as a complete sac; while, if the abortion has been induced, the sac is likely to be ruptured, and the embryo and the fetus discharged at different times. The discharge of the complete, unruptured ovum may not be the rule for the whole of the first three months, but it is generally conceded to be the usual form in the first six weeks, though even here a ruptured ovum could not be taken as very strong evidence of interference.23 In the later months the instrument used to enter the uterus may produce some traumatism upon the body of the fetus, as in a case reported in the London Medical Gazette24 of an abortion brought on by introducing a skewer into the uterus, the skewer perforating the skull of the fetus.

90. Signs of induced abortion in mother. In the mother the evidences of the drugs may be found in some cases.25 The effects of the general traumatisms will be those of wounds in general, as described in the chapters on wounds. The local methods used leave their mark in proportion to the lack of skill with which they are used. The douches may produce local ulcerations; the instruments used may be broken off in the uterus. Not a few instances of broken off twigs and branches of trees being found in the uterus have been recorded,26 and several of bent wires which could not be removed after they had been inserted. Equally significant are the traumatisms to the vagina, cervix, and uterus made by instruments. In the most skilful hands at times the instrument introduced into the pregnant uterus perforates its wall; and in the hands of the unskilful, perforation of the vagina and cervix as well as of the uterus not infrequently occur. If the instrument is sterile, as the responsible operator's always should be, such a perforation may cause no harm; but if in the hands of one not acquainted with the methods of modern surgery, it usually carries infection with it. Yet Vibert,27 who had occasion to examine seventytwo women who had had recourse to the good offices of a girl named Thomas, with a very extensive practice, says that on no one of them was it possible to find the least trace of injury to the genital organs. 90a. Rupture of the uterus.-To be distinguished from these perforations are the ruptures of the uterus occurring in the undisturbed course of pregnancy in a certain number of cases. The spontaneous rupture usually occurs in cases where the cause of the rupture is evident; most frequently during labor, and where there is some marked obstruction to the birth of the child; for example, marked deformity

Friedrich's Blätt. f. gerichtl. Med. 1892, XLIII., 165.

London Med. Gazette, Vol. XLV.
See sections on toxicology.

Brouardel, L'Avortement.

"Vibert, Précis de Méd. Lég. 1900. p. 436. Quoted by Brouardel, in L'Avortement, p 51.

of the pelvis of the woman; large size, malformation, or malposition of the fetus; or pathological changes in the uterus, such as congenital deformities of the uterus, or tumor growths in the uterus. On the other hand, in perforations due to interference with the pregnancy, there is usually no evident cause why there should be a rupture of the uterus, and no obstruction to the exit of the fetus.

The age of the woman having a spontaneous rupture is usually over twenty-five, and there may be a history of previous difficult labors.28 In the perforation cases the age is not of significance, for the woman may be an old married woman who does not desire to be burdened with an increasing family, or she may be an unmarried girl who has indulged where she should not.

The period of pregnancy at which the rupture occurs in the spontaneous cases is most frequently at full term, during labor; sometimes, in the pathological conditions of the uterus, the rupture occurs in the early months, due to the great stretching of the uterine walls. In the perforation cases the injury rarely comes at term, much more frequently during the middle third of the pregnancy.2

29

As to the appearance of the rupture itself, in the spontaneous cases it is situated most frequently at the junction of the cervix with the neck, at the sides or across the fundus connecting the uterine ends of the two Fallopian tubes.30 In the induced cases the injury usually is in a straight line with the vaginal canal, therefore involving most frequently the anterior lip of the cervix, the posterior wall of the uterus, or the fundus;31 but instruments jabbed indiscriminately into the vagina in hope of reaching the uterus may lacerate any part of the uterus, or, for that matter, any of the pelvic viscera, or even the abdominal viscera. One case is reported of a woman who, in her attempt to produce abortion, lost her implement, an umbrella rib,which a few days later, at autopsy, was found to have perforated the liver, gone up through the diaphragm, and entered the right lung.32 The size of the rupture is often distinctive. In the spontaneous cases the rupture is usually of large size, several centimeters in the long diameter, while those of the induced cases are usually smaller, and are characteristic in proportion as they approach the size of the in

Coutagne, Rupture of the Uterus, Lyon Medical, Paris, 1882, p. 54. Brouardel, L'Avortement, Paris,

1901, p. 49.

Marsais, Des Blessures de la Matrice dans le Maneuvers Criminelles Abor

tives, Thèses, Lyon, 1890, Ser. 1, Vol. LV., No. 579, p. 86.

"Brouardel, L'Avortement, p. 214.

Case of Thomas, cited by Kleinmann, Inaug. Disser. Berlin, 1881, Ueber die Verletzungen der Gebärmutter, etc.

strument that produced them. The size of the ruptures in the cases of induced labor are modified occasionally by the subsequent uterine contractions which tend to increase the size of the rupture. They are also modified by the inflammatory conditions which may be associated with them, and not infrequently the instrumental perforations are multiple, due to repeated attempts to empty the uterus. Moreover, the majority of instances in which the injuries to the uterus are due to instruments, certainly the majority of those done for criminal purposes, are infected, and it may be possible to trace the course of the instrument by a channel of inflammation, and at its end find a suppurating or gangrenous tear in the uterus, with either an acute inflammation of the uterus, or of the peritoneum, which is the most common cause of death in these cases.33 On the other hand, in the spontaneous rupture cases the edges of the wound are generally clean, if not so sharply cut, and in these cases death usually follows, not from the infection, but from the hemorrhage into the peritoneal cavity.

91. Age of fetus. In the examination of these cases another point of great importance is that of the period of pregnancy at which the abortion has taken place,—that is, the age of the fetus,-whether the pregnancy has not really gone to term; and, if it has not, whether the infant was viable at the time of delivery. The age of the fetus is estimated according to its period of development, and especially its length; though, of course, these are subject to a certain amount of variation, just as adults vary among themselves.

The following description of the fetus at the progressive stages of development are drawn from those of Williams's Obstetrics, Cunningham's Anatomy, and Brouardel's L'Infanticide :34

In the first week of the life of the ovum it is probably to be found in the Fallopian tube. The only ovum so far described as found in the tube is that of Hyrtl, in the uterine end of the tube, on the fifth day after the cessation of the menstrual flow. Peters has described one in the uterine cavity which he considers to be three days old. It is the youngest human ovum known to Williams. It measured 1.6 by 0.8 by 0.9 mm. in its diameters, presented a primitive embryonic area, amnion and chorion.

In the second week the ovum attains a size of 6 by 4.5 mm. In the early part of the second week the primitive streak appears, and in the earliest ovum described by Graf Spee, the primitive streak was

83 See note 30, supra. "Williams's Obstetrics, 1903, p. 128; J. D. Cunningham's Text Book of An

atomy, 1902, p. 62; Brouardel, L'Infanticide, 1897.

0.4 mm. long. At the end of the second week the neural groove appears, the outline of the heart becomes visible, and also the outlines of the fourteen protovertebral somites.

In the third week the cerebral and optic vesicles appear, the visceral arches and clefts, and at the end of the week budlike projections represent the beginning of the limbs. The yolk-sac becomes more and more constricted.

In the fourth week the embryo increases considerably in size, and becomes markedly flexed upon itself; the ears are just visible as small nodules. At the end of the first lunar month the embryo measures 7.5 to 10.0 mm. in length.

In the second lunar month the genital tubercle appears, the digits are differentiated, the external ear assumes an adult appearance, and the other visceral clefts disappear, the tail is reduced to a small nodule, and the embryo begins to look like a mature human being. At the end of the month the fetus has attained the length of 2.5 cm. to 3.5 cm. (1 inch to 1.5 inches) and weighs about 4 grams.

In the third month the eyelids close, the nails appear on the fingers and toes, and the sex can be distinguished on examination of the external genitals. At the end of the month the fetus is 7 to 9 cms. in length, and weighs from 40 to 70 grams. The placenta is formed, and the umbilical cord is inserted just above the pubes.

In the fourth month the skin becomes firmer and fine hairs are developed. The total length from vertex to heels is 16 to 20 cms., from vertex to coccyx is 12 to 13 cms., and its weight 100 to 150 gms.

By the end of the fifth month the hair on the body has become more apparent and a certain amount of typical hair has appeared on the head, and nails are distinct on the fingers and toes. The length of the fetus from vertex to heels is about 25 cms.; from vertex to coccyx about 20 cms. It weighs 250 to 300 gms.

At the end of the sixth month the skin presents a wrinkled appearance, and is of a dirty reddish color. There is a deposit of sebaceous material in the axillæ and groins, and the eyelashes and eyebrows appear. The length from vertex to heels is about 30 cms., and the weight about 650 gms.

By the end of the seventh month the skin is red and covered with vernix caseosa, and the pupillary membrane has just disappeared from the eyes. The length from vertex to heels is about 35 cms. and the weight about 1,200 gms.

At the end of the eighth month the skin is still red and wrinkled. The umbilicus rather higher from the pubis, but still not as high as at term. The length is about 42.5 cms. and the weight 1,900 gms.

At the end of the ninth month the body has become more rotund and the face has lost its wrinkled appearance. The testicles have descended into the scrotum. The fetus has a length of about 46.5 cms., and weighs about 2,500 gms.

Full term is reached at the end of the tenth lunar month. The average child at term has a length of about 50 cms. (20 inches), and weighs 3,250 gms. (7 pounds). The skin is smooth and firm, the lanugo hairs have disappeared, and the hair of the scalp is usually 2 to 3 cms. long. The entire body is covered with vernix. The fingers have nails which project just beyond the flesh, and the toe nails are just even with flesh. In male children the testicles have descended into the scrotum. In females the labia majora conceal the rest of the genitalia. The umbilical cord is inserted 1 to 2 centimeters below the center of the body. The bones of the head are well ossified and in contact except at the fontanelles. The head measures 11.5 cms. in the occipito-frontal diameter; 13.5 cms. in the occipito-mental; and 9.0 cms. in the biparietal diameter.

In the lower epiphysis of the femur the center of ossification has usually attained a diameter of 2.5 to 5.0 cms. This center of ossification of the femur has been given a great deal of weight in determining the maturity of the infant. According to Brouardel it appears the last two weeks before term in 90 per cent of the cases; before the last month he has never found it; at nine and a half lunar months he found it in five of twenty-six cases; during the last two weeks of the ninth month he found it in nine of twenty-one cases; at term he found it in 175 of 182 cases; and in one case of an infant born at term who had lived nine days he was unable to find any trace. Once in an infant at term and once in an infant of nine and a half months, he found the center of ossification in the condyle of only one femur. Hofmann36 in one instance found the center of ossification of the femur 4 mm. in diameter in a fetus 45 cm. long; and reports one found by Hassenstein37 in a child 40 cm. long. This center has been found absent in the mature infant at term in twelve of 102 cases by Hartmann,38 and in fourteen of 413 cases by Liman.39 Hofmann him

"For variations in the size and weight of infants at birth in extreme cases see Gould and Pyle's Anomalies and Curiosities of Medicine, p. 347, where the extremes of a one-pound child, seven to eight inches long, and a twenty-three and three quarter pounds child, measuring thirty inches in length, are mentioned.

Hofmann, Gericht. Med., 1903. "Hassenstein, Zeitschr. f. Medicinalb., 1892, p. 129.

"Hartmann, Beitrag. Z. Osteol. d. Neugeborene, Tübbinger, Diss., 1869. "Liman, Gericht. Med. p. 848.