135
Gültekin-Zootfctnann, History of monitoring the human fetus
Review article*
J. Perinat. Med.
3 (1975) 135
The history of monitoring the human fetus
Brigitte Gültekin-Zootzmann
l
Origins of monitoring the unborn child
1.1 Signs of fetal life or death
In old books of midwifery or obstetric textbooks
one finds regularly the "signs of life or death"
of an unborn child ennumerated. Only if one
were certain of a child's death during a difficult
birth, one could terminate it by Perforation and
thus, decrease the maternal risk. Lists of these
signs for a dead fetus included: inability to feel
fetal movement, the fetus falls like a rock to the
other side when the mother turns over, the
mother feels an unusual heaviness in the abdomen, the head of the infant becomes soft and
the skin separates [6, 36], the women have a
"stinking breath" and yawn frequently [42].
Another possibility to obtain Information about
fetal life was to palpate for pulsations, but
even this sign was not intended to recognize a
fetal risk. In most cases a prolapsed umbüical
recommended to feel for pulsation on the
Curriculum vitae
BRIGITTE ZOOTZMANN was
born in Berlin in 1940. After
completing higbshool in 1959,
she studied sociology in Berlin
for 2 semesters before beginning her medical courses. In
1966 sbe passed the stateboard-examinations, followed
by certification and conferral
of the degree in medicine by
the Free University of Berlin.
After a short internship in the
pediafric ward of a South
German hospital, she speciali^ed in the field of medical microbiology at the Robert-KochInstitut of the Federal Board of Health in Berlinfrom 1969to 1971.
In 1971 she received training äs a medical officer of health at the
Academy of Public Health in Düsseldorf. She has been active in
public health service in Hamburg since 1972.
presenting parts. BÖSSEL [6] in his textbook for
midwives of 1793 listed äs a sign of fetal death if
one could not feel a pulse on the presenting parts:
*Editorial opening comment
In the present era of electronic and biochemical fetal monitoring it is of interest to consider its
history. The following study was suggested by us six years ago and is part of an extensive doctoral
thesis. Two facts were surprising: first, that the history of fetal monitoring äs compared with
other medical accomplishments of past centuries is still very young, secondly, that several basic
important insights which have now been proven by continuous fetal monitoring equipment had been
gained by some clinicians and scientists in the past Century. Thus, it was recognized äs early äs 1858
that decelerations of the fetal heart frequency which extend into the interval between contractions
may indicate a serious risk.
It is easy to tegard the insights and measures of earlier generations superciliously; this is a psychological
error and often a grave mistake. The following paper looks at a past Situation from a modern point of
view and intends not only to give us a sense of respect for our collegues of the past Century, but it is
also meant to show us how much easier it is for us today to offer more safety to the human fetus.
Erich Saling
J. Perinat. Mcd. 3 (1975)
10»
136
head, foot, or umbilical cord. This sign was also
mentioned by VOGEL, GEHLER and LÜTZELBERGER in their midwifery books [43, 12, 24].
Frequently attempts were made to palpate the
pulse over the fontanelle [40, 3]. Other obstetricians went further and advised to search £or
pulsations on parts situated higher. BERNSTEIN [3]
may serve äs an example when he mentioned the
beating of the heart, äs long äs one could reach
the area with the finger, or MARTENS [25] who
lists äs a sign of death the absence of cardiac
pulsation, the radial or popliteal pulses. SCHÜTZEN
[35] gave detailed advice on means of informing
oneself about the Status of the fetus which has
not yet entered the pelvis by introducing one
hand into the Uterus. He recommended, among
other measures, to introduce a finger into the
mouth and to determine whether the fetus would
suck or to determine whether there were movements of fingers or toes äs a response to a pinch.
