNS.
Cutaneous discoloration of the abdomen is present in the vast majority of pregnant women. The line of discoloration — linea fusca or nigra, the yellow, brown, or black line — supplants the linea alba, and may extend as far as the xiphoid cartilage. It is most marked in brunettes, and may be altogether absent in blondes. It is by no means diagnostic, however, as boys and unimpregnated girls may pre- sent the linea fusca. The linea alba also darkens at the menstrual epochs and in certain forms of pelvic disease, as ovarian cystoma and uterine myoma.
Progressive enlargement and protrusion of the abdomen is an essential sign of pregnancy, but it is patent that the same symp-
FiG. 4— striae, or linese albicantes (Auvard).
tom must occur whatever be the nature of the intra-abdominal growth. The protrusion in pregnancy first becomes evident about the fourth month, and is most marked in women of small stature. The same errors of fallacy are to be noted as in the case of uterine enlargement.
The striae are the purplish lines of discoloration that appear on the distending abdomen in the iliac region and toward the flanks (Fig. 4). They are not diagnostic of pregnancy, but may result from any exces- sive distention of the abdominal walls, as from cysts or ascites.
A change in the condition of the umbilicus is noted in preg- nancy, and while this alteration may result from other causes of disten- tion, it is most commonly associated with gestation. At the sixth month the umbilical depression is obliterated, and after that date there is a pro- gressively increasing protrusion to term.
The percussion-note over the growing uterus is flat, while to the sides and above there will be found an area of tympany known as
THE SIGNS OF PREGNANCY.
55
the ^^ coronal resonance/' Any solid or fluid tumor, however, will give the same result ; hence it is not characteristic.
Abdominal ballottement is an absolute sign of pregnancy, elicited by steadying the uterus with a hand placed on each side of the abdomen. An impulse given by one hand will cause the fetus to im- pinge upon the opposite hand ; the shock is more distinct when the fetus is small and undersized.
All women are essentially constipated, but in pregnancy this may become an exceedingly prominent symptom. This results from the stagnation of the pelvic circulation, and is accentuated by direct me- chanical pressure of the enlarged uterus upon the lower bowel. It is of value as a diagnostic means only when taken in connection with the other symptoms of early pregnancy.
Quickening and Fetal Movements. — By quickening is meant the first fetal movements appreciated by the mother. It usually occurs about the middle of the fifth month of gestation, but may be felt as early as the third month (twelfth week). It is peristaltic in nature, and when noticed, the woman is said to be "quick with child.'' All subsequent sen- sations of fetal life are des- ignated as fetal movements, and they constitute an abso- lute sign of pregnancy. They are not invariably pres- ent, however ; hence their absence does not indicate the absence of gestation. It is likewise possible for the wo- man to mistake intestinal peristalsis and choreic move- ments of the abdominal mus- cles for the sensation of quick- ening. The use of the stetho- scope or of an anesthetic will demonstrate this condition. Active fetal movements can rarely be appreciated by the physician before the middle of the sixth month. The placing of the cold wet hand on the abdomen will sometimes cause an exaggeration of their intensity. Once detected, they steadily grow stronger with the advancing weeks. They appear either as distinct blows, as from the spasmodic movements of a fetal limb, or as a peculiar undulating movement, advancing across one side of the abdomen as the swell of a wave ; this is produced by a straightening of the fetal ellipse, the back coming in contact with the uterine and abdominal walls. These movements may be absent throughout pregnancy, and the woman be delivered of a living fetus, as when there is an excess of
Pig. 5.— Diagram illustrating the points of maxi- mum intensity of the fetal heart-sounds in vertex and breech presentations.
56 THE LEGAL ASPECTS OF PREGNANCY.
liquor amnii ; or they may be suppressed for variable periods only. Several examinations should be insisted upon before the positive absence of movements is asserted. At times the movements of the fetal limbs in the liquor amnii or in contact with the uterine wall will produce faint indescribable sounds, which, if distinctly heard, are characteristic of pregnancy. It is exceptional, however, for this sound, termed the fetal shock, to be heard. When present, it is usually preceded by a churn- ing sound known as the fetal bruit.
The fetal heart-sounds constitute an absolute and unmistakable sign of pregnancy. They may be detected as early as the third month, although usually not until the fifth month ; from this time they grow steadily in intensity as the fetus develops. They simulate the muffled ticking of a watch placed under a pillow. The rate is about twice that of the maternal heart-beat, or from 120 to 160 beats a minute. This sign may be absent or indistinguishable in women with very fat ab- dominal walls, in hydramnion, when there is an excessive amount of flatus in the intestines, or when the fetal back is directed posteriorly, the sounds being most distinct over the dorsum of the fetus. Commonly they are best heard at a point below the level of the umbilicus, and to the right or left, according to the position of the fetal back (Fig. 5).
GENERAL SYMPTOMS.
Certain urinary changes are noted in gestation, none of which, however, is of positive diagnostic value. Frequency of micturition and vesical irritability are common, and are valuable presumptive signs of early gestation if taken in connection with menstrual suppression and moderate uterine enlargement. The presence of kiestein, or the for- mation of a fatty pellicle upon the urine which has been allowed to stand for some hours, at one time regarded as of special diagnostic value, is now known to bear no relation whatever to pregnancy.
Pressure exerted by the tumor of pregnancy upon the sacral plexus of nerves is common during the later months, and may be productive of intense neuralgic attacks or of the so-called " dead limbs.'' These manifestations may follow the pressure exerted by any pathologic growth.
Pigmentation of the face, forming the so-called chloasmata, liver-blotches, or liver-patches, is common in women of dark complexion. The discoloration is most marked upon the forehead and cheeks and around the eyes. If general over the face, it constitutes the mash of pregnancy. Such a condition may be present during menstrua- tion and in association with uterine and ovarian disease.
Nausea and vomiting, the well-known " morning-sickness '' of pregnancy, is a valuable reflex symptom, dependent upon irritation of the peripheral uterine nerves consequent upon progressive stretching of the uterine muscular fibers. It may immediately follow conception, although it usually does not appear until the sixth or seventh week. One-third of all pregnant women do not sufler from this symptom
THE SIGNS OF PEEGNANCY. 57
(Giles), and, again, it may be produced by many conditions other than pregnancy. If it occur, it presents itself in 70 per cent, of the women in the first month, very rarely in the fifth and seventh months, and seldom in the second, third, or fourth month. Its duration varies from a few days to throughout the entire pregnancy, but it is rarely protracted beyond the fourth month. The nausea may be slight or severe, and generally appears immediately on rising — hence its popular name. It may occur, however, at any time during the twenty-four hours, and especially after the ingestion of food. Other conditions that may produce nausea and vomiting are uterine displacements, uterine tumors, endometritis and metritis, chlorosis, gastro-intestinal disease, ovarian and tubal disease, and menstrual retention from atresia.
Alterations of disposition and other nervous phenomena may become prominent symptoms of gestation, and are strongly suggestive because of their unwonted presence. A fretful, irritable, or moody change will be noted, and this may be associated with the morbid crav- ing for strange and disgusting articles or for certain kinds of food. There may be noted an unusual tendency to syncope and fainting fits. Neuralgic pains are of frequent occurrence, especially Beccaria's sign — an intense pulsating pain in the occipital region. Owing to the increased amount of circulating fluid with compensatory hypertrophy of the left ventricle, the woman's pulse generally becomes somewhat accelerated, reaching not infrequently 90 or 94 beats a minute, and this may be associated with an annoying sensation of throbbing and palpita- tion. The cardiac symptoms are dependent upon the hydremic condi- tion of the blood. During pregnancy the entire glandular system of the body shows increased functional activity. This is especially notice- able in the salivary glands, which may throw out an abundant watery secretion (the salivation of pregnancy).
Finally must be noted an important series of mammary changes which are strongly suggestive of the existence of pregnancy, although not absolutely diagnostic. These changes are all peculiarly well marked in primiparse, and include general enlargement and bagginess of the organs ; enlargement of the glands of Montgomery ; the deposit of pig- ment around the nipples ; the development of colostrum ; erectility of the nipples ; tortuosity of the superficial veins ; and pricking sensations around the nipples. The pigmentation assumes the form of areolae surrounding the nipples, and are most prominent in brunettes. The colostrum is a very valuable sign, and consists of a serolactescent fluid appearing during the third month and persisting until the third day of the puerperium. The enlargement of Montgomery's glands results in the formation of tubercles clustering around the nipples and strongly suggesting advancing gestation. The presence of milk or milky fluid is not an absolute proof of gestation, since it has been noted in the breasts of males and in young and unimpregnated women. Again, the absence of mammary changes does not cofttraindicate the existence of pregnancy.
58 THE LEGAL ASPECTS OF PREGNANCY.
THE DIAGNOSIS OF PREGNANCY*
The diagnosis of pregnancy will be made by reference to the signs just enumerated, many of which will be present in any given case. While considered separately some of these signs would not be absolutely diagnostic, when taken in combination with others a fairly presumptive diagnosis of gestation may be made. After the date of quickening the presence of the positive signs will make the diagnosis absolute. The signs to be looked for will naturally vary with the period of pregnancy to which the woman has advanced.
For convenience in examination, pregnancy is universally divided into three three-months' periods or trimesters, each of which has its own peculiar manifestations. Thus, one would not look for the positive signs prior to distention of the abdominal walls — that is, in the first trimester. In the first half of the first trimester an absolute diagnosis is not possible. There are present, however, in the first trimester, the two most important subjective signs of pregnancy : namely, menstrual suppression and nausea and vomiting. Associated with these will be found the vesical irritability, the increase in the anteroposterior diameter of the uterine body, the mammary changes, and the four soft signs : namely, the softened cervix, the soft and boggy uterine fundus, the softened lower uterine segment, and the softened and enlarged mammfe. The coexistence of these signs will be strongly presumptive of an exist- ing gestation.
In the second trimester of pregnancy — the fourth, fifth, and sixth months — there will be developed the positive signs of the condition. Thus, by the beginning of the fourth month Jacquemin's sign (blue dis- coloration of the vulva and vagina) will be well marked, and Braxton Hick's intermittent uterine contractions may be detected ; by the middle of the fourth month ballottement may be elicited, and quickening occurs shortly afterward ; and by the beginning of the fifth month it is pos- sible to detect the fetal heart-sounds.
In the third trimester the fetal presentation may be ascertained by vaginal exploration, and abdominal palpation will disclose the fetal outlines.
Another interesting series of correlated subjects will now arise. One of the parties in a question at law may be a young girl, presumably too young for the question of gestation to arise ; or, on the other hand, she may be an elderly woman well beyond the usual date of the meno- pause. Thus, it may be inquired. How early is gestation possible, or what is the latest period at which pregnancy has been noted ? Again, is it possible for a woman to become pregnant without a consciousness of the fact at the time of conception ? Can she be pregnant any length of time and yet be unaware of her condition ? Again, is there any rea- son why the woman should endeavor to conceal an existing pregnancy ; or is there, on the other hand, anything to be gained by her by feigning to be in the pregnant state ?
THE DIAGNOSIS OF PREGNANCY. 59
It is a safe general rule to consider every female from eight to eighty years of age either as pregnant or as possible of conceiving, even when other apparently impossible circumstances, aside from the ques- tion of age, may be present. Thus, the existence of an unruptured or apparently imperforate hymen will not necessarily exclude the possi- bility of gestation ; nor will the positive affirmation of lack of penetra- tion preclude conception. Sherwood-Dunn records the case of a woman from whom he removed both ovaries ; subsequently she married and gave birth to a male child.
Precocious Preg"nancy. — By this term is meant the occurrence of gestation at an unusually tender age. Probably the earliest instance of pregnancy is that famous case recorded by Tidy : A girl who had menstruated first at four years of age, conceived and was delivered of a living child when but eight years old. An allied case is recorded of a seven-pound baby being delivered from a mother but eight years and ten months old. Wharton and Stills report an instance of a baby men- struating in her first year, and being delivered in her ninth year of a child weighing 7f pounds. Gleaves records the birth of a five-pound baby from a mother but ten years of age, and there are many instances recorded of girls of eleven to fourteen years giving birth to full-sized children. Wilkinson records the case of a negro girl who, when thir- teen years, nine months, and five days old, gave birth to twins.
I<ate Pregnancy. — Cases equally as interesting as the foregoing have been filed of women conceiving late in life, and being delivered of normal children. Thus, Halles ^ records a labor occurring in a woman seventy years of age, and another in a woman of sixty-three years. Another physician records the birth of twins in a woman sixty-four years of age (Reese). It is not very uncommon to hear of women in the sixth decade giving birth to children. Hence, while the normal menopause occurs at from forty to forty-five years of age, this phenome- non may be indefinitely postponed, or ovulation may continue actively long after its associated phenomenon, menstruation, has ceased. Wolfe records an interesting case of a woman who menstruated for the first time when in her forty-third year, and continued to do so at irregular in- tervals until forty-five years of age, when she conceived and gave birth to a healthy child after a labor lasting but thirteen hours.
Concealed Pregfnancy. — It is a much more common occurrence for a young girl to endeavor to conceal the fact that she is pregnant than it is for her to feign pregnancy for purposes of extortion or of forcing a marriage. The English law imposes no obligation to make pregnancy known. In Scotland, however, should the pregnancy be concealed and the child be dead or missing, the woman is liable to prose- cution on the charge of infanticide. The concealment of birth is a much more serious misdemeanor (see Concealed Birth, p. 85).
Feigned Pregnancy. — It is rarely for purposes other than ex- tortion or blackmail that a woman will pretend to be in gestation ; hence such a claim merits the closest investigation to prevent the perpetration
* Manuel complet de medecine legale.
60 THE LEGAL ASPECTS OF PREGNANCY.
of an injustice. Almost invariably such women feign an advanced pregnancy — that is, after the first trimester, and, fortunately, this is at a period when the true condition of affairs can generally be readily and positively recognized. It is easier, however, to prove the absence of a gestation than it is to prove that an existing distention of the abdomen is due to pregnancy. A refusal on the part of a woman to undergo a necessary examination will be safe grounds for declaring her imposi- tion. Occasionally hysteric women may balloon the abdomen and pro- duce curious movements of the abdominal muscles closely simulating the fetal motions. This constitutes a form of pseudocyesis that can be diagnosed by the administration of an anesthetic.
IMPREGNATION DURING UNCONSaOUSNESS.-UNCON- SaOUS PREGNANCY,
Here there are two closely allied and yet quite distinct propositions. The one indicates the occurrence of conception and early pregnancy in a woman, usually a married woman, without her entertaining any knowl- edge as to her true condition — unconscious pregnancy. The other is the occurrence in a woman, usually young and single, of gestation while the subject was in an unconscious condition, the result of deep sleep, coma, hysteria, hypnotism, or from the administration of an anesthetic. It must be recognized that intercourse during profound sleep (lethargy), either natural or the result of design, is quite possible. Such a condi- tion will necessarily involve the question of rape. Under such circum- stances it is not at all improbable for the woman to be unconscious of her delicate state during the first two or three months. After the fifth or sixth month, however, the continued menstrual suppression, together with the development of other diagnostic signs, should lead a woman with ordinary intellect to suspect her true condition. If she be a vir- gin, the soreness in and injuries to the vagina and vulva invariably associated with the first coitus should lead her to suspect violation im- mediately on a restoration to consciousness. Only in idiotic or feeble- minded women is it possible to conceive of the unconscious carrying of a child to term, although several such cases are on record.
An assumed unconsciousness is, however, quite a possible complicat- ing factor. A woman may thus ascribe her symptoms to some pathologic growth, her labor-pains to intestinal colic, and, even when confronted by the child, deny knowledge as to the time and circumstances of its con- ception. Again, in rare cases of artificial impregnation of a woman by means of a syringe, conception may follow without the knowledge of the woman. When there exist motives for so pleading, the case re- quires the closest examination. In married women who have remained sterile for many years, or who conceive at or subsequent to the meno- pausal period, it is quite possible to conceive of a gestation advancing to near term without an accurate knowledge on their part of the actual state of aifairs. Such women are much more prone to ascribe their condition to some pathologic affection (ovarian cystomata, ascites, uterine
IMPREGNATION DURING UNCONSCIOUSNESS. 61
fibroid) than to gestation. An examination by a qualified obstetrician will readily reveal the true condition.
