minable to a certain extent by the growth in size of the center of ossification of the lower epiphysis of the femur. The size at birth is from 2.5 to 5mm. If the child has an epiphyseal center more than 5mm. in diameter the child may safely be said to have lived more than ten days, if the birth was at term, and the duration of pregnancy not protracted. On the other hand, cases have been found in which the infant has lived from eight to ten days after what was supposed to be birth at term, and yet no sign of an epiphyseal center was found. Hence, even this sign must be considered as secondary to the evidence offered by the umbilicus, its area of inflammation after the second day, the falling of the cord on the fourth, fifth, or sixth day, and the healing of the granulating area behind it up to the end of the second week. V. CAUSES OF DEATH DURING LABOR. 114. Placental separation.-One more point must be considered before we take up the direct evidence as to infanticide, and that is the causes of death during or immediately after labor, to which the infant is exposed. In the early stages of labor, if the placenta is separated while there is yet no possibility of the fetus receiving air from the outside world, the fruitless attempts at respiration will lead to the death of the infant from asphyxia with the inspiration of the liquor amnii and of meconium and urine if they have been passed by the fetus, as they usually are. These substances may later be found in the lungs of the fetus on autopsy. 115. Prolapse of cord. The umbilical cord may become prolapsed and compressed so as to shut off the circulation of the blood, and similarly cause asphyxia. Brouardel says35 that 55 per cent of those dying during labor have a prolapse of the cord. These cases also show the inspired liquor amnii in the lungs, and usually the subpleural ecchymoses, and other signs of asphyxia. 116. Cord around neck. The cord may be the cause of death also in another way. In one case out of about every four36 of normal births the umbilical cord is wound around the neck. These coils of the cord may be so tightly constricted as to cut off the flow of blood through the cord, or possibly of the circulation to the head, by compression of the vessels in the neck of the child, thus causing asphyxia. These cases of coiling of the cord around the neck have been cited as an Brouardel, p. 76. Med. Rep. Soc. Lying-in Hosp. C. N. Y., 1893, p. 21. 575 cases out of 2328: that is, one in 4.04. explanation of the cases of apparent strangulation of the child. There are no marks that are always present in these cases, by which they can be identified. In a few instances marks on the neck evidently due to the cord have been described. Elsässer examined over three hundred cases in which the cord was around the neck, without finding any mark that could be attributed to the cord.37 The marks are described as varying greatly in their character, sometimes mere furrows in the skin, without color, sometimes red or blue marks around the neck. Foster38 reports a case in which the child was born dead after a very tedious labor; the cord had been twisted around the neck, leaving three parallel colored depressions. Brouardel39 considers the cord about the neck as the cause of death in 4 per cent of the still births, and describes one case in which the cord left a mark on the neck of a child that survived, the mark being visible for four days after birth. The differentiation of criminal strangulation and death from the cord around the neck is very difficult. If the width of the mark corresponds to the diameter of the cord, goes completely around the neck, and is continuous with a mark of similar character leading towards the umbilicus, and if there is no evidence that the child has breathed, and therefore that the death took place during or very soon after labor, the chances are that the death was due to the cord. 117. Head compression.-In the cases where the labor is protracted, on account of the small size of the mother's pelvis, the rigidity of the parturient canal, or the large size of the child, there is a marked moulding of the child's head, which may be sufficient to cause the death of the child. The evidence of such a condition would be seen in the elongated head and the marked caput succedaneum, as well as in the disproportionate size of the child and mother. 118. Rupture of cord.-In exceptional cases the umbilical cord may be so short as to interfere with the birth of the child. This shortness may be due to the winding of the cord around the neck or body of the child, or to a cord that has primarily an extremely short length. Brouardel cites two cases of the kind;40 one of Dr. Sclafer with a cord 10 millimeters long, the other reported by Dr. Stude, where there was no cord at all, but the placenta adherent to the umbilicus. In such cases the cord must be ruptured or some other accident occur to allow the child to be born. If the cord is ruptured, Henke's Zeirschr. 