1.2 Passage of meconium
Midwives had recognized early the passage of
meconium äs a sign indicating the endangered unborn child. A reference about this is
found in the first midwifery book published in
Würtemberg by Christoph VÖLLTERN [42] in
1679. He said the midwives since ancient times
had found that with a rupture of the umbilical
cord the fetus secreted in his agony a sticky mass
and that this was a certain sign of death. In the
following period vertex and breach positions
were differentiated and meconium passage was
considered an unfavorable sign only if it was
associated with vertex presentations. But, repeatedly, Statements were qualified in that this
was not a certain sign of death, but only an
indication that the fetus was "deadly ill"
(SHÜTZEN [35]). GEHLER [12] examined the
passage of meconium in 1798 more accurately in
two papers. He argued that since the healthy
fetus did not pass meconium, one could conclude
from its passage that the fetus did not "feel quite
well". However, one should consider shape,
consistency, odor and amount of meconium and
one should regard homogeneously discolored
amniotic fluid äs a poor sign. The prognostic
evaluation of meconium passage has changed
Giiltekin-Zootzmann, History of monitoring the human fetus
little in the course of time. Thus, SCHWARTZ [36]
concurred in 1858 in his r book on "Premature
Respiratory Movement", pointing out that meconium may be passed hours bef ore a deterioration
of the fetal heart tones and emphasized its importance in monitoring the fetus. Likewise
HEYNE [14] judged that the early passage of
meconium in his thesis of 1896 was a dangerous
sign that should cause the fetal heart äctivity to be
monitored carefully.
Theories about the mechanism of meconium
passage have changed over the years. VÖLLTERN [42] in 1679 saw the cause simply in the
agonal fear of the child. DE LA MOTTE [26] considered in 1732 the atonia of the "fibers of the
intestine" by disease or weakness of the fetus.
ERB [11] in 1766 was of the opinion that meconium came from the neck of the "expired fetus"
äs might be seen in adult cadavers. WEISSENBORN [46] thought in 1780 that meconium could
be passed in a live fetus if it were seized by a
"colic". GEHLER [12] reasoned in 1798 that the
weakened health of the fetus might either lead
to the weaking of the rectal sphincter or to a
nerve Stimulation, causing "convulsive" movements of the intestine. He also considered "compression of the brain" äs a cause. With SCHWARTZ
[36] we find then the concept of the "asphyxiant
intoxication" of the fetus.
2 Fetal heart äctivity
2.1 KERGARADEC'S predecessors
On December 26, 1821 KERGARADEC read to
the Academie royale de medecine in Paris his
paper "Memoire sur TAuscultation appliquee a
TEtude de la Grossesse". On the basis of this
lecture and the publication with the same title
KERGARADEC is generally thought of äs originator of obstetricauscultation.Howeve^diligent
search in the literature yields the name of several
individuals that can be cited in connection with
obstetric auscultation and who may be considered
äs predecessors of KERGARADEC. Their common
characteristic is that they did not attribute any
importance to their discovery, or if they did,
not pursue the matter further and did not
think of any practical applications. These are
J. Perinat. Med. 3 (1975)
Gültekin-Zootzmann, History of monitoring t he human fetus
the 17th Century French physicians LE GOUST,
LUSSAUD, and MARSAC äs well äs the Göttingen
anatomist, WRISBERG and the Geneva surgeon,
MAYOR. The French physicians mentioned were
engaged in a dispute in 1750 in the function of the
fetal heart. LE GOUST, who did not consider it
possible that fetal circulation was different from
that of the adult, described in an öde "Humani
Foetus Historia" [29] the state of the fetus in
utero. He criticized his collegue MARSAC, who
was said to have likened the fetal heart tone the
clapping of a mill. However, there are no more
detailed descriptions on the perception of the
fetal heart tones. Similarly WRISBERG'S remarks
have been considered äs the beginning of auscultation. In a note on ROEDERER'S Elementa
Artis Obstetriciae [32] he depicted the possibility
to evaluate the finer resistances of the fetus and
its movements better by placing his temple and
cheek on the nude abdomen. He did not mention listening. Francois Isaac MAYOR went a step
further. In the Bibliotheque Universelle of 1818
[5] the editor remarks on an apparently verbal
Statement of MAYOR in a comment on a lecture by
LAENNEC the originator of the auscultation of
thoracic organs. The comment notes MAYOR'S
claim that one could state with certainty whether
a fetus is alive or dead by placing the ear on the
maternal abdomen. If the child were alive, one
would be able to hear his heart tones which
could be difierentiated from the maternal pulse.
No further investigations of MAYOR nor a
publication are known.