Pregnancy in the Dead. — Occasionally, as fi3r the purpose of identifying a woman or to prove her chastity, it will become necessary to make an autopsy to ascertain the condition of the genitalia. It must not be forgotten that in certain quarters there is a common practice of placing an unrelated fetus in the coffin of a woman in order to turn aside suspicion from the guilty person. The marks of gestation and delivery in the dead are to be found in the uterus, lower birth-canal, and in the ovary. An investigation of the uterine contents, even to a microscopic examination of the uterine scrapings, may become of posi- tive value in certain cases. Owing to the excessive hypertrophy of the uterine muscles in gestation, decomposition will speedily take place in that organ after death, and it may be converted into a putrescent mass long before the other tissues yield. Quite the contrary is true of the unimpregnated uterus, and should an examination of such a body be made some months after death, the soft structures will be found well advanced in decomposition, with the exception of the uterus, which will probably be firm and resistant. This will be accepted as a positive proof of chastity. Should the woman have given birth to a child just prior to her death and the examination be made within a few days or weeks, the usual lesions in the vagina and cervix will be found, to- gether with perineal and vulvar lacerations and contusions.
The uterine contents that would indicate a pregnancy include an ovum, embryo, fetus, or fragments thereof; decidual and chorionic debris ; bones, and moles. The earlier the examination is made, the more conclusive will be the proof ; but if the embryo be advanced be- yond the period of ossification, its bones may be recognized even though several years have elapsed since the maternal death. Microscopic ex- amination of the uterine scrapings will reveal decidual cells and chori- onic villi, both of which are diagnostic of pregnancy.
Moles, also, if found, are proof positive of gestation. These in- clude the placental or fleshy mole, and the uterine hydatids, or the vesicular or hydatidiform mole. The former is a thick, fleshy mass of tissue attached to the original placental site and consisting of both de- cidual and chorionic tissue, as shown by microscopic examination. It may include portions of an early ovum. Care must be taken not to confound such a growth with a uterine polypus, which generally con- sists of fibrous or muscular tissue suspended by a pedicle from some portion of the uterine wall, even as low as the cervical canal ; it is not necessarily attached to the fundus, the common placental site. The ves- icular mole is comparatively common, and consists of a mass of grape- like tissue filling the entire uterine canal and at places penetrating the wall of the uterus, even causing perforation. A fatty mole is merely a fragment of retained placental tissue that has undergone fatty change. Partially organized blood-clots may also be found in the uterine cavity. All the foregoing may be advanced as valuable evidence of pregnancy. Other instances, not conclusive proof of gestation, which may be found
62 • THE LEGAL ASPECTS OF PREGNANCY.
postmortem in utero are true hydatids, which are exceedingly rare (not more than four or five such cases having been recorded), and the mem- branous formation that is shed in the rare condition known as membran- ous dysmenorrhea. Should any of the true products of gestation be found in the uterine cavity of a woman whose pregnancy could not have advanced beyond the third month, the indications would point to a criminal abortion, and spontaneous abortion in the first trimester is accompanied usually by the discharge of an intact ovum.
An ovary of a dead woman may show a recent scar, or co7'pus luteumy following the discharge of an ovum from a Graafian follicle. Formerly it was believed that a difference existed in the corpus luteum following an unfruitful ovulation and that associated with pregnancy. The latter was believed to be much larger in size and deeper in color. Hence arose the terms true and false corpus luteum, the former being the cor- pus luteum of pregnancy. It is now recognized that no diagnostic significance can be attached to the scar of ovulation. Pregnancy can occur without an appreciable corpus luteum being found, and a so-called true corpus luteum may accompany ovulation occurring during the growth of a uterine fibroid or any other condition, inflammatory or non-inflammatory, resulting in marked pelvic congestion, of which con- dition alone it is indicative, irrespective of the cause.
LEGITIMACY -THE DETERMINATION OF SEX.- SIGNS OF DELIVERY.^
LEGITIMACY.
I/eg"itimacy is defined as ^^ the state of being born in lawful mar- riage/^ ^ The question of legitimacy from the medicolegal point of view embraces the subjects of disputed chastity, the duration of preg- nancy, viability of the child, the physical incapacity of husband or wife, child-substitution, superfetation, and posthumous birth. In order to arrive at a definite conclusion in a given case medical and moral evi- dence, either alone or combined, may be employed. The question of illicit intercourse, with possible subsequent conception, while bearing indirectly upon the subject, is not to be included here.
It is presumed that any person born during the continuance of a lawful marriage between the mother and any man, or within a com- petent time after the dissolution of such marriage, is legitimate.^ A child may, however, be shown to be illegitimate when it is possible to demonstrate that the man claimed to be the husband is practically incapable of being the father, as — (1) when he is under the age of puberty f (2) when he exhibits some physical incapacity, as extreme age, or some natural infirmity, as azoospermism ; (3) when he was out of the country at the time the child was begotten, or a considerable length of time had elapsed since coitus had occurred, or from absence from home or death of the husband f (4) where the impossibility is based on the laws of nature — that is, a white child is born of black parents, or vice versa.® The date of the birth is the time that receives special consideration, since it is a fixed time ; the date of conception cannot accurately be determined, even when there has occurred but a single intercourse the date of which is known ; conception in such a case may not follow for many days, during which time the spermato- zoids retain their vitality in the female generative tract. Again, the child will be pronounced illegitimate if adultery on the part of the woman can be proved and the offspring is repudiated by the husband.
^ Grateful acknowledgment is due John C. Hinckley, Esq., of Philadelphia, for information on all legal questions touched upon in this chapter.
^ Rawle's Bouvier's Law Dictionary, p, 183.
3 Greenleaf-Lewis's edition, Philadelphia, 1896, sections 28 and 150; Chase's Stephen on Evidence, p. 255, second American edition, 1898.
* King vs. Luffe, 8 East 207, 1807.
*> American and English Encyclopedia of Law, first edition, p. 225.
6 Whisterlos's case in Cross vs. Cross, Paige Ch. New York, 139.
63
64 LEGITIMACY.
The evidence of illegitimacy must be clear and decided in order to dis- turb the presumption of legitimacy.^ Children born after marriage, no matter how soon, are presumed to be legitimate.^ Even if the woman be pregnant by another man and be so far advanced at the time of her marriage as to have her condition recognizable by her husband, the law takes this as a recognition on his part of paternity, and, therefore, of legitimacy (Reese). Taylor recognizes the possibility of a child being conceived prior to marriage and born subsequent to the paternal or maternal death (postmortem Cesarean section), and yet being legitimate. By the Common Law all children born out of lawful wedlock are bast- ards.^ This is still the law of England. The Civil Law, however, provides that subsequent marriage of the parents renders the issue legitimate, and this rule has been enacted in many of the states of the United States — e. g,, Maine, Pennsylvania, Illinois, Michigan, Iowa, Minnesota, California, Oregon, Nevada, Washington, the Dakotas, Idaho, Montana, and New Mexico. In Massachusetts, Virginia, Indiana, Wisconsin, Nebraska, Maryland, Virginia, West Virginia, Kentucky, Missouri, Arkansas, Mississippi, and Arizona the father must acknowledge the child as his.*
Fecundity. — The question of the physical incapacity of the father is one of considerable elasticity. How young may a boy be and yet be able to fecundate ? It is stated that spermatozoa generally first appear in the semen at the fifteenth or sixteenth year, and fecundity dates from this time. They may, however, be found at an earlier date. Probably the youngest case of paternity on record is that furnished by Hirst, of a boy of thirteen who impregnated his sister of fourteen. It is generally believed that sexual ability in the male ceases after the age of sixty-five. Hirst, however, mentions two authentic instances of paternity at eighty- two and over one hundred years respectively. The absence of the male or female generative organs would imply inability to propagate ; in the case of a female who w^as so incapacitated and was presenting a child as her legitimate oifspring, the question of a supposititious child (child- substitution) would arise.
The age of maternity is another variable factor. As we have already seen, cases of precocious pregnancy have been recorded at eight and nine years of age. In the Eastern countries maternity is not at all unusual at from ten to twelve years of age. It is rare for a woman to give birth to a child after the date of the menopause, and Barker states that women never conceive after fifty-five years of age.
Supposititious Children. — In the case of supposititious children it becomes the duty of the medicolegal examiner to inquire into the traces of heredity presented by the child, and the resemblance, physical or mental, to the alleged father. This will include examination as to features, voice, the gait ; peculiar habits, traits, or tastes ; the presence
Plowes vs. Bossey, 31 L. J. Chan., 680, 1862.
2 Page vs. Dennison, Greenleaf-Lewis's edition, Philadelphia, 1896, p. 168. " American and English Encyclopedia of Law^ second edition, p. 895. * Rawle's Bouvier^s Law Dictionary, p. 184.
IE DURATION OF PREGNANCY.
65
or birth-marks which have appeared in successive
pposed father's fixm'^\ An important point for
the age of the child and the questions as to whether
coincide with the alleged date of delivery. It is
! proper time to secure a new-born child of the
slopment for the case in question.
/^^>CX O )f the mother is also necessary in order to reveal
^J'; ^ , which should be recent or remote, according to
'X' ^ "S birth. The difficulty of adjusting the maternal
^rs,^^. i {_ ^ )f the child is greatest in the more recent cases.
7s^; ^ I month's postnatal development would not be ac-
)| '^ ^ i caminer as the child of a woman whose physical
^ ° u ^ delivery at a period not more remote than a week.
Q i < '? if not from a purely obstetric point of view, at
I ^ ^al standpoint, that every woman claiming to have
I Id shortly prior to the arrival of her physician be
^ al examination. This examination will be made
I if any of the secundines remain, or if any ex-
s occurred from lack of proper supervision of the
, ^ — J J .. .rill also prevent the perpetration of the crime of
child-substitution should that be contemplated. If the woman or her family resist the making of such an examination, the physician would be justified in entertaining suspicions of some underhand proceeding, such as, in the wealthier classes, an attempt to secure title to an estate, and, in the lower classes, the extortion of blackmail. In case the re- fusal is persisted in, it becomes the duty of the physician to explain the serious medicolegal aspect that such a refusal entails, and if, then, the examination will not be permitted, his grounds for suspicion will be strengthened materially.
The Duration of Pregnancy. — In the determination of the legitimacy of a child it is very important that a knowledge be had of the normal average duration of pregnancy, the degree to which it may be prolonged (partus serotinus), and the degree to which it may be shortened and yet a living and viable child be born. The duration of a ; given pregnancy is a question incapable of accurate determination, as must be evident from the absolute uncertainty attendant upon the date of conception. If in every instance the time of the fruitful coition, or rather of the meeting of the ovum and the spermatozoid, could be as- certained, a basis could be had from which to calculate the probable date of confinement. As this accuracy is, as a rule, impossible in any given case, an approximate idea only can be obtained, and by taking the average of a large number of such approximations, an estimate of the normal duration of pregnancy can be made. There are but two factors upon which an estimation can be based, namely, a single coitus the date of which is known, and the date of menstrual suppression.
From a study of the relationship existing befween menstruation and ovulation, the ' two phenomena not necessarily coexisting, it is patent ^ that an error of three weeks or more may be made in a calculation
K Vol. II —5
I
I
■r
64 LEGITIMACY.
The evidence of illegitimacy must be clear and deci turb the presumption of legitimacy.^ Children bor matter how soon, are presumed to be legitimate.^ be pregnant by another man and be so far advance marriage as to have her condition recognizable by 1 takes this as a recognition on his part of paternit legitimacy (Reese). Taylor recognizes the possibil conceived prior to marriage and born subsequent maternal death (postmortem Cesarean section), and By the Common Law all children born out of law] ards.^ This is still the law of England. The < provides that subsequent marriage of the paren legitimate, and this rule has been enacted in man; United States — e, g., Maine, Pennsylvania, Illinc Minnesota, California, Oregon, Nevada, Washir Idaho, Montana, and New Mexico. In Mas Indiana, Wisconsin, Nebraska, Maryland, Virgi Kentucky, Missouri, Arkansas, Mississippi, and must acknowledge the child as his.*
Fecundity. — The question of the physical incapacity ol the tatlier is one of considerable elasticity. How young may a boy be and yet be able to fecundate ? It is stated that spermatozoa generally first appear in the semen at the fifteenth or sixteenth year, and fecundity dates from this time. They may, however, be found at an earlier date. Probably the youngest case of paternity on record is that furnished by Hirst, of a boy of thirteen who impregnated his sister of fourteen. It is generally believed that sexual ability in the male ceases after the age of sixty-five. Hirst, however, mentions two authentic instances of paternity at eighty- two and over one hundred years respectively. The absence of the male or female generative organs would imply inability to propagate ; in the case of a female who was so incapacitated and was presenting a child as her legitimate offspring, the question of a supposititious child {child- substitution) would arise.
The age of maternity is another variable factor. As we have already seen, cases of precocious pregnancy have been recorded at eight and nine years of age. In the Eastern countries maternity is not at all unusual at from ten to twelve years of age. It is rare for a woman to give birth to a child after the date of the menopause, and Barker states that women never conceive after fifty-five years of age.
Supposititious Children. — In the case of supposititious children it becomes the duty of the medicolegal examiner to inquire into the traces of heredity presented by the child, and the resemblance, physical or mental, to the alleged father. This will include examination as to features, voice, the gait ; peculiar habits, traits, or tastes ; the presence
^ Plowes vs. Bossey, 31 L. J. Chan., 680, 1862.
2 Page vs. Dennison, Greenleaf-Lewis's edition, Philadelphia, 1896, p. 168.
•'' American and English Encyclopedia of Law.^ second edition, p. 895.
* Rawle's Bouvier^s Law Dictionary, p. 184.
THE DURATION OF PREGNANCY. 65
of characteristic iievi or birth-marks which have appeared in successive generations of the supposed father's famiiy. An important point for close investigation is the age of the child and the questions as to whether or not its age will coincide with the alleged date of delivery. It is quite difficult at the proper time to secure a new-born child of the proper degree of development for the case in question.
An examination of the mother is also necessary in order to reveal the signs of delivery, which should be recent or remote, according to the alleged date of birth. The difficulty of adjusting the maternal condition to the age of the child is greatest in the more recent cases. Thus, a child of one month's postnatal development would not be ac- cepted by a careful examiner as the child of a woman whose physical signs would indicate a delivery at a period not more remote than a Aveek. It becomes imperative, if not from a purely obstetric point of view, at least from a medicolegal standpoint, that every woman claiming to have given birth to a child shortly prior to the arrival of her physician be subjected to a physical examination. This examination will be made ostensibly to ascertain if any of the secundines remain, or if any ex- tensive traumatism has occurred from lack of proper supervision of the labor ; in reality, it will also prevent the perpetration of the crime of child-substitution should that be contemplated. If the woman or her family resist the making of such an examination, the physician would be justified in entertaining suspicions of some underhand proceeding, such as, in the wealthier classes, an attempt to secure title to an estate, and, in the lower classes, the extortion of blackmail. In case the re- fusal is persisted in, it becomes the duty of the physician to explain the serious medicolegal aspect that such a refusal entails, and if, then, the examination will not be permitted, his grounds for suspicion will be strengthened materially.
The Duration of Pregnancy. — In the determination of the legitimacy of a child it is very important that a knowledge be had of the normal average duration of pregnancy, the degree to which it may be prolonged (partus serotinus), and the degree to which it may be shortened and yet a living and viable child be born. The duration of a given pregnancy is a question incapable of accurate determination, as must be evident from the absolute uncertainty attendant upon the date of conception. If in every instance the time of the fruitful coition, or rather of the meeting of the ovum and the spermatozoid, could be as- certained, a basis could be had from which to calculate the probable date of confinement. As this accuracy is, as a rule, impossible in any given case, an approximate idea only can be obtained, and by taking the average of a large number of such approximations, an estimate of the normal duration of pregnancy can be made. There are but two factors upon which an estimation can be based, namely, a single coitus the date of which is known, and the date of menstrual suppression.
From a study of the relationship existing between menstruation and ovulation, the ' two phenomena not necessarily coexisting, it is patent that an error of three weeks or more may be made in a calculation
Vol. II— 5
66 LEGITIMACY.
based upon menstrual suppression. The nearest that it is possible to estimate the duration of a pregnancy upon this basis is to compute 280 days — ten lunar or nine calendar months (forty weeks) — from the date of the last menstruation. This will give a date tliat is about the mid- dle of a fortnight in which the labor will occur. Still, it must be borne in mind that pregnancy may begin during a period of pathologic men- strual suppression ; and, again, that menstruation may continue for variable periods after conception, so that we have additional sources of error in this computation.
Merriman has collected 150 pregnancies in which the duration is counted from the date of the last menstruation. His table is as follows :
Duration of Pregnancy Dated from the Last Day of the Catamenia.
Weeks. Days. ^Ss^e^s^ Percentage.
37th . . . from the 225th to the 259th day 5 3.33
38th ... " 260th " 266th " 16 10.67
89th ... " 267th " 273d " 21 14.00
40th ... " 274th " 280th " 46 30.67
41st ... , " 281st " 287th " 28 18.67
42d . . . " 288th " 294th " 18 12.00
43d .. . " 295th " 301st " 11 7.33
44th ... " 302d " 308th " ^ 3.33
Total 150" 100.00
The difference between the two extremes of this table is fifty-six days, and supposing every woman to have become pregnant five days before the menses, five, at least, passed the term of nine months by ten or twelve days.
It is probable that the history of a single coitus will give a more accurate means of estimating the duration of pregnancy, although here again there exists an element of doubt. It has clearly been demon- strated that spermatozoa may retain their functional activity within the generative tract for eight or ten days or longer, and during any portions of this time might fecundate an ovum. Hence, as the precise time of the meeting of spermatozoid and ovum cannot be determined, it is again impossible to ascertain definitely the duration of the pregnancy. Various obstetricians have computed the duration from a single coitus, and have obtained an average of 272 days. Thus, Faye found it to be 270 days ; Ahlfeld, 271 days ; Lowenhardt, 272 days; Stadfeldt, 272 days; Hecker, 273 days ; Yeit, 276 days ; and Duncan, 275 days. The French authors usually give 270 days as the normal duration of gestation.
Reid has collected the history of 40 cases of pregnancy in women in whom impregnation was the result of a single intercourse, the date of which was accurately known. All the cases were instances of single women who dated from one coitus, or of married females whose husbands had been absent for a considerable time before the last inter- course. His table, which follows, demonstrates the varying duration of pregnancy, and, consequently, the variable date of parturition and delivery in women, even when the date of coitus is previously accurately established.
THE DURATION OF PREGNANCY. 67
Pregnancy in Women Calculated from a Single Coitus. Weeks. Days. SxSsS*. Percentage.
38th . . . from the 260th to the 266th day 5 12.50
39th ... " 267th " 278d " 7 17.50
40th ... " 274th " 280th " 18 45.00
41st ... " 281st " 287th " 6 15.00
42d . . . " 288th " 294th " _4 10.00
Total 40 100.00
This table shows a variation of 34 days, while 18 cases, or 45 per cent., were delivered during the fortieth week, or from the two hundred and seventy-fourth to the two hundred and eightieth day.
Montgomery collected 56 cases of pregnancy in which the date of fruitful intercourse was known, as follows :
Weeks. Days. ?f^SslJ. Percentage.
35th
36th
37th
38th
39th
40th
41st
42d
43d
from the 239th to the 245th day 1 1.79
0 0.00
2 3.58
2 3.58
10 17.84
....;.. 22 39.28
9 16.70
8 14.28
2 3.58
|
246th ' |
252d |
|
253d ' |
259th |
|
260th ' |
266th |
|
267th ' |
273d |
|
274th ' |
280th |
|
281st ' |
287th |
|
288th ' |
294th |
|
295th ' |
' 301st |
Total 56 100.00
The variation in this table is 59 days. The shortest duration of gestation is 242 days ; the longest, 301 days. The greatest number of children were born in the fortieth week.
Of the 246 cases in the preceding tables, 86, or 39.96 per cent., were delivered in the fortieth week; 43 cases, or 17.48 per cent., were delivered in the forty-first week ; 38 cases, or 15.45 per cent., were de- livered in the thirty-ninth week. One case was delivered on the two hundred and forty-second day (thirty-fifth week), and 5 in the forty- fourth week ; the variation is 64 days.
The estimation of the duration of pregnancy from the date of quick- ening is also open to appreciable error. Thus, quickening, while generally occurring when pregnancy is half completed, — that is to say, at about the middle of the fifth month, may occur as early as the twelfth week or not until the twenty-fifth week ; in a few cases there may not be noted any fetal movements throughout the entire gestation. Again, intestinal peristalsis and irregular contraction of the abdominal muscles may simulate fetal movements so closely as to mislead not only the patient herself, but her attending physician also. Moreover, few women can tell the exact day, or even within fourteen days, of the appearance of quickening. Hence this is an uncertain date from which to reckon.
There is, therefore, no absolute figure that may be stated as the positive duration of pregnancy in the human fernale. In some women eight calendar months is the full period to which they can carry their young, while others invariably go well beyond the average of 280 days. Thus, while the average may be as stated, normal gestation may last but
i)H
LEGITIMACY.
240 days, or be extended to 300 days or longer. This irregularity is but carrying out the law as observed in lower animals, in whom, even when the date of a coitus is well known, a marked variation in the duration has been noted. Eeese has made a careful study of the dura- tion of pregnancy in rabbits, cows, mares, and sheep, and noted the following points : The average duration of pregnancy in rabbits is 31 days, with a variation of 8 days. The average duration in cows is 285 days ; yet in a certain proportion gestation will end as early as the thirty-eighth and in others not until the fifty-first week, giving a period of difference of 90 days, or three calendar months. In sheep the average duration of pregnancy is 151 days, with variations from 145 to 171 days, giving a period of difference of 26 days. In mares the average term of pregnancy is 300 days ; it may not terminate until 360 days, or even, as Tessier has noted, not until 394 days. Wilier, as quoted by Velpeau, proved, by hatching chickens in an oven, that the process takes from 18 to 25 days. A more detailed account of the experiments of Tessier, in France, and of Spencer, in England, as presented by J. Y. Simpson, is as follows :
Period of Gestation in Cows.
|
Weeks. |
J)g\ra |
Number of Cows. |
Percentage. |
||||
|
•J"' |
Tessier. |
Spencer. |
Tessier. |
Spencer |
|||
|
37th, from the 253d |
to the 259th day . |
. 6 |
12 |
1.05 |
1.60 |
||
|
38th, |
' 260th |
266th " . |
. 8 |
4 |
1.40 |
0.55 |
|
|
39th, |
' 267th |
273d " . |
. 51 |
24 |
8.91 |
2.80 |
|
|
40th, |
' 274th |
280th " . |
. 166 |
121 |
29.02 |
16.53 |
|
|
41st, ' |
' 281st |
287th " . |
.202 |
392 |
35.31 |
52.27 |
|
|
42d,' |
' 288th |
294th " . |
. 105 |
175 |
18.36 |
23.18 |
|
|
43d, ' |
' 295th |
301st " . |
. 27 |
16 |
4.72 |
2.12 |
|
|
44th and |
|||||||
|
upward, ' |
' 302d |
u |
321st " . |
. 7 |
7 |
1.22 |
0.93 |
|
Total |
|
.572 |
751 |
Joulin ^ records the case of a cow that bore almost sixteen months, parturition being impossible ; and another that bore her calf fifteen months and two days. Gronier observed a cow that bore twelve months, and Numan one that bore eleven and a half months. Joulin further remarks that it has been offered as an explanation of protracted gesta- tions that they depend on the imperfect development of the fetus, which remains in the mother's womb until it has become fit for extra-uterine life.
Period of Gestation in Mares.
Of 200 mares, 3 foaled the 311th day.
|
1 |
" 314th " |
|
|
1 |
" 325th " |
|
|
1 |
" 326th " |
|
|
2 |
" 330th " |
|
|
47 |
from the 340th to the 350th day. |
|
|
25 |
" 350th " 360th " |
|
|
21 |
" 360th " 377th '* |
|
|
1 |
the 394th day. |
The difference between the two extremes is 83 days.
^ Traits complet d' Accouchements.
PROTRACTED GESTATION. 69
Protracted Gestation (Partus Serotinus). — From the fore- going statement it must be admitted that it is possible for gestation in the human female to be carried well beyond the normal duration ; a knowledge of this truth is exceedingly essential for the medicolegal expert. Indeed, as J. Y. Simpson/ as long ago as 1855, remarked : " The obstetricians who maintain that the period of human gestation is a fixed period and can never by any possibility exceed forty weeks (as was sworn to by five doctors in the Gardner Peerage Case, London ; and by six doctors in the American Court, at Lancaster Quarter Ses- sions, Pennsylvania), have none of them adduced any reason why the period of pregnancy should thus be stable and invariable, while all other periodic processes in the human body, as dentition, puberty, menstruation, the date of quickening, etc., are universally known and acknowledged to be apt to vary extremely. These obstetricians have offered no reasons, so far as I know, for holding that similar variations could not take place in the duration of pregnancy. Indeed, it would be against all analogies from other actions and processes in the animal kingdom to suppose that such variations did not occur in regard to the function of gestation. ''
Extreme care should be taken in every instance to ascertain the truthfulness of the statements offered by the interested party, and to learn what reasons, if any, exist why a legitimate offspring is desirable. The earnest desire of a woman to save her reputation or to present an heir may influence her statements, and every reasonable element of doubt should receive careful consideration. In many countries the utmost limit to which a legitimate pregnancy may extend is decided by^ law. Thus, in Scotland, France, and Italy, if the pregnancy exceed 300 days, legitimacy is denied ; in Germany a duration of 302 days is permitted. Unfortunately, no such legislation is recognized in the United States or in England, and the disputants are placed at the mercy of the medicolegal experts. Reese states that a pregnancy lasting 317 days has been allowed in America in a lawsuit on the charge of seduction.
Many interesting cases are recorded of exceptionally protracted ges- tation, and the current medical literature from time to time contributes additional authentic instances. In each case it would be well to take the physical appearance of the child, together with its weight, into con- sideration as important evidence of the overduration of pregnancy. This increase in the size and weight of the child is, however, not always to be noted. On the contrary, as Duncan ^ remarks, we find authors stat- ing that in these so-called cases of protracted pregnancy the child is no larger than usual or is even smaller than ordinary. Montgomery ^ also states that " although in some of these cases of protracted gestation the child was of enormous size, it by no means follows that it should be so in all such instances ; and in point of fact "we find it expressly
^ Ohstetrtc Memoirs and Contributions, vol. i.
^ Fecmidity, Fertility, and Sterility, Edinburgh, 1866.
^ Signs and Symptoms of Pregnancy^ London, 1856.
70 LEGITIMACY.
mentioned in some of them that the child was smaller than usual, as happened in one of Dr. Hamilton's cases ; and Fodere says that in three instances in which gestation was evidently prolonged, the children were undersized and ill-thriven ; while, on the other hand, the largest children are often produced where no extension of the term could have taken place.'' It is an incontestible fact that some children born three or four weeks before the estimated completion of pregnancy present the evidences of weight, of size, and of development of a mature infant, while a mature child may be small and undersized, though this is un- doubtedly exceptional. Male children at term are more likely to be larger, stronger, and better developed than female children, although the average weight of all mature babies is seven and a half pounds. Necessarily the duration of the pregnancy will be unlimited when the fetus lies outside of the uterine cavity. In these cases of extra-uterine gestation the child almost invariably dies at or shortly after term, but the product may be retained indefinitely, even for a space of forty years, as is recorded in an authentic instance.
Murray ^ records a case in which the interval between the cessation of menstruation and delivery was 330 days, but the child, which was still-born, weighed only seven and a half pounds — a very average weight. In this instance it is probable that either the pregnancy was of normal duration, gestation having been ingrafted upon pathologic suppression of the menstruation, or the child had died at the normal end of pregnancy and had been retained until the time of delivery. R. Wilson ^ records a pregnancy in which 371 days elapsed between the date of the last menstruation and the date of the labor. Subtracting a possible error of 23 days for suppression from some other cause before pregnancy began, the duration would still be 348 days, or 11 months and 14 days — 2 J months beyond the usual term. Even then, accord- ing to the history of the case, quickening must have occurred at the third month — an unusually early period. Velpeau records the case of a quartipara delivered on the three hundred and tenth day ; Hamilton, the case of an elderly primipara, aged thirty-seven years, who carried her child to the eleventh menstrual period. Wigodosky^ reports the history of a tertipara whose pregnancy, based on the history of menstrual suppression, lasted eleven months. Dewees mentions four women who habitually carried their children ten calendar months. Desormeaux records the case of a woman who gave birth to a child after nine and a half months of gestation. Burns has met with a case in which gestation persisted for ten calendar months and ten days, dated from the last menstruation ; and La Motte mentions the case of a woman delivered after a term of at least 297 days. Montgomery observed an authentic case in which the period of gestation covered 292 days. Resnikow ^ personally observed the case of a duipara who gave birth to a male child, considerably macerated and decomposed, eleven months
* British Medical Journal^ 1889. ^ University Medical Magazine^ July, 1890.
^ Medicmsk Obzreme, No. 2, 1896. * Centralblatt fiir Gyndkologie, No. 24, 1894.
PROTRACTED GESTATION. 71
after the beginning of her pregnancy. Acker ^ reports a case in which, dating from a single coitus, gestation persisted for 305 days, the child not exceeding in development an infant at term. Piirkhauer ^ records a case of partus serotinus on the three hundred and sixteenth day ; Taussig,^ a case of 323 days' duration ; Hames,* a delivery 320 days after the date of menstrual suppression in a primipara, the child weigh- ing 9 pounds 10 ounces ; Holland,^ the case of a primipara in whom 340 days were noted between the birth of the child and the date of the last normal menstruation ; in this case from the date of the last coitus to the birth was 323 days, and from the date of the menstruation fol- lowing the last coitus (an abnormal period lasting only 2 days) the duration was 316 days. Armstrong^ reports the case of a woman who, in her second pregnancy, advanced to the three hundred and third day, and in her fourth pregnancy to the three hundred and nineteenth day. Reid^ records an authentic case in which pregnancy lasted 291 to 293 days; while Simpson reports four cases that carried their young a long time beyond the usual limit. The first bore her child 336 days from the last appearance of the menses ; the second, 332 days, the patient having in the meantime passed through the perils of a shipwreck; the third, 319 days; and the fourth, 324 days, the child being born 198 days — 6 months and 16 days — after the date of quickening. Tarnier^ delivered a woman 40 days after term, the macerated fetus weighing two and a half pounds. The exact date of the child's death could not be determined. Leishman mentions a case in which labor occurred on the two hundred and ninety-fifth day ; and Hedrick records the case of a primipara who was delivered on the three hundred and ninth day after intercourse. Woollett reports the case of a girl, sixteen years of age, in whom gestation lasted 316 days from the date of coitus ; and R. McBride reports another case with an interval of 296 days between a single intercourse and the occurrence of labor. Issmer*-^ finds that the duration of pregnancy increases with each child until the ninth, and then there is a decrease. The age of the mother is also an important factor, as every pregnancy up to the thirty-fifth year of the mother's life is four or five days longer than the previous one. The social condition plays a part, as it has been found by Pinard that of 1000 pregnancies among working women, 51 per cent, were concluded before 280 days had elapsed, whereas of 1000 women without active occupation, only 34 per cent, were deliv- ered before 280 days. These figures show the influence of rest upon the lengthening of pregnancy. Women who have been vaginally ex- amined are on an average confined 5.2 days sooner than those not examined. Issmer has also found that the average duration of preg- nancy in 912 strong women was 278.6 days; in 288 weak ones, 276.8
1 American Journal of Obstetrics^ 1889. "^ Friedreich^ s Blatter fur gerichtliche Medicine, 1890. ♦
^ American Journal of Obstetrics, October, 1901. * Lancet, May 25, 1901.
5 Brit. Med. Jour., March 15, 1902. « Lancet, 1890.
' Ibid., 1890, vol. ii., p. 79. ^ Journal des Sages-Femmes, May 1,'1894.
^ American Journal of Obstetrics, October, 1901.
72 LEGITIMACY.
days. It is probably true that in about 6 per cent, of pregnant women the duration of pregnancy is over 300 days, and von WinckeFs statis- tics show that prolongation occurs in 11 per cent, from 302 to 322 days.
Abnormally Shortened I^abor. — While we have seen that pregnancy may be lengthened abnormally, it is just as true that it may terminate many days or weeks ahead of time. Indeed, this is a much more frequent occurrence than the former anomaly, and the two points of especial value to the medicolegal expert are the determination of the degree of development of the fetus at any given period, and the deter- mination of the period of viability of a child, or its capacity to live after birth — that is, as an independent being.
It is not at all infrequent for a woman periodically to terminate her pregnancy at the eighth month. For her, eight months' growth consti- tutes the development to term. Hence, should the question arise. Was this child conceived prior to marriage, no coitus having been indulged in by the couple before the consummation of the vows ? an examination of the physical characteristics of the infant will probably decide as to its period of development. Especially will this be simplified if the child be still-born, so that an examination of its organs and bony struc- tures will be possible. A most instructive point to note in this connec- tion is the length of the fetus, which is a factor bearing a more perma- nent relation to the development of the child than do the size and weight. There is no relationship existing, however, between the size and degree of stoutness of the mother and the size of the oftspring, a large and well-developed woman often producing a small and immature baby with considerable difficulty, and vice versa.
Recognizing the importance of the length of the fetus in determin- ing the degree of development in a given case, Ahlfeld has formulated a rule and table whereby fetal size may be determined pretty accurately even before birth. He finds that the long axis of the fetus lying flexed in the uterus (the fetal ellipse) is nearly half the entire length of the fetus when extended. The long axis of the fetal ellipse may be determined approximately by placing one arm of a pelvimeter in the vagina against the fetal presentation, while the remaining arm rests on the extremity of the fetal ellipse in the uterine fundus. On doubling this measurement the approximate length of the fetus at the given period of pregnancy will be obtained. In the following table are given the measurements and weights of the fetus at varying periods in the latter half of pregnancy, as determined by this method :
|
Time. |
Axes |
of Fetal Ellipse. |
Length of Fetus. |
Weight. |
||||
|
the 25th week . |
. 171- cm. |
(6.88 in.) |
35 cm. (13.-77 in. |
1213 gm. (39 oz.) |
||||
|
" 28th |
. 20 |
(7.87 " ) |
40 " (15.75 " |
H |
pounds. |
|||
|
" 30th |
. 20f |
(8.12 " ) |
41^ " (16.25 " |
H |
||||
|
" 33d |
. 2H |
(8.36 " ) |
42i " (16.73 " |
U |
||||
|
" 34th |
• 21^ |
(8.61 " ) |
43f " (17.22 " |
4 |
||||
|
" 35th |
. 22 |
(8.75 '' ) |
4U " (17.51 " |
6 |
||||
|
" 36th |
• 23^ |
(9.40 " ) |
47f "• (18 80 " |
6i |
||||
|
" 38th |
" |
. 241 |
(9.65 " ) |
49 " (19.29 " |
Ji |
40th " . . 25 " (9.84 " ) 50 " (19.68 " ) 6f-7|
PATERNITY VIABILITY LIVE BIRTH. 73
There is, of course, just as much variation in new-born infants as regards size and development as in children of older growth. A fetus carried to term may be smaller and punier than a fetus of eight months' growth ; and one fetus of eight months' development may be larger than another of the same age. As a rule, however, there will be pres- ent characteristic marks that will determine pretty accurately the age of dev^elopment.
Paternity. — The question of paternity may arise not only in these cases of birth of a child at some time before the normal duration of pregnancy, but also in cases of posthumous birth occurring over nine calendar months subsequent to the paternal death ; in cases of sup- posititious children advanced as legitimate heirs to an estate ; and in cases of bastardy with an attempt at blackmail. This intricate question can be solved only by the presence or absence of paternal characteristics of face, form, speech, traits, and manner ; or by the presence or absence of paternal physical peculiarities or defects, although the latter may be present in a given case without any possibility of paternity — namely, as a result of the occult process known as maternal impression, in which a peculiarity, mental, physical, or both, is stamped upon an offsjiring as a result of some profound mental impression made upon the mother while carrying the child. This impression may be made merely on sight by a man other than the legitimate husband, and the defect in the child does not necessarily imply illicit relations. The equally occult question of telegony, or the influence of a previous sire upon the chil- dren of a subsequent one through the same woman, must also be borne in mind. Such a transmission of previous paternal traits is well rec- ognized in horses and cattle, and isolated instances have been noted of a similar character in man.
Viability. — By the viability of a child is meant the ability mani- fested by the child to survive as an independent being apart from its mother. The age of viability varies in divers species of animal-kind. It is conceded generally that 180 days, or six calendar months, is the age of viability for the human infant. Undoubted cases have been reported where the fetus was born just at six months of intra-uterine development. Infants born in the fifth month or even as early as the fourth month, have survived for a short time, but such infants can never be conceived as having reached the period of viability. In instances in which infants of supposedly less than six months' duration have sur- vived, doubts must be entertained as to the accuracy of the calculation. The only reliable evidence in such cases consists in a careful expert investigation of the tissues and organs of the child if it subsequently die, or of the physical^ manifestations at the time of birth. Children born at this tender age (six months), if they survive the perils of infancy, are very prone to succumb in early childhood or in early adult life to diseases that children of ordinary vitality would survive.
I/ive Birth. — An interesting medicolegal question naturally arises in this connection — namely, what constitutes a live birth ? Upon the answer to this query will often depend the decision in important trials
74 LEGITIMACY.
for the rights of inheritance and similar legal questions. It is now generally recognized that, for a live birth to be accomplished, it is neces- sary that the whole body be brought into the world. There must be independent circulation ; the whole body of the child must have come forth from the body of the mother, but the umbilical cord need not have been separated, lieese states that " according to the laws of the United States and England neither breathing nor crying are essential to establish a live birth ; the pulsation of the child^s heart, or of one of its arteries, or the slightest voluntary movement, is regarded as suffi- cient for this purpose. In Scotland, crying is regarded as essential ; in France, respiration ; and in Germany, crying, attested by unimpeach- able witnesses.'' Live birth, therefore, is to be looked upon as quite a different thing from viability. A live birth at four or four and a half months will win a law-suit, it may be, of one kind — as, for instance, a question of tenancy by courtesy ^ where a husband acquires a life interest in the property of his wife at her death, provided a living child is born during the life of the mother, — that is, not postmortem Cesarean sec- tion,— and not manifesting the traits of a monster ; but it would not win a suit requiring the delivery of a viable infant in the full sense of the term as already given. It is now ver^^ well settled that a child en ventre sa mere, for all practical purposes tending to its own benefit, is considered as absolutely born.^
The Appearance of the Fetus at the Different Months of Gestation. — From the foregoing statements it becomes evident that an exact knowledge of the characteristic features of the embryo and fetus in successive months of gestation is most important in medico- legal practice. In the following classification these features are fully presented.
Fetal Development at the Successive Months of Gesta- tion.— From the Fourth to the Twelfth Day (the Time of Entrance into the Uterine Cavity). — The embryo exists at first merely as the disk-like embryonic spot. Soon a tube appears, the primitive neural canals opening below and supporting below a globular bag. The dorsal or abdominal plates are visible. The embryo lies within the zona pel- lucida. Size of the ovum, f cm. (J in.) ; of the embryo, \ cm. (^-^ in.).
From the Fourteenth to the Eighteenth Day. — The embryo appears as a semitransparent, gelatinous, flocculent mass, measuring about 2 J lines in length, or \ inch.
First Month. — The amnion and umbilical vesicle are fully formed ; the allantois is present, but is not united with the chorion ; there is but a small amount of liquor amnii ; the visceral arches are distinct ; the spinal canal is closed. The curved form of the fetus is noticeable. The fetal heart may be distinguished ; there are primitive traces of the liver and kidneys ; the nasal pits and eyes appear, as do also the intes- tine and the anal and oral orifices ; the extremities are rudimentary. The length of the ovum is about j inch ; of the fetus, 1 cm. (J inch or 4 to 6 lines) ; its weight is 20 grains.
^ American and English Encyclopedia of Law^ second edition, p. 719.
FETAL DEVELOPMENT AT DIFFERENT MONTHS. 75
Second Month. — The embryo is the size of a pigeon's egg. The amnion is distended with fluid, and is in contact with the chorion. The chorionic villi are well developed at the placental site. The umbilical vesicle is small ; the umbilical cord is distinct, and the umbilical ves- sels visible. The visceral clefts, with the exception of the first, are closed ; the head forms more than two-thirds of the embryo ; the eyes, nose, mouth, and ears are distinguishable ; there are primitive traces of the hands and feet, which are webbed ; the vertebrae are present ; the form and disposition of the brain and cord can be recognized. There is beginning formation of the external genitals, although sex is not diifer- entiated ; the Sylvian fossa is present ; there is a beginning of the ossi- fication of the lower jaw, ribs, vertebral bodies, and clavicle ; the cir- culatory system is forming ; the Wolffian bodies are present, although beginning to disappear ; the kidneys and suprarenal capsules are form- ing. The length of the fetus is 4 cm. (IJ inches or 15 to 18 lines) ; its weight is 4 grams (60 to 62 grains).
Third Month. — The embryo has attained the size of a goose-egg ; nourishment takes place by means of maternal blood ; the chorionic villi are lost ; the placenta is formed, but is small ; the umbilical cord is spiral, and about 3 inches long ; the decidua reflexa and decidua vera come in contact ; the pupillary membrane is present ; the eyes and mouth are closed ; the teeth begin to appear ; the digits become distinct (they are not webl^ed, and show membranous nails ; the toes are still webbed) ; the neck is distinguishable ; the ribs are formed ; the genital organs are very prominent, the penis and clitoris being of equal length ; the uterus appears, thus distinguishing the sex ; the integument is form- ing ; the tubercula quadrigemina, optic thalami, and corpora striata may be seen ; points of ossification are present in most of the bones. The length of the fetus is 9 cm. (3J inches) ; its weight is 30 grams (450 grains).
Fourth Month. — The placenta weighs about 3 ounces. There is a formation of Wharton's jelly in the cord ; the latter is two or three times the length of the fetal body ; the head is about one-fourth of the body- length ; there is a formation of short silvery hair upon the scalp, and of lanugo upon the body ; the skin is rosy and very delicate ; the mouth is open ; the external ear measures 5J to 7J mm. ; there are a develop- ment of the convolutions of the brain and a formation of the muscles ; the pupillary membrane is quite distinct ; the intestines contain mecon- ium ; the sex is well defined ; ossification begins in the lower segments of the sacrum, and in the frontal and occipital bones ; the liquor amnii is relatively less in quantity, and the fetus nearly fills the uterine cavity. The umbilical cord is about 7 inches in length, and is inserted above the lower fourth of the linea alba. The length of the fetus is 16 cm. (6J inches) ; its weight is 55 grams (848| grains).
Fifth Month. — The placenta weighs 6 ojances ; the umbilical cord measures 12 inches; the hair and nails are fully formed ; the head, heart, kidneys, and liver are disproportionately large ; the vernix case- osa appears; the face is wrinkled and senile. The external ear
76 LEGITIMACY.
measures from 8 to 12 mm. in length; the pupillary membrane is still present. The eyelids begin to open ; the Sylvian fossa becomes tri- angular; the fissures of Rolando appears; the brain weighs 720 grains (Wenzels) ; ossification begins in the pubis, calcis, and ischium. The length of the fetus is 25 cm. (9} inches) ; its weight is 273 grams (10.8 ounces). Fetal movements are perceptible.
Sixth Month. — There is a beginning deposition of fat in the sub- cutaneous cellular tissue ; the color of the body is cinnabar red (Reese) ; the palms and soles are purplish in tint ; there is increased growth of hair, and the appearance of eyebrows and eyelashes ; the head is very soft, and the fontanels wide open ; the membrana pupillaris is present ; the eyelids are adherent ; the umbilicus is slightly above the pubis ; the testicles commence to descend toward the inguinal rings ; the labia pro- ject but do not cover the clitoris ; there is beginning ossification of the manubrium and pubic bones ; a small quantity of meconium is found in the colon ; the bladder is small, hard, and pyriform. The external ear measures from 16 to 24 mm. ; the Sylvian fissure is formed, and the precentral, inferior frontal, and intraparietal cerebral sulci appear. The length of the fetus is 30 cm. (10 to 11 inches) ; its weight is 715 grams (23 ounces).
Seventh Month. — The skin is still wrinkled and reddish, and is covered with vernix caseosa ; the lanugo begins to disappear from the face ; the hair on the scalp is about J inch long ; the eyelids are open ; the membrana pupillaris disappears ; the medulla oblongata can be dis- tinguished ; the cerebral convolutions begin to form ; the ears lie close to the side of the head ; the external auricle measures 26 mm. ; the testicles are at or in the inguinal canal ; the decidua reflexa and decidua vera have now thoroughly merged into one ; the finger-nails do not quite reach the fingers' ends ; meconium exists in the large intestine ; ossification centers appear in the astragalus and first piece of the ster- num. The length of the fetus is 35 cm. (13} inches); its weight is 1213 grams (39 ounces).
Eighth Month. — The lanugo begins to disappear from the face ; the skin is thicker and of a more natural color ; the nails are harder, but do not project beyond the finger-tips ; valvulse conniventes are found in the small intestine ; the breasts often project ; the liver is still very large ; the left testicle is in the scrotum ; the lungs are reddish ; the insertion of the funis is but slightly below the middle of the body ; the external auricle measures from 26 to 28 mm. ; ossification begins in the second piece of the sternum and in the lower epij)hysis of the femur ; the brain Aveighs 4860 grains (Wenzels). The length of the fetus is 40 cm. (15} inches) ; its weight is 1617 grams (4J pounds).
Ninth Month. — There is a great increase in the amount of sub- cutaneous fat ; the face loses its wrinkled and senile appearance ; the lanugo begins to disappear from the body ; both testicles are in the scrotum ; the vulva is closed ; the gray portion of the brain begins to appear; the weight of the brain is 6150 grains (Wenzels) ; all the di- ameters of the fetal head are about 1 cm. (^ inch) smaller than at term.
MULTIPLE PREGNANCY SUPERFETATION. 77
The length of the fetus is 45 cpi. (17| inches); ils weight is 1990 grams (5J pounds).
The Fetus at Term. — The body of the fetus at full maturity is well rounded ; the lanugo has disappeared ; the face has lost its wrinkles ; the skin is rosy ; the nails project beyond the finger-tips ; the eyelashes and eyelids are well formed ; the eyes are open ; the bones of the cranium are in contact ; the fontanels are small ; the cerebral convo- lutions are numerous ; the cuboid bone is beginning to ossify. The osseous deposit in the inferior epiphysis of the femur measures 2 or 3 lines in diameter ; meconium is present in the large intestine only, which it nearly fills ; the breasts are well formed and contain secretion ; the bladder contains urine; the length of the foot is 8 cm. (3.14 inches) ; this is regarded by many as an important proof of fetal maturity. The external auricle measures 33 to 36 mm. ; the ear and nose cartilages feel hard ; the cord is inserted from 8 to 10 lines below the center of the body (Moreau). The length of the fetus is 50 cm. (19| inches) ; its average weight is 2737 grams (7 J pounds). Children at full term may weigh only from 4 to 6 pounds, or they may, without prolongation of pregnancy, have a weight of from 12 to 14 pounds. Such a weight, however, presupposes an overextension of pregnancy. The weight is not so constant as the length of the child.
Multiple Pregnancy. — Closely allied to the question of legiti- macy is the subject of multiple pregnancy, which may manifest itself in various and perplexing ways. This will include a consideration of twin pregnancy, in which one child is delivered, but the other is not born for several weeks or months subsequently ; superfetation ; a double uterus ; and a coexisting intra-uterine and extra-uterine fetation.
Superfetation. — By this term is meant the fertilization of an ovum when there is another ovum from a previous ovulation in utero- gestation. These children may be delivered at the same birth, the one showing signs of maturity and the other of immaturity ; or else both are born at full term at an interval of from one to three months, according to the diiference in the dates of conception. For a long time the possibility of such an occurrence as this was absolutely denied. A few authentic cases, however, have shown that it may ex- ceptionally occur, but only within the first three months of gestation, before the union of the decidua reflexa and decidua vera has been com- pleted. During this time a new ovum can be fecundated, no insur- mountable barrier existing to the ascent of the spermatozoid. A more difficult point to decide is the question as to the continuance of ovulation during gestation. While it is undoubtedly true that, as a rule, this process is abolished during the progress of a uterogesta- tion, exceptions to the rule occur here just as readily as they do in all the other functions of the body. This has been proved by the delivery of twins one black and the other white, the product of different coitions ; and by the presence of combined intra-uterine and extra-uterine gesta- tion advanced to different periods, the extra-uterine product showing the more advanced development, although subjected to greater difficulty in
78 THE DETERMINATION OF SEX.
the securing of proper nourishment than its fellow in utero, hence being of prior formation. The mere suppression of the menstrual function during the progress of pregnancy does not necessarily indicate the abol- ishment of ovulation at the same time. As we have seen, the two are not interdependent.
The theory advanced by obstetricians who do not believe in the pos- sibility of superfetation as an explanation of cases of this description is that of the existence of a twin-gestation in which one embryo, imbibing more nutriment than the other, outgrows its fellow ; thus one may ap- pear of but seven or eight months' development and the other show full maturity ; or they advance the possible existence of a double uterus {uterus bipartitus) in which one ovum is fertilized in either uterus at successive coitions. The unmistakable evidences, however, of double conception in lower animals prove the possibility of the same in women. Thus, Reese reports the instance of a mare covered successively by a horse and an ass, and