1 nized after the first few weeks. The bloody, or carneous, moles are blood clots forming between the chorion and the wall of the uterus, and may be either organized into fibrous tissue, or still remain blood clot. The hydatid mole is a cystic degeneration of the chorionic villi, appearing as a vast number of cysts. The blood clots or the firmer mass of a uterine polyp could scarcely be mistaken for a product of conception. The membrane of certain cases of dysmenorrhea resembles an early ovum; but the history of the cases in the two instances would be entirely different, and a microscopical examination of the membrane would settle the question beyond doubt by the absence of the chorionic villi from the dysmenorrhea membrane. 27. Signs remaining in woman.—The signs remaining in the woman depend upon the changes produced in her body by the pregnancy; and if that state comes to an end in the early months, before any marked changes have taken place, there may remain nothing to prove the previous state except slight increase in the size of the uterus, and the changes in its endometrium. Similarly in the cases of uterine mole and ectopic pregnancy: after a few days nothing may remain that can be demonstrated on the living woman to prove the pregnancy, though by curettage of the somewhat enlarged uterus it may be possible to find some of the decidual cells in the mucosa, which appear early in the pregnancy; and by a post-mortem examination it might be possible to demonstrate the development of the corpus luteum of pregnancy. II. AFTER SECOND-HALF ABORTION AND LABOR AT TERM. 28. In general.-On the other hand, if the pregnancy continues into the second half, it leaves certain traces, depending for their distinctness on how near to term the pregnancy has continued, they being most clearly marked after labor at term. These signs appearing after labor near term may be classified as temporary, those which last only for a few days after labor; and persistent, those which continue for years to show the previous pregnancy. 29. Temporary signs in general. Of the temporary signs there is, first of all, the general condition of the patient immediately after labor, marked by the exhaustion, the warm, perspiring skin, and possibly, the slow pulse. The abdominal wall is lax and shows the striæ of the recent distention. 30. Breasts.-The breasts show the changes from the virgin con See §§ 91 et seq., post. dition, produced by the pregnancy, as described under the diagnosis of existing pregnancy. For the first day or two after labor at term the secretion of the breasts is scanty, thin, watery; contains the colostrum corpuscles, and has the characteristic composition of colostrum. On the third or fourth day the breasts become somewhat more tense, tender, and the colostrum begins to give place to the whitish milk secretion, though the colostrum corpuscles may be identified in the milk until the ninth or tenth day. As the milk secretion increases, the breasts, if relieved of their secretion, become soft and pliable, and produce steadily increasing quantities of milk for several months. If not emptied, the breasts tend to become hard, lumpy, painful, and caked. Either secreting or caked breast is characteristic of the active mammæ; but, as we saw in the signs of existing pregnancy, this condition may be produced by other conditions besides pregnancy, and therefore is not a positive sign of recent delivery, although extremely suggestive. 31. Parturient canal. The parturient canal shows evidences of the passage of the child. For the first few days the vulva is gaping, the vagina relaxed and very capacious, even admitting the entire hand through the cervix and into the uterine cavity on the first day. The parts are likely to be covered with blood, vernix caseosa, and, perhaps, with meconium.5 The secretion from them, especially from the uterus, is very profuse. Gradually they contract, approximating their previous size, and the cervix, which is the most satisfactory guide, becomes firmer; for a few days admits two fingers; at the end of the first week, one finger; and at the end of two weeks admits the end of one finger with difficulty. It is not completely closed for two months. 32. Uterus.-The uterus, immediately after labor, contracts down to about 12 centimeters above the symphysis pubis; then, as involution goes on, the uterus contracts till, usually on the sixth day, it is 4 to 5 centimeters above the pubes, and towards the end of the second week the fundus sinks behind the symphysis. 33. Lochia.-The most distinctive sign of recent delivery is the lochial discharge from the interior of the uterus. For the first three of four days it is largely of blood, with some mucus, alkaline in reaction, and having an odor which is characteristic. It contains the See § 13, ante. Holt's Diseases of Children, 2d ed., p. 127; and Williams's Obstetrics, p. 319. See § 13, ante. "Test for Blood, von Jaksch, Klinische Diagnostik, 5te. Aufl., 1901, § 93; Tests for Meconium, ibid., § 319; Composition of Vernix Caseosa, Williams's Obstetrics, p. 132. 1 breaking down elements of the remaining uterine contents: bits of the placenta and membranes, if any have been left behind, and the remnants of the decidua, which can be identified under the microscope. After three or four days the lochia becomes thinner, paler, and less in quantity; after the tenth day it becomes more mucoid and opaque, and then gradually disappears. It can generally be identified as a milky discharge for two or three weeks. 34. Permanent signs in general. There are a few signs that remain permanently. The relaxed abdominal wall retains its striæ, and the breasts retain their striæ. After a few weeks the fresh pink striæ become silvery. Both have only presumptive value. In the parturient canal are the signs which are generally considered to have permanent positive significance. 35. Parturient canal.- The hymen, which may have been slightly lacerated before delivery, is destroyed and represented by the tags of mucous membrane called the carunculæ myrtiformes. Yet Budin reports a case where, after labor, the hymen showed scarcely more injury than the lacerations due to coitus. The destruction of the fourchette, and the laceration of the perineum are frequently found, and when found are almost equally diagnostic of delivery, if traumatism (as by vaginal operations on the uterus) can be excluded. Lacerations of the cervix are still more characteristic, changing the oval os tincæ of the virgin to the transverse slit of the parous woman. When large lacerations have been made their scars are still more characteristic. The size of the uterus is also changed by pregnancy from a small virgin uterus to the uterus of the multipara, which is usually about one third larger. Exceptionally the uterus is not increased in size after childbirth. Similar changes might be produced in the uterus by disease and operation, but very great probability of a previous pregnancy can be stated on the evidence obtained from the uterus some time after delivery; though the temporary signs-the great laxity of the parturient canal and the uterus, the presence of colostrum in the breasts, and the lochial discharge from the uterusgive the only absolutely positive proof of the previous pregnancy which can be obtained without a post-mortem examination of the organs, or an operation on the pelvic organs. III. POST-MORTEM EXAMINATIONS. 36. Temporary signs in general.-If the woman is dead and a Williams, p. 306. veau Nés, Paris, 1897, p. 1. Quoted by Budin, Femmes en Couche et Nou- Williams, p. 30, with illustration. post-mortem examination is possible, further and conclusive evidence may be obtained. In addition to the evidence obtainable during life, the examination of the ovaries and uterus may now be made more closely. In the first few days after labor the lacerations in the vagina, the increased size and weight of the uterus, the lax, wrinkled peritoneum covering it, the hypertrophied muscular wall undergoing retrograde changes distributed uniformly throughout the upper segment of the uterus (as shown unmistakably by the aid of the microscope), the tortuous blood vessels of the uterus, and the condition of the mucous membrane, all bear incontrovertible proof of the previous state. Perhaps the most important of all is the condition of the mucous membrane, which shows the irregular surface of the detached decidua, and at the site of the previous attachment of the placenta an elevated area about 10 centimeters in diameter, with many thrombosed vessels. At the end of the second week the placental site is still blood-pigmented and elevated, but only about 3 or 4 centimeters in diameter. 37. Corpus luteum. In the ovaries during pregnancy there is developed a body, the corpus luteum, which was formerly supposed to be characteristic of pregnancy, but has since been proved to be identical in origin (from the ruptured Graafian follicle) with the corpus luteum of menstruation. Moreover, not merely is the origin of the two bodies identical, but the development and the retrogression in both cases follow the same course. The only well-established difference between the two is in the rate and degree of the changes taking place. The corpus luteum spurium (of menstruation) reaches its maximum size in eight or ten days and then begins to atrophy, so that, at the end of six weeks, it is merely a scar, and scarcely to be identified. On the other hand, the corpus luteum verum (of pregnancy) develops like the corpus luteum spurium during the first week, but then continues developing in the same lines, though at a much slower rate, until the end of the third month of pregnancy, when it ceases to grow, and begins the retrograde changes which bring it, at the end of the ninth month of pregnancy, to about the same stage as the corpus luteum spurium at the end of its third week. There seems to be some difference of opinion as to the size attained by the corpus luteum verum. Most observers are content with saying that it is distinctly larger than the false corpus luteum. Longet in his Physiologie (Paris, 1850), says that sometimes the corpus luteum VOL. III. MED. JUR.-2. verum is larger than the ovary itself. On the other hand, Orth says the true are seldom larger than the false, and, in the early stages, the true are the smaller. And Kreis considers the size of the two to be practically the same, though the periods of development of the two vary so much. He describes four cases at the end of pregnancy, one at 290 days, of the same size as a corpus luteum spurium of the twelfth day; and three between the 270th and the 285th days, where the development represented the third week of the menstrual corpus luteum. Montgomery gives10 a table of measurements of true corpora lutea at different periods of pregnancy which gives averages as follows, the measurements being taken in lines: 11 Cornil,11 in an article on the histology of the corpus luteum, discusses the appearance in abnormal conditions where there is an excessive congestion of the pelvic organs, causing a congestion of the ovaries similar to that of pregnancy, and he finds a corresponding increase in size of the corpus luteum. In one case he found two corpora lutea of the same size, very large, in the same ovary. At another operation he found three corpora lutea of apparently the same age, and in a third case, four corpora lutea. In none of the cases had there been recent fecundation or pregnancy. In conclusion he says: "On ne peut distinguer des corps jaunes ainsi hypertrophies sous l'influence de congestions ovariennes, de ceux de la grossesse." Hence, what was formerly considered the sure proof of pregnancy has now become of scarcely any legal value, though, when taken in connection with the other findings in the body, and when examined during certain stages of pregnancy, it still has some weight. 38. Permanent signs,-size of uterus.-In the later months after pregnancy, in addition to the persistent signs existing in the living |