2.2
KERGARADEC
In spite of these early steps, one can speak of
obstetric auscultation in the sense of fetal
monitoring only since the work of KERGARADEC and the publication of his paper in
1822 [20]. The French physician Jean Alexandre
Le Jumeau Vicomte de KERGARADEC lived from
1788—1877. He was active intermittently in
Paris, but later he lived predominantly at his
estate in the Bretagne. He was an obstetrician
neither before nor after his discovery. Nor did he
publish any other work on obstetrical topics.
KERGARADEC describes how he came to hear the
fetal heart tones. Being convinced of the useJ. Pcrinat. Mcd. 3 (1975)
137
fulness of the stethoscope in diagnosing the
diseases of the thoracic organs, he attempted to
extend its application to other areas. He intended
to hear the noise produced in the amniotic fluid
by the fetal movements in Mrs. L., a young
pregnant woman, when he suddenly heard a
noise reminiscent to the ticking of a clock. With
repeated attempts, he was able to hear the noise
again. He recognized that he was listening to the
double pulse of the fetal heart and counted
frequencies between 143—148 per minute. KERGARADEC repeated his observations in the subsequent days and extended them to other pregnant women. In his publication, he reports on
his observations and adds a section on practical
implications. He lists points which speak in
favor of the practical application of obstetric
auscultation. Some are listed here:
1. It is a certain sign of existing pregnancy,
2. The importance of judging the state of health
or disease of the fetus by changes in strength
and frequency of the heart tones,
3. Diagnosis of multiple pregnancy,
4. Determination of fetal position,
5. The diagnosis of extra-uterine pregnancy.
He considered it important to continue the investigation in order to consider under which
circumstances heart tones are changed.
2.3 First attempts at obstetric auscultation
after KERGARADEC
KERGARAPEC'S suggestions were quickly subjected to a systematic investigation in France and
Germany. A translation was published in FRORIEP'S Notizen [21] and in July 1821 the entire
monograph appeared in German. Among numerous obstetricians confirming KERGARADEC
there were two who raised objections äs early äs
1822: v. SIEBOLD and Du GES. DUGES [10] whose
own attempts at auscultation were negative,
came to the conclusion that it was for theoretical
reasons impossible to perceive fetal heart tones.
The fetal heart were not surrounded by
air, but by solid viscera. Therefore, if it was
indeed possible to hear heart tones, one should
hear sounds from other vessels. But then it was
difficult to imagine that one would be able to
138
differentiate the fetal heart tones. The German
obstetrician, v. SIEBOLD [1], also did not attribute
great importance to obstetric auscultation. He is
said to have given the opinion that the tactile
sense could accomplish more than the fallible
auscultation. Adam ULSAMER [41] published in
1823 in Germany his work on the auscultation in
the pregnant woman. In the presence of his
teacher D'OUTREPONT he had made the first
attempt at obstetric auscultation in Würzburg. He
describes how at first D'OUTREPONT and subsequently all present and he himself, could not
hear fetal heart tones either with or without the
stethoscope. What was audible was indistinct
and appeared to be the pulsations of one's own
arteries. After five unsuccessful examinations they
discontinued the attempts. Only ULSAMER resumed the examinations and he then succeeded
in hearing the double pulse between the umbilicus
and the anterior iliac spine. He remarked that the
pulsations were so characteristic that one could
not confuse them with any other sound. After
further observations he comments in his publication on the importance of this new method of
examination. In the same department, C. J.
HAUS [13] extended the investigation and published his results also in 1823. He had listened to
women during pregnancy and during the entire
labor. He describes how there was an arrested
labor in one case and Perforation was considered.
Solely the fact that he still heard fetal heart tones
occasioned D'OUTREPONT to terminate the delivery by forceps. A live infants was born. As in
Würzburg, obstetric auscultation was now
given a try in other clinics. The subsequent two
decades had numerous publications which mostiy
confirmed KERGARADEC, but did not contribute
much new to the method. Noteworthy are two
lengthy publications by Anton Friedrich HOHL
[17] 1833 and v. DEPAUL [9] 1847.
Gültekin-Zootzmann, History o£ monitoring the human fetus
ULSAMER [41] had gotten to the point where
he did not need uncoyfer the patient's abdornen. Between ear and adbomen remained a
cloth o£ linen. He also did not have his patients
in the recumbent position, but had them standing and sät, himself, on a low stool next to
the patient. This he considered the "most decent manner" to perform auscultation. HAUS
also thought it the best method to examine the
Standing patient with a covered abdomen. HOHL
[17] thought that the patient could either stand
or lie down, but he preferred the latter. He
agreed that it was an advantage that the uncovering of the body was not necessary. He was
often successful in listening through the bedcovers. Opiriions were divided äs to the use of
the stethoscope in auscultation. Again, ULSAMER and HAUS are cited. ULSAMER preferred the
auscultation with the naked ear and used the
stethoscope only after locating the fetal heart
tones. HAUS, too, advised to begin with the
direct auscultation before using the indirect
method, because it was far simpler. The majority
of obstetricians later on preferred the indirect
auscultation with a stethoscope. Among these
was HOHL who thought it was too confortable
to position the ear next to the abdominal wall
because one would easily develop "congestion
in the head" which interfered with hearing.
GELE [27] was of the opinion that the stethoscope defined the area better and that one
could exert a certain pressure on the abdomen.
The obstetrician v. HOEFFT [15] preferred the
stethoscope because he thought direct auscultation was "very difficult, uncertain, and even
indecent". While the first attetjipts utilized the
LAENNEC stethoscope, several obstetricians
construed their own models later on. HOHL
[17], v. HOEFFT [15] and DEPAUL [9] describe in
detail their own Instruments in material, shape,
and application.
2.4 Differences in technique of auscultation
In discussions of the technique of obstetric
auscultation four points were dealt with repeatedly: Should the patient stand or lie down?
Should the adbomen be covered? Is direct or
indirect auscultation preferable? Which stethoscopes are to be recommended?
25
'
New points of view and physical methods
U
ClfCa
New points of view about monitoring the unborn
child by its heart tones emerged in papers published after 1850. There were investigations
about topics such äs the change of the heart
' J. Perinat. Med. 3 (1975)
Gültekin-Zootzmann, History of monitoring the human fetus
tone by contractions, fetal movements or
maternal heart täte and temperature. The
conviction that fetal jeopardy was heralded
primarily by change of the cardiac action was
expressed by the following authors.
SCHWARTZ [36] recommended in bis book on the
symptomatology and diagnosis of fetal asphyxia,
published in 1838, to count the heart rate äs
often äs possible from the beginning until the
termination of the delivery during and
between contractions. Thus, the important
"individual normal frequency" could be determined. This was easiest obtained at the beginning
of the birth process. Then it would be possible to
judge the modifications of fetal heart tones
occurring during birth. Among these were: increase and decrease in frequency, irregulär and
skip rhythms, attenuation and disappearance of
both heart sounds and disappearance of the
second sound. The cause of these changes was
the movements of the fetus, the pressure from
contractions, and paralysis of the cardiac muscle
by "asphyxic intoxication". The contraction was
thought to influence cardiac action very often,
commonly in the form of weakening and slowing
of the heart sounds repeatedly during each
contraction. It should be observed during each
delivery, how early these changes by contractions
occurred and whether they extended into the
pauses between contractions. In those cases in
which the heart sounds returned slowly to their
earlier rhythm after contraction or when the
attenuations persisted or deteriorated during the
pauses the result would be a weak, moribund, or
dead fetus.
Similarly HÜTER [18] and KATZ [19] attempted to
determine normal frequencies in order to determine a deceleration or acceleration of the cardiac
action. A more extensive work was published by
ZIEGENSPECK [47] in 1882. He considered it
important to examine the heart tones before,
during and after birth and to extend the auscultation for an entire minute. He too found the
cardiac action to be dependent on movenqtent and
temperature even during pregnancy and from
contractions during delivery. LUDWIG [23] likewise considered increase or deceleration of
the cardiac frequency during the pauses of
contraction a sign for an endangered fetus.
J. Pcrinat. Mcd. 3 (1975)
139
He judged äs unfavorable when the heart tones
sounded dull or if there were disturbances of
rhythm during the pause.
Of great importance is the thesis by SEITZ [38] in
1903. He stressed that there was no sharp delineation between the so-called physiologic
deceleration during the contractions and that
seen with the endangered fetus. The common
cause was the impaired gas exchange between
mother and fetus. He attempted to examine in
which way the heart tones were altered with
prolonged and more pronounced impairment of
the gas exchange and to what extent the changes
in frequency continued up to the point of an
endangered fetus or the necessity for assisted
delivery. His experiences about the changes of
the heart tones during the contraction indicated
that they continue to change towards deceleration
from the onset to the termination of the delivery.
The more and the longer the heart frequency
decreased during the contraction and the longer
the deceleration extended into the pauses, the
more impaired was the blood renewal of the
fetus and the more was his life endangered. He
differentiated three stages of pathologic decereration of heart tones progressing from
early danger to fetal death. These alterations of
the heart tones are based upon Irritation of the
vagal and vasomotor centers and paralysis of the
vagal center and in the third stage on the complete paralysis of all extracardiac nerve centers.
He concludes from his observations that one was
able to recognize gradually developing hazard
before the actual occurrance of danger for the
fetus necessitating artificial delivery, provided
one listened during the contraction or immediately after it had abated. If the heart tones sank
uncommonly low during the contraction or if
this deceleration extended into the pause between
contractions, he considered this äs a poor prognostic sign. Thus the heart tone changes are the
solely important indicator and the regularity
with which they change during impaired gas
exchange enabled one to recognize the risk to the
fetus early.
Basically the same points of view are found in
some of the following works of the subsequent
years which are listed here briefly. BUMM [7]
depicted in his textbook of 1917 the changes of
j 40
Gültekin-Zootzmann, History of monitoring the human fetus
the fetal heart tones and their evaluation. RIHL without a rigid connection between the patient
and WETNZIERL [31, 44] investigated in 1927 and the recording device, A soap bubble served
besides the frequency in particular the changes in äs a membrane, the movements of which were
rhythm, pitch, and strength of the heart tones. transmitted to a thin glass lever and registered
RECH [30] thought in 1931 that the knowledge of photographically. Phono-cardiograms were rethe reaction of the fetus to a change of his en- corded by the Americans SAMPSON, McCALLA and
vironmental conditions was scanty, however, KERR in 1926 with the aid of an electrical amplievery unfavorable influence was reflected in an fying and filtering stethoscope and chord galalteration of fetal heart action.
vanometer. Other methods for the graphic
Subsequently methods for the more detailed recording of fetal heart tones were described by
examination of cardiac action such äs ampli- SCHWARZ [37], BERÜTI of Buenos Aires [4],
fication of heart tones, graphic recording, and BENATT [2] and RECH [30]. Among these
fetal electrocardiogram were developed. A BERÜTI who had also described methods for the
Suggestion by SCHÄFFER [34] is worth mentioning. acoustic amplification of heart tones was partiin 1923 he designed a method to make the heart cularly optimistic. He considered it probable
tones audible throughout birth, and thus making that a physician would be able to listen to
changes recognizable at any time. From a ste- fetal heart tones transmitted from the materthoscope fixed to the abdomen with an elastic nity hospital into his home. Similarly amplibaüdage the sound waves were to be led to a fication and graphic recording would be helpful
microphone. PESTALOZZA from Pavia reported in for teaching purposes, and he considered it
1981 first about the graphic recording of heart possible to establish a record library with the
tones [28]. He recorded the heart tones with a recordings of fetal cardiac action. Finally the
sphygmograph. SEITZ [38] also developed his first attempts of fetal electrocardiography should
own method of graphic recording in which not be mentioned. CREMER [8] recorded in 1906 with
only the frequency was recorded but in which an EINTHOVEN galvanometer from the maternal
rapid beats could be depicted äs dots and more abdomen, vagina or rectum and recognized
extended ones äs dashes. HOFBAUER and WEISS traces of fetal electrocardiograms. Later works on
[45, 16] in 1907 and 1908 described their phono- this method which was fülly developed only after
scope. Thus heart tones could be registered 1930 is not the subject of this study.
Keywords: Ausculation (obstetrical), fetal death, fetal heart, history of medicine, meconium, obstetrics, prenatal care.
Zusammenfassung
Die in alten Hebammenlehrbüchern erwähnten „Zeichen
des Lebens oder Todes" eines ungeborenen Kindes sollten
Gewißheit darüber geben, ob das Kind im Mutterleib mit
Sicherheit abgestorben war und man eine schwierige
Geburt durch Perforation zur Rettung der Mutter beenden
konnte. Neben zahlreichen allgemeinