Charles Delucena Meigs Alfred Velpeau.

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

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and recover its ordinary volume within the excavation, if we may give credit to
the assertions of Boer; and, in all cases, admit of the child's being born alive.
A woman whose pelvis measured but two inches and a half in its sacro-pubic
diameter, was delivered without assistance at the amphitheatre of Solayres. M.
Noury mentions another, who was about to submit to the Caesarian operation, and
who delivered herself unaided, of a child weighing six pounds and a half, whose
coocy-pubio diameter measured but eighteen lines. M. Faurichon states that, in
1831, at the MatemxU at Paris, he saw the head of a child escape, while they
were attempting to apply the forceps, and that, after the death of the mother,
the sacro-pubic diameter was found to measure but two inches and nine lines.
The child was dead, and its head was reduced to two inches and nine lines in its
bi-parietal diameter. Lastly, how many women are there who have been fortu-



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528 OF OBSTETRIC OPERATIONS.

nate enough to bring their children into the world without any aid, when in their
previous confinements they could be delivered only by symphyseotomy, the Cassa-
rian operation, or embryotomy? Here, then, the operator stands in need of all
the integrity of a sound judgment, of prudent and sage counsels, of attention to
a thousand diversified circumstances, and of proceeding only with extreme caution,
if he desires not to compromise the dignity of his art, or the safety of those beings
who look to him for the conservation of their existence.

Instead of accommodating itself to the form of the openings, the head may be
fractured, or the brain mortally compressed. Long-continued pressure upon the
foetus, and particularly upon the umbilical cord, which most commonly gets down
into the excavation, rarely permits it to escape with its life ; the woman herself
soon becomes exhausted; the bladder and other soft parts, against which the head
presses with great violence, may inflame, be lacerated, or perforated. The womb,
violently irritated by its repeated contractions, may be ruptured, and death ensue.
The softening and separation of the symphyses often leave behind them a mov-
able state of the articulations, and a degree of lameness which are at least very
troublesome, and, where the distension is carried to a great extent, are often fol-
lowed by caries and abscesses, which sooner or later terminate in the death of
the patient There are, therefore, two evils, which it imports us to avoid with
equal care; there is a just medium which we should endeavor to secure.

Let us suppose that the application of the forceps and turning have been
attempted in vain, or that the pelvis is so deformed that no greater confidence
is to be placed in those means than in the efforts of the woman, one question
presents itself; on whom shall we operate — the child or the mother? Where
there is a certainty that the pelvis is so contracted as to render the delivery of a
mature and full-grown child either dangerous or impossible, have we a right to
bring on abortion, either at an early stage of pregnancy, or only between the
seventh and eighth months. Would it not be possible, by means of regimen, or .
of a debilitating treatment, to oppose, to a certain extent, the development of the
foetus, so that at full term it stall be of very small size ?

ART. I.— OF REGIMEN, AS A MEANS OF ENABLING WOMEN WITH CON-
TRACTED PELVES TO BE DELIVERED WITHOUT THE ASSISTANCE OF ANlf
SURGICAL OPERATION.

Were it true that the strength of the foetus, while enclosed in its involucre, is
always in proportion to that of the mother, nothing would be more natural, nor
better indicated, than to weaken a deformed woman during the progress of her
pregnancy. But, as the most robust women do not always bear vigorous children ;
as those who are naturally feeble and sickly often give birth to very stoat and
large ones, it is to be feared that the severest diet and most abundant sanguine
evacuations would only serve in such a case to incapacitate the woman from
supporting the operations that would, notwithstanding, be requisite when she
should fall into labor. I know one person who, having been delivered twice by
means of art, was bled ten times, and confined to a vegetable diet during her
third pregnancy, with a view of retarding the growth of the child. This lady was,
it is true, exceedingly weakened by it, but the foetus did not appear to have been
affected, and in parturition she required the same succors as before. Another
woman who had two very fatiguing pregnancies, and could not be delivered until
after three days of painful labor, and then by means of the forceps, also became
pregnant for the third time, found herself less incommoded than usual, and was,
nevertheless, delivered without assistance, and without difficulty, of a child sen-
sibly smaller than the preceding ones. I am well aware that practitioners worthy
of credit, as Assalini, Merriman, and Moreau, assert that they have obtained
directly contrary results; and I can well conceive, as a general rule, that, by ex-
hausting the woman, the growth of her offspring will be retarded; but there



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NARROWNESS OF THE PELVIS. 529

are so many exceptions to this rule, and what we gain on the one hand is so dis-
advantageous^ compensated by the loss of resources of which we deprive ourselves
on the other, that I would scarcely venture to recommend such a course, first
proposed by James Lucas, except to persons affected with a very slight degree
of contraction, and in whom delivery might, in fact, take place spontaneously,
should the head of the foetus not be very large.

ART. n.— ARTIFICIAL PREMATURE LABOR.

It was about the middle of the last century that the most distinguished phy-
sicians of London decided that, in women affected with deformity of the pelvis,
it is proper to solicit delivery as soon as the viability of the child is well esta-
blished. According to the statement of Kelly, Macauky was the first person who
had recourse to this operation, which resulted favorably in his hands. Sue
pretends that the idea originated with A. Petit about the same time. M.
Dezeimeris seems to ascribe it to Puzos. It has been also referred to Deventer,
who says that it is sometimes necessary to bring on labor between the seventh
and ninth month to save the life of the mother; but it is easy to understand that
Deventer and Puzos entertained different views from Kelly, who proposed his
operation in 1755. It was revived twenty years afterwards, according to Burns,
by Roussel de Vauzesme. Since then, Dr. Barlow has published a memoir in
which he attempts to prove that artificial abortion ought to be substituted for the
Sigaultian and Caesarian operations in all cases. May, the father-in-law of M.
Naegele, has boldly maintained the opinion of Kelly in Germany, since the year
1799. Ramsbotham says he brought on abortion three times with success in a
woman in whom the perforation of the foetal head had been deemed necessary in
a preceding pregnancy. Drs. Davis, Clough, Wigand, and, very recently, Bang
and Dr. Blundell, have supported the doctrine advanced by Barlow. M. Costa
has even inquired whether it is proper to resort to it in the cases of women
affected with aneurism of the heart. •

In France, this question has been considered under a point of view which has
not admitted of a discussion of its value. It was at first confounded both by
myself and others with that of abortion, although there is a great difference be-
tween them. In induced abortion, it is proposed to destroy the ovum for the
preservation of the mother. In premature labor, on the contrary, we endeavor
to deliver the child alive, without compromising the life of the woman, when
they both run the risk of perishing if the pregnancy progresses to full term.

§ 1. THE INDUCTION OP ABORTION.

Abortion, which was frequently practiced formerly in the Greek republics,
with which Aspasius is said to have been very familiar, and which Aetius and Paul
of Egineta advise, should be considered out of the question and inapplicable,
unless in cases of extreme contraction of the pelvis, when, for example, there is
less than two inches in the sacro-pubic diameter. Its dangers are, however, less
than they are said to be. At two, three, four, or five months, we may reach the
ovum without difficulty with a bougie, or even with the finger. The womb will
afterwards free itself of its contents, as it does of clots of blood, of false mem-
branes, &c., and as it does in all cases of abortion. It is the abuse and criminal
extension of such a practice which should be feared and deprecated, and not its
restricted and reasonable use.

It has been said that no one has a right to destroy a living foetus even in the
first months of its existence. But delivery provoked previously to the seventh
month kills it inevitably, and if it must be destroyed, why not wait until full term ?
The slight chance of a successful termination should not be destroyed. Doubt-
less this is generally true, but in the cases which I suppose there is no euoh
34



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530 OF OBSTETRIC OPERATIONS.

chance, and most women delivered at term, under such circumstances, perish.
The question is, whether true humanity requires us to give the child a chance,
at the expense of the Caesarian section or symphyseotomy.

For my own part, I confess I cannot possibly balance the life of a foetus of
three, four, Ave, or six months, a being which so for scarcely differs from a plant,
and is bound by no tie to the external world, against that of an adult woman
whom a thousand social ties engage us to save ; so that, in a case of extreme con-
traction, if it were mathematically demonstrated that delivery at full term would
be impossible, I would not hesitate to recommend abortion in the first months of
gestation.

§ 2. THE ARTIFICIAL INDUCTION OF PREMATURE LABOR.

But the case is different whenever there is a space of two inches and a half,
at least, between the sacrum and the pubis. As in that case the ovum has been
seen to come away without assistance, and the foetus born alive, the honor of the
art and humanity combine to forbid the employment of any destructive instru-
ment, or any attempt that must end in the death of the child.

Happily the method in question, that is, premature delivery, is really the best
means of bringing the child away alive, without exposing it to injury. Indeed,
it is not proposed to pass the hand rudely into the womb and to extract the child
forcibly before term, by practicing forced delivery, but rather to induce the uterus
to contract and to expel the product of conception, before the head of the child
has acquired so large a volume as to prevent it from passing through the straits
of the pelvis.

A. Appreciation.— The induction of labor at the seventh month would be par-
ticularly applicable where the pelvis is two inches and a half at the least, and two
inches and three-quarters at the utmost, because it is clear, from measurements
taken by Madame Lachapelle, that at seven months the bi-parietal diameter is at
most not over three inches, and may be much less in extent, which gives the same
chances as if the delivery were to take place at term, and through a strait of three
inches and some lines. But how are we to learn accurately whether the foetus
is viable? If, for greater security, we should defer the operation till two weeks
later, what assurance could we have that the head is not already too large to pass
through the straits? And if it can clear them at eight months, is it not probable
that it will succeed equally well at the end of the ninth ?

A patient, whom M. Kelsch wished to submit to premature labor, delivered
herself alone without any assistance, and without difficulty. In M. Vroiick's
case the sacro-pubic diameter was three inches and three lines ; it was the first
pregnancy, and the child was born dead. One of the last cases, published in
the name of M. Lovati, allows us to believe that the operation was not indispens-
able. I will add, with Madame Boivin, that it suffices to examine the work of
M. Ferrario, to be convinced that premature delivery is often induced without
necessity in Germany, Holland, and Italy. But we should not, on that ac-
count, reject its use. The dangers which have been considered its reproach, and
whioh I myself attributed to it in part in the first edition of this work, have been
singularly exaggerated in France, from the time of Baudelocque — who said that in
hemorrhage artificial delivery is a duty, but that it is a crime in cases of con-
traction of the pelvis — up to the time of M. Capuron, who characterises the ope-
ration as an outrage against aU law, both human and divine.

1. On the part of the mother, at the present day, experience has proved that
the dangers of the operation are reduced to a small matter. Hemorrhages,
convulsions, peritonitis, scirrhus, and all possible alterations of the neck of the
uterus do not occur more frequently after a provoked delivery than after an
accouchement at term. The two women operated on by Kelly met with no
accident. Duncan was not less fortunate in the eight cases which he reported.



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NARROWNESS OP THE PELVIS. 531

It was the same thing with the woman who was operated on three times by
Macaulay, and also with the case published by James, and with another mentioned
by M. Rieeke. Of the sixty-seven women mentioned by M. Salomon; of the
twelve of M. Kluge ; of the seven of M. Ferrario, not one perished. One only
of the fourteen, mentioned by M. Reisinger in 1820, died. We may count
two unfortunate cases among thirty-four collected since; but Merriman lost
none in forty-six; from which we may conclude that the mother does not incur
much more risk in a provoked delivery than in a spontaneous accouchement at
term. Besides, these women died, one of hydrothorax, another of rupture of the
uterus, and all of accidents altogether unconnected with premature delivery.
The woman whose pelvis M. Stoltz showed me died during an attack of phthisis
pulmonalis, six months after delivery. I can bear witness that the pelvis pre-
sented the conditions which require premature delivery, and that the history of
the patient, given by M. Stoltz, proves that delivery would have been otherwise
impossible in two preceding labors.

2. On the part of the child. — Provoked delivery is unfortunately not so encou-
raging for the foetus. In the practice of Merriman, of forty-seven children, twenty-
six were born dead, five were living though not viable, and sixteen only lived.
Of twenty-seven cases, however, Hamilton saved twenty-three; Ferrario ^Ye out
of six; M. Kluge nine out of twelve; M. Salomon saved thirty-four of sixty-
seven; M. Burckhard thirty-five out of fifty-two; and Marshall only one in
four, which is on the whole about one-half. But, as it has been nearly demon-
strated that not one in ten survives at term, and that the operations by the aid
of which delivery is effected expose the mothers to great dangers, so that a great
number perish, this objection to premature artificial labor should not prevent it
from affording a precious resource, which it would be inhuman to reject.

The dangers to the foetus are, moreover, so much the less, all other things
being equal, as it is advanced in age at the time of the operation. It is the
want of viability, the extreme contraction of the pelvis, or the manipulations
which we are forced to employ, which occasion the death of the child in such
cases. Now, whenever we are obliged to provoke its expulsion, at the end of
the eighth month, it is because the pelvis is so much deformed that we can hope
for nothing better from any other method. If the danger arises from the
resource adopted, it will increase with the period. The question is, besides, of
so easy solution in the twofold point of view, as it regards both mother and
child, that it should be looked upon in France, as it has been in other countries
of Europe, in its true aspect. In order not to hesitate on this point, it is only
necessary to compare the results of symphyseotomy, the Caesarian section, and
omphalotomy with those of premature delivery. We hope that this doctrine —
elucidated as it has been by all that has been published in the journals; in the
bulletin of FeYussac; in the essays of Barlow, which embrace fifteen examples;
in those of Merriman, the uncle, who cites ten cases ; in those of Merriman,
the younger, and of Kluge, who give at least fifteen ; in those of M. Ritgen,
who says that he observed nineteen cases at the clinic of Giessen from 1818
to 1822 — which has been defended at Strasburg by Fode>e* and Stoltz, and which
is well explained in the dissertations of Burckhard, and Dezeimeris, and in the
memoir presented to the Royal Academy of Medicine by M. Stoltz — will be soon
universally adopted among us, as it has been in England, Germany, and Italy for
many years.

B. Indications. — In fine, we may bring on premature labor when the dia-
meters of the pelvis are less than three inches and two or three lines, and more
than two inches and a half. It offers still some chance of success at two inches
and a half, and even at two. In certain cases, it may be resorted to, although
the straits measure nearly three inches and a half. It is true that, at term,
the bi -parietal diameter rarely measures three inches and a half, and that one ci



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582 OF OB8TBTRIC OPERATIONS.

the parietal protuberances descends almost always before the other, and that the
whole head is easily reduced two or three lines during labor; it is also true thai
the soft parts, the vitiated inclination and projections of the pelvis, take away
at least some lines from the dimensions of the straits, and that, without present-
ing an insurmountable obstacle to the escape of the child, a slight pelvic coarcta-
tion often renders parturition extremely difficult. On the other hand, as the head
is an inch smaller at seven than at nine months, and as it is susceptible of a
much greater reduction, we may conceive that a viable foetus may in reality pass
through a strait measuring two, or two and a quarter inches. The difficulty
here is to determine exactly the extent of the pelvic diameters, and to establish
with precision the age or development of the foetus; but this difficulty will be
only met with in the extremes of the limits indicated, and when a first labor
has already shown how much the organism is capable of. After all, what evil
results when we are mistaken in a few lines? If the pelvis proves to be
more capacious than we expected, the premature delivery will take place without
any difficulty, and the child will run scarcely any risk. If the contraction is
on the contrary greater, the foetus will doubtless only perish, and the woman will
be saved, while at term the lives of both are jeopardized. Thus, far from pro-
scribing it in first pregnancies, as many authors have done, it should be always
put in practice when the pelvis measures from two and a half to three inches.
Above or below that, we should wait for a first labor to clear up the diagnosis.
With other than first labors, the embarrassment will be infinitely less. None
have taken place unassisted. The forceps, version, or omphalotomy, has each
time been indispensable, and the child has never been born alive. In this
case, premature delivery is evidently the means which offers itself with the
greatest prospect of success.

It is not, however, necessary that all the children born of the same woman
should be still-born, to authorize such a practice, as Denman thinks; for, among
the causes which may induce the death of the foetus, there are some which may
disappear during several successive pregnancies ; but I will undertake to say
that this accident is the surest indication for its performance, when it actually
depends on contraction of the pelvis.

Nature sometimes does that which art endeavors to generalize, and it is that
which gives us our first lesson on this point. If certain women, who are so
unfortunate as to be delivered only of dead children, in consequence of a narrow
pelvis, after a time are brought to bed with a living child without any assistance,
it will be usually found that, this time, the infant comes before term, or that
it is less developed than usual. Premature artificial labor is then only an imita-
tion of nature. Guided by this remark, I tried it for the first time in France,
in 1831, with complete success.

Madame Tarlet, whom Desormeaux, M. Deneux, and myself were unable to
deliver except by cephalotomy, in 1825, whom I have delivered twice since of dead
children with die forceps or by version, and with whom another practitioner,
M. Patrix, was not more successful in a fourth labor, experiencing some difficulty
at the commencement of the eighth month of her fifth pregnancy, was induced
to call me in. The circumstance seemed to me a fortunate one. I proceeded to
separate and then to rupture the membranes. Labor, which was uncertain during
the day, did not fairly come on until the third day. It was a pelvic presenta-
tion, the feet descended, and the head was brought down only by strong traction;
but I delivered her of a living child.

Smellie reports a very nearly similar case. The sacro-pubic diameter measured
only two inches and a half. The sixth child was delivered without assistance,
because it was of eight months, and small.

MM. Eiecke and Fodere* each mention a still more conclusive ease, in
which the women, who had always before been delivered with instruments,



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NARROWNESS OF THE PELVIS. 588

delivered themselves without assistance by premature labor, and could not, in
subsequent pregnancies, go to full term.

Premature labor, which Mai wishes to apply in case of the death of the foetus,
has not then the same advantage as under the foregoing circumstances, for on
the one hand a dead child does not remain long in the uterus, unless as an ex-
ception, and on the other no operation should be practiced on the mother when
it is slow in coming away. However, as the presence of a dead child in the
womb exposes the mother to many dangers, and as a woman seen by me with
Moreau died from it, I believe that it would be more prudent to provoke its
expulsion, than to wait an indefinite time, as M. Froriep wishes.

We may also inquire whether the physician should not induce premature
labor in women affected with chronic diseases, which pregnancy renders more
and more dangerous, or which may terminate fatally before natural labor comes on.

Besides in cases of contracted pelvis, MM. Mai, Ritgen, and Carus recom-
mend premature labor in prolonged pregnancies, when the children die habitu-
ally some time before term; in diseases brought on by pregnancy, which threaten
the life of the mother, as metrorrhagia, retroversion (Lyne, Hunter); and in cases
of ascites (Siebold). M. Costa did not think of it, except in diseases of the heart,
when he consulted the Academy on this point. Siebold succeeded in this way
in prolonging the life of an unfortunate woman afflicted with hydrothorax ; and
Ingleby believes, with Conquest, that it should be resorted to in cases of obstinate
vomiting, and in extreme feebleness towards the close of pregnancy.

This is a delicate question, and should not be treated lightly. I will only say
that it should be accomplished in all diseases which may hasten a fatal termina-
tion towards the close of gestation, as well as in hemorrhages and other accidents
which occur before, or during labor. If it is admitted that we may aid the
woman in the second case, I do not see why she should be left without assistance
in the first. After premature labor, the child may live; but, if the mother dies
before term, the foetus almost always perishes at the same time.

A very advanced disease of the heart, hydrothorax, or ascites with grave
organic lesion, an extensive gangrene without a line of demarkation, &c., may
then justify provoked labor after seven and a half or eight months. M. Dnclos
tried it for a simple dropsy of the amnion; and how often is it put in practice in
placenta previa?

We should not run the risk of the delivery : 1st. When there exists some
deformity, some alteration of the soft parts capable of presenting an obstacle
to the escape of the foetus, that is to say, when the contraction of the pelvis is
not the only cause of the difficulty. 2d. K it can be perceived that the contracted
strait is sensibly larger on one side than the other, and that if in the first delivery



Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 83 of 102)