Charles Delucena Meigs Alfred Velpeau.

A complete treatise on midwifery: or, the theory and practice of tokology ... online

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before the end of the sixth month, nor that it is always so at the commencement
of the seventh. The determination as to the viability of the child ought to depend
on the degree of perfection attained by the foetal organs, and not on the stage of
pregnancy. But, as the evolution of the foetus is not always in the same ratio, it
follows that an eight months' foetus may be less viable than one of seven months.

Should we refer on this head to the cases related by various authors, we might
have examples of children that were infinitely small, of some born at four months
or four months and a-half, and, nevertheless, become robust and vigorous men.
Who is unacquainted with the history of the celebrated Fortunio Liceti, related
by Van Swieten ? His mother, frightened by the roughness of the sea while
passing from Beco to Bapallo, brought him into the world before the sixth month
of her pregnancy; he was not bigger than a hand ; his father had recourse to the
heat of an oven to bring him up, and notwithstanding all that, Fortunio lived
to be seventy-nine years old. An embryo, says Brouzet, was born in 1748, at
the fifth month of pregnancy, and lived to the ninth month, without sucking,
without producing any excretion, or performing any other motion than to swallow
a few drops of milk ; but, four months after its birth, it suddenly cried, and sucked,
and moved its limbs, so that at sixteen months old it was stronger than children
of that age commonly are. Thebesius also pretends to have seen a foetus, born
before the seventh month, which could not cry until the ninth, but which was
still very weak after the lapse of a year. Pleissmann cites another such case,
quite similar to that of Brouzet, except that the foetus was born at a more ad-
vanced stage of the pregnancy. The daughter of P. Soranus, according to Car-
dan, came into the world at the sixth month : to nourish her they were obliged
to pour milk into her mouth by means of a funnel, which did not prevent her
from reaching a good old age. Spigelius speaks of a man who was born at the



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OF THE VIABILITY OP THE FCETUS. 255

commencement of the sixth month; and who was obliged to be kept wrapped up
in cotton for more than six weeks. Montus says that the cup-bearer of Henry
m. was born at five months; Avicenna, Diemerbroeck, Vallesius, and Mena
speak of facte nearly similar, and quite as authentic 1

Millot, who, in the matter of proof, does not seem to be very tenacious, speaks
of a certain Julius Modie, born in the year V, at five months and a half, and who
was so small and weak that at first he could not suck at all. This child, however,
grew very well. Have we not also had, as proof of anticipated viability, the
history of the famous Bebe de Nanci, who only weighed one pound at birth, whose
first cradle was a sabot, says the Count de Tressan, and of which there is a wax
model in the cabinets of the School of Medicine at Paris ? Mauriceau goes still
farther when he says that the wife of the porter of Saint Come aborted with a
foetus of two months, a finger in length, and which was baptized alive. De la
Motte pretends that he has seen one born alive not bigger than a humming bird.
But I ask, what conclusion can we draw from observations so imperfectly substan-
tiated, from facta encompassed with so many marvels, and citations so impro-
bable?

While admitting, with Chaussier, M. Orfila, and some others, that none of the
facts related by the authors demonstrate beyond doubt that the foetus is viable
before the seventh month, I cannot, however, agree with them that the thing is
impossible. A woman came in 1825 to bo delivered at my amphitheatre, after
she had had a fall; her last child was six months and three days old; she sup-
posed herself to be only five months gone with child ; and if she had had commerce
with her husband fifteen or even twelve days after her lying-in, it was at any rate
impossible for her to have entered on her seventh month. Now this woman
brought into the world a little girl that weighed two pounds, which besides pre-
sented all the appearances of a foetus of about five months, whose cries were so
weak they could scarcely be heard, who notwithstanding breathed, and lived in
this state for four days.

In the course of the same year, a young woman miscarried at the Hospital de
Per/ectumnement Having been delivered of a child at term, five months and
twelve days before, in the same hospital, it was impossible for her to be more
than five months pregnant. The foetus she brought forth weighed only one pound
and a quarter ; its skin was of a bright rose color, and had on it no down nor
sebaceous matter; its length from the vertex to the sole of the foot was only nine
inches. Notwithstanding this, my attention and that of the pupils was attracted
to it by some stretchings and slight movements of its limbs. We wrapped the
delicate creature in cotton, and placed it near its mother, who was told to pour a
few drops of milk into its mouth from time to time; but, as she thought such an
abortion could not live, she did not judge it proper to do anything to prevent it
from dying. It expired, in fact, the next morning, twenty-eight hours after it
was born. I saw a similar case at the Hotel Dieu in Paris, in 1834.