1835 and 1842, "Brouardel, p. 89. 40 as is the most likely, there is the danger of death from hemorrhage from the torn end of the cord. The same danger is imminent in the cases of velamentous insertion of the cord into the placenta. Here the separated vessels of the cord are also liable to rupture and lead to the hemorrhage. The likelihood of death from such rupture will be considered in connection with the discussion of the untied cord after delivery. 119. Fracture of skull.- Fractures of the skull of the infant may occur during labor, either from excessive pelvic deformity, the application of the forceps in the hands of the obstetrician, or precipitate labor, the child being born while the woman is about doing her work, and the child falling and fracturing its skull by striking the ground. Possibly, also, the woman may receive an injury during pregnancy of such a character that the child's skull will be broken. These last cases have little bearing upon infanticide, for in the instances of intrauterine fracture of the skull, the infants have all been born dead soon after the injury, and have not gone to term.41 119a. From contracted pelvis.- Depressions and fractures of the skull do, in rare instances, occur in connection with pelvic deformity12 or bony exostoses from the pelvis.43 These fractures are most frequent at the parietal and frontal bones, and appear either as a radial splitting of the parietal bone from the center of ossification, or as a depression of a single area of the skull. These fractures must be distinguished from the congenital disease of the bone, which usually appears as rarefaction of the bone tissue in several places.44 119b. From forceps application. Fracture of the skull by the application of the forceps, or rather, by their compression, would scarcely be advanced as an explanation of the fractures of the skull in a case of infanticide. But here, too, the fracture is a single depression, as distinguished from the multiple fractures of infanticide, 45 and in the forceps cases, too, the fracture usually involves the frontal and parietal bones. 119c. Precipitate labor. It has been argued that fractures of the skull may be the result of a precipitate labor, in which the woman is delivered while standing at her work; that the child fell to the "Froebel, Die Nabelschnur im ihrem pathol. Verhalt. wahrend der Geburt, Gaz. des Hôp., Nov. 1846; Gurlt, Lehre von den Knochenbruchen, Frankfort am Main, 1860, p. 211. "Lizè, Lancet, Feb. 1860, p. 180. Tardieu, L'Infanticide, p. 143. 43 "Zur Kentniss der Naturlichen Spalten und Ossifications defecten am Schädel Neugebornener, Vrtljschr. f. d. prakt. Heilk. CXXIII., p. 53. Hofmann collects cases of mistaken congenital and traumatic fissures, etc. See § 133, infra. ground and, in so doing, broke its skull. Landsberg46 gives a good illustration of this accident in the following case: A woman who had already borne several children was taken in labor at the time that her house was on fire; as she ran from the house the child fell from her upon a heap of broken bricks and stones. Fourteen days afterwards there was found upon the left parietal bone of the child a swelling the size of a pigeon's egg, without any discoloration of the skin, and with slight fluctuation. The fragments of the bone and crepitation could be easily distinguished at this spot. The child got well. The fractures thus produced naturally occupy the top of the skull, are usually linear, and not associated with any marked traumatism of the soft parts, and do not always lead to the death of the infant. So much we must admit. But when we come to examine into the frequency of these fractures, we find, first, that while it is possible for a woman who has borne several children to be taken so suddenly that she does not have time to lie down, it actually occurs but very rarely. Moreover, granting that the labor has come on suddenly, and the child has fallen to the ground, fracture of the "Henke's Zeitschr., 1847, III., Heft. sive injuries were produced by striking "Hofmann tried sixty cases and got the head against a table or wall. Four no fractures; Casper, in his Vierteljahr- bodies were placed two or three inches schrift, 1863, Heft 1, gives his experi- under ground which was then stamped ments bearing on this point. Twenty- level; in three of the cases fractures refive experiments were made upon the sulted. No result was obtained by combodies of newly-born children. From a pressing the head with the hands, or by height of 30 inches, ten infants were falling suddenly upon the child placed dropped upon an asphaltum and fifteen upon a hard surface. Compressing the upon a stone pavement. There were no head into a narrow box was attended with visible injuries to the surface produced, no result in two cases, but in a third a but in twenty-four cases fractures of the slight cleft extended from the lamdoidal skull were found. The fractures were suture into the left parietal bone, while distributed as follows: one parietal, the coronal suture was somewhat sepsixteen times; both parietals, six times; arated. Extensive injuries were easily once the parietal and frontal of the produced by blows with a mallet or same side; once the frontals of both hammer. In all the cases the fractures sides; and once the occipital had sus- were like cracks in glass. In five only, tained a fracture. Numerous fractures out of sixty fractures, were serrations were not found. The peculiar form of present. Detachment of dura mater, injury is also worthy of notice. Almost separation of sutures, extravasations of always one, two, or three fissures ex- blood beneath the pericranium, and cotended from the parietal protuberance to agulations at the seat of fracture are the margin of the bone, and sometimes not peculiar to the living. More or less extending across the sagittal suture to coagulated extravasations were pretty the parietal of the opposite side; twice constantly found, and the other appeara small portion of bone was broken off. ances mentioned were not infrequent. In Twice, when the body was allowed to conclusion, we are warned that the fetal fall from the table, fracture of the parie- skull, like that of the adult, may be tal resulted. When the head was trod- more resistant after death than it is durden upon by a heel, fractures were al- ing life. The cases are perhaps too few ways produced, not only in the parietal to establish laws, but coming as they do touched, but in the opposite bone, which from so high an authority, are worthy looked much as if done in life. Exten- of the most careful consideration. skull as a consequence is by no means the inevitable result; in fact, Klein18 collected one hundred and eighty-three cases of delivery in the erect position, in none of which the head of the child was fractured. Still, the instances of fracture in this way are authentic enough to leave no doubt as to the possibility, so that, while the general law is that such a fall does not produce a fracture of the cranium, still the exceptions must be admitted, and these must be differentiated from the criminal fractures.49 In the differentiation from criminal fractures, if the fracture is sufficient to cause immediate death of the infant the absence of air from the lungs would tend to support the mother's plea that the fracture was due to precipitate labor; but the converse, that the presence of air in the lungs supports criminal fracture, cannot be argued, for it is well known that even after the destruction of the child's skull in utero by the operation of craniotomy, the infant, after birth, has made efforts to breathe.50 Another 120. Hemorrhage from rupture of the cord. cause of death immediately after labor, and intimately associated with this manner of fracturing the skull, is by hemorrhage from the rupture of the umbilical cord in precipitate labors. In these cases the woman may be standing, and the weight of the child fall upon the cord, though such instances are very rare. In the 183 cases collected by Klein, in none of them was the cord ruptured. Tissier, however, reports one such case. And what is still more worthy of comment, Budin52 reports two cases of rupture of the cord where the woman was lying down, and under the usual hospital care, when, with a single strong pain, the infant was shot from the woman, in one case driving the fetus 30 centimeters from the woman's vulva, and breaking the cord. 121. Breech presentation.- Another real, though not common, cause of death during labor, is in the delay of the birth of the aftercoming head in the instances of breech presentation. In some cases where the extraction of the child is difficult even in the hands of the physician, there is so much delay as to endanger the life of the child, sometimes even to be accounted as the cause of death. If, then, a woman comes to labor by herself, with no one to help her, and the Quoted by Brouardel, L'Infanticide, p. 111, from Eléments de Méd. Lég., Hofmann, Traduise francaise, p. 576. Of the 183 cases twenty-one were primiparæ. The positions in which they were confined were as follows: Standing, one hundred fifty-five; squatting, twenty-two; and on the knees, six. "Tardieu, L'Infanticide, p. 142. Tissier, Ann. d'Hyg. Pub. et de Méd. 52 Budin, Ann. d'Hyg. Pub. et de Méd. Lég., 1887, XVII., p. 534. |