My object is not by any means to maintain that these foetuses were viable ;
nor, moreover, that that one was, of which Portal speaks, which was only four
months old. I merely wish to show that it is not strictly correct to say, in a
positive manner, that a child born previously to the last three months of the
pregnancy must be reputed not viable. M. Meli, who professes the same opinion
which I do, has surrounded it with so many proofs that it seems to me to be
difficult of refutation at the present day.

A foetus is viable when sufficiently developed to move its limbs, and when it
really does move them; when it cries and breathes freely; when its head is
covered or begins to be covered with hair; when its skin is no longer transparent,
is covered with down, and coated with sebaceous matter; when the bones of the
cranium touch along the greater part of their edges, and the sutures and fontanelles
are consequently very much closed; when it passes off its meconium and urine;



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256 OP THE VIABILITY OF THB P(BTUS.

when the proportions and dimensions of the different parts of its body are not too
far removed from what is observed in foetuses at term : and not because it is
exactly seven months old or more. For the same reason it ought not to be
declared not viable because it is born before the three last months of gestation,
but rather because the absence of its cry, a respiration scarcely discernible, very
feeble motions, inability to take hold of the nipple or finger, to void its meconium
and urine, softness and separation of the bones of the head, the absence or fewness
of the hairs, the transparency and red color of its skin, the want of a sebaceous
deposit, the thinness of its nails, &c., prove that its organs are still far from the
degree of perfection necessary for the maintenance of its exterior life.

Hippocrates and many other physicians of antiquity taught that the foetus is
more viable at seven months than at eight. At first view, such a proposition
appears somewhat absurd. All other things being equal, a foetus likely to live at
the seventh month will be viable if not born until the eighth month. Mauriceau
and De la Motte long ago maintained it, and the moderns have adopted com-
pletely the opinions of these celebrated practitioners. The very strong move-
ments of the foetus about the seventh month, and which gave rise to a belief in
the somerset, rendering premature delivery much more common at that period
than at any other, led the ancients to draw from it the conclusion that the seventh
month is a natural term of pregnancy, and that if the foetus over-passes that, it
could not be born without danger until the end of the ninth month. It is diffi-
cult to understand how they should have made a double mistake on this subject,
unless, with M. Dubois, we admit as a met that, if labor takes place in conse-
quence of the lively agitation of the foetus, as pretty often happens at the seventh
month, the cervix dilating with its accustomed gentleness and regularity, the
child will be exposed to less risk than if born at eight months, when delivery is
provoked by a fall or some other external accident. In the former case, in fact,
early parturition is in some sort natural, while in the latter, as Dewees remarks,
it is only a kind of abortion.



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PART IV.
OF THE TERM OF GESTATION.

The natural duration of gestation in the human species is generally nine months,
or rather two hundred and seventy days. "Man only," says Aristotle, "is born
at seven, eight, nine, or ten months; the last-named period is the most common;
sometimes, however, pregnancy lasts until the commencement of the eleventh
month." According to Pliny, gestation may continue a whole year. Riolan
thought he had seen pregnancies of twelve, thirteen, fourteen, fifteen, and even
of eighteen months. Kiperus, according to Millot, and Chanvalon pretend that
the duration of pregnancy varies according to climate. Heister thinks we may
establish that the term of nine months is the most ordinary one, and that the
time fixed by nature is that which elapses from the seventh to the eleventh month.
Sennertus thinks that every birth should be deemed regular that happens within
one year. Blancard, Hoffmann, Mauriceau, Schenk, and De la Motte have
related cases confirmatory of the opinion of Heister. Levret contents himself
with advancing that the woman most commonly carries the child nine months,
that many exceed that term, but that few go beyond the tenth month.



CHAPTER I.

RETARDED BIRTHS.



In a cause that was pleaded by the celebrated lawyer Oerbier, the duration of
pregnancy suddenly gave rise to some very animated discussions, about the middle
of the last century.

Haller, Bertin, Iieutaud, A. Petit especially, and Lebas, Vioq-d'Azyr, and
Roussel, who were partisans of protracted pregnancy, were vigorously opposed by
Bouvart, Hebenstreit, and Louis. The latter author had no difficulty in demon-
strating, as Courtin has already said, that the numerous histories of protracted
pregnancies mentioned by his antagonists prove nothing in the present case, and
that women scarcely ever know the precise period at which they were fecundated ;
but he was wrong to appeal to the immutability of the laws of nature, and the
necessity of not interfering with social order. On the other hand, Petit, Bertin,
and Lebas too complaisantly admitted as proved what was not even in every
instance probable ; so that, in spite of the numerous analogies with which they
fortified their opinions, and the observations made by the two surgeons, Pennenc
and Dulignac, each one on his own wife, the question remained undecided both
by naturalists and physicians.

At present, the state of the case is changed. The antagonist of Petit relied

chiefly on the circumstance that, according to Aristotle, " the period of gestation

in animals is limited to a fixed space, and the term at which they bring forth is

not subject to any variation." But, as Buffon had before pointed out, this asser-

17



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258 . RETARDED BIRTHS.

tion is wholly false. Wilier saw the hatching of eggs in the same nest vary
from eighteen to twenty days. Millot speaks of a cow which brought forth its
calf five days after the term; and of a cat that kittened nine days before the regular
period. Besides, M. Tessier, member of the Academy of Sciences, a man whose
honor and good faith cannot be called in question, has removed all doubt upon
this subject.

He found that, of one hundred and sixty cows, which commonly carry their
young nine months, as women do, only three brought forth on the two hundred
and seventieth day ; that fifty of them went from the two hundred and seventieth
to the two hundred and eightieth ; sixty-eight from the two hundred and eightieth
to the two hundred and ninetieth; twenty to the three hundredth ; and that five of
them did not calve until the three hundred and eighth day, which is thirty-eight
days beyond the term. On the other hand, fourteen of them calved from the two
hundred and forty-first to the two hundred and sixty-sixth; so that we find sixty-
seven days between the two extremes.

Of one hundred and two mares, whose term is eleven months, three of them
foaled on the three hundred and eleventh day ; five from the three hundred and
tenth to the three hundred and thirtieth; forty-seven from the three hundred and
fortieth to the three hundred and fiftieth ; twenty-five from the three hundred
and fiftieth to the three hundred and sixtieth ; twenty-one from the three hundred
and sixtieth to the three hundred and seventieth ; and one on the three hundred
and ninety-fourth day, which gives a latitude of eighty-three days.

Thus, far from being fixed, the duration of pregnancy, in brutes, is, on the
contrary, extremely variable, and as the habits and constitutions of women render
them incomparably more liable to impressions than any of the inferior species of
animals, it is evident they must be liable to the same irregularities. Besides,
the following proof taken in the human species, and admitting of no reply, is
related by M. Desormeaux. A lady, the mother of three children, was seized
with insanity in consequence of a severe fever, and all the resources of hygiene
and therapeutics had been exhausted upon her case in vain ; a physician thought
that a new pregnancy might perhaps restore her intellectual faculties. The husband
consented to note down in a register the day of each sexual union, which took place
only once every three months, so as not to interfere with any still imperfect con-
ception. Now, this lady, who was watched by her servants, and who was, more-
over, endowed with very rigid principles both of morality and religion, was not
confined until the lapse of nine months and a half.

Being agitated anew in a celebrated cause before the House of Lords, at Lon-
don, in 1825 and 1826, this question was decided in the affirmative; but the
physicians did not agree upon a fixed term which must be always admitted. Out
of twenty-five who were examined, seventeen said that pregnancy terminates
about the thirty-ninth or fortieth week, or betwixt the two hundred and seventieth
and the two hundred and eightieth day; but some of them did not consider the
case of Elizabeth Adderly, the wife of Lord Hyde Gardner, who was brought to
bed on the three hundred and eleventh day, as impossible. Dr. Blundell men-
tioned one pregnancy of two hundred and eighty-seven days. Dr. Merriman said
he had seen several of two hundred and eighty-five, and two hundred and eighty-
seven days ; two or three of two hundred and ninety-six, one of three hundred
and three, and one of three hundred and nine days.

From a mass of four hundred and five observations collected at the Hdtel
Dieu by himself and Madame de Lamarche, Mauriceau noticed that the term of
pregnancy varies from six to eleven months and eight days. Dr. Dewees relates
one where the woman was not delivered until the two hundred and eighty-third
day, &c. To these testimonials I may add a case which fell under my own notice.
A woman in her fourth pregnancy computed that she was four months gone when
she came to my amphitheatre. I distinctly felt both the active and passive mo-



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RETARDED BIRTHS. 259

tioDs of the foetus. Appearances of labor took place at the end of the ninth
month, were soon suspended, did not return for thirty days, and continued imper-
fectly a whole week; so that in fact the delivery did not take place until the three
hundred and tenth day.

We may therefore conclude that tardy births are incontestable. To the eight
observations which I published in 1829, 1 could easily add at the present time
many others. Perhaps A. Leroy is not mistaken in considering them rare in the
first, and as sufficiently frequent in subsequent, deliveries. In the present state
of our knowledge, it is not possible to affix to them any precise limits. Moreover,
since the French code, in order to do away anything arbitrary in the decision on
such cases, has determined that the legitimacy of a birth may be contested when
it occurs after the three hundredth day, or the tenth month, this point of physi-
ology has lost much of its importance ; for at present what is essential for the
physician to know is, whether a child can or cannot remain longer than nine
months in the womb.



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260 WOMAN AT FULL TERM.



'•



PLATE V.

WOMAN AT FULL TERM.

The Fcbtub in the Second Position.

a, a. Body of the foetus.

6. Section of the mons veneris.

c. Section of the pubis.

d. Section of the bladder.

e. Vesicovaginal septum.
/. The vagina.

g. Recto-vaginal septum.
h. The rectum.
t, t. Section of the sacrum.
k. Section of the perineum.
/. Coccy»pubic diameter.
m. Sacro-pubic diameter,
n. The abdominal parietes turned back,
o. The navel,
p, p. The lips of the os uteri slightly swollen.
q. The recto-vaginal excavation.



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'iin/iujnr IdA



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OF PRECOCIOUS, OR EARLY BIRTHS. 261



CHAPTER II.

OF PRECOCIOUS, OR EARLY BIRTHS.

If fruits ripen sooner in certain climates and years than others ; if the appear-
ance of flowers, if vegetation generally may be more advanced : if the hatching of
the chick varies from the eighteenth to the twenty-fifth day ; if some cats, who
carry their young only nine weeks, may bring them forth nine days before their
term ; if, out of one hundred and sixty-two cows, fourteen of them calve from the
two hundred and forty-first to the two hundred and sixty-sixth day; if, out of one
hundred and two mares, six of them foal from the three hundred and eleventh
to the three hundred and twenty-sixth day, while their natural term is three
hundred and thirty days ; if sows, rabbits, &c., exhibit the same variety, where-
fore may not the duration of human pregnancy be also advanced or abridged in
the like manner? I do not see that anything reasonable can be objected against
the possibility of precocious or early births.

Everybody knows that one foetus is sometimes larger and stronger at six
months than another at seven or more ; that a child at term is sometimes not
so stout or tall as another which is only of seven or eight months' gestation ; that
on this point the development of the ovum exhibits varieties that are almost infi-
nite ; that the changes that take place in the organization of the womb, from the
period of fecundation onwards, tend to develop in it a force similar to that which
directs the action of the muscles; that, except in case of accidents, parturition is
not effected until this force attains such a degree that the uterus may contract
with the utmost force of which it is susceptible, which necessarily takes place
sooner or later, according to an infinitude of circumstances; all these things
are known, I say, and shall any one dare to maintain that precocious births are
impossible ?



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BOOK V,



PRACTICAL DIVISION.



PART L

ABNORMAL PARTURITION.

Parturition, or the escape of the product of conception, has received different
names, according as it occurs at or before full term ; and in the first instance it
constitutes true labor ; in the second it is called fausse couche, abortion, or pre-
mature labor.



CHAPTER I.

OF ABORTION.



When the expulsion of the ovum takes place within the first six months of
pregnancy, it is called an abortion, miscarriage, fausse couche, or blessure.

According to Aristotle, " if the foetus comes away before the seventh day after
the conception, the accident is called a show; at a later period, but before the
fortieth day, the woman is said to be wounded" In the former case, it is an
efflux, according to Bonacciolus, effluxiones quse intra diem septimam; in the
latter it is an aborsus — aborsus quseprimis mensis; or an abortus — abortus quae
intra quadragesimam. But these arbitrary and insignificant distinctions have been
neglected for a century past both by physicians and accoucheurs.

SECT. L— MECHANISM OF ABORTION.

ART. I.— FREQUENCY. .

In twenty-one thousand nine hundred and sixty cases of pregnancy, Madame
Lachapelle informs us that she observed one hundred and sixteen abortions.
According to that author, miscarriages are more frequent at six months, then at
five, then at three, than at any other period of gestation. M. Desormeaux, in
accordance with almost all the ancient authors, with reason, and with my own
observation, thinks, on the contrary, that it is the more common as pregnancy is



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MECHANISM OF ABORTION. 263

lees advanced. If Madame Lachapelle mentions a different result, it is evidently
because abortion in the early periods does not occasion so much inconvenience to
women as to cause them to go to the hospital — which is not the case after the
first half of pregnancy has been passed through ; or, perhaps, because in the first
six weeks the ovum and the embryo, frequently confounded with clots of blood,
induce the woman to suppose that she has only had a return of the menses,
while at a later period she cannot make such a mistake. It is this, without
doubt, which permitted Marcetus to say that abortion is more frequent than deli-
very at term. The statistics at Westminster give 147 in 515, and M. Deubel
has given 35 in 420.

Morgagni was of opinion that he had noticed more abortions of female than of
male foetuses ; M. Desormeaux is of the same way of thinking, and says that, if
the vulgar think differently, it is owing to the circumstance that in the early
stages it is very easy, at a first glance, to mistake a girl for a boy. This remark,
which had been previously made by Morgagni, is very just, provided it be ap-
plied only to the first two or three months. Madame Lachapelle has seen more
female than male embryos, and more male than female foetuses. Upon the
whole, abortions of females seem to exceed those of males in proportion to the
approximation to the period of conception.

ART. II.— CAUSES.

It appears that the causes of abortion have been till lately but ill understood,
and the labors of M. Desormeaux, of Madame Lachapelle, of M. Duges, and
Madame Boivin could not have come more opportunely to throw some light upon
this matter. They may be divided into remote and proximate causes ; or into
efficient and determining causes. The proximate or efficient causes are con-
stituted by the contractions of the womb, assisted by the muscular efforts of the
woman ; the determining causes may be divided into predisposing and occasional.

§ 1. PREDISPOSING CAUSES.

The predisposing causes may be connected with the state of the woman or of
the ovum. Relatively to the woman, some of them depend on certain general
dispositions of the economy, and others on a special state of the sexual organs
only.

A. Diseases of women. General state. — Women who are plethoric, who men- '
struate abundantly and regularly, who are irritable, excessively sensitive, nervous,
hysterical, lymphatic, of a fair complexion, weakly, sickly, who have large eyes
and a bluish sclerotica; persons affected with syphilis, scurvy, rickets; those who
have a badly-formed pelvis, some organic lesion, or any chronic disease ; those
who are asthmatic, dropsical, affected with cancer; those who are badly nourished,
and those who compress their bellies by lacing, or wear their clothes too tight,
miscarry more frequently than others : and the reason of it may be easily con-
ceived. We may say with Juncker, and M. Stoltz reports a good example, that
it is the same with fat women when they are not sterile. Marshy and unhealthy
countries; certain atmospheric constitutions, formerly mentioned by Hippo -
crates, and frequently observed since his day, render abortions really epidemic
at some seasons, as we see at Vienna in 1778 and 1779. Many authors say
that they have observed epidemics of abortions. Such happened after the moist
hot weather of 1696 ; after the dry summers of 1710 and 1711 ; after the mild and
windy weather of 1776; after the very great heat of 1811; after the mild winter
of 1816; after the rainy seasons of 1821, &c. Watching and fatiguing labor
have also been classed among the predisposing causes of abortion. The age of



Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 39 of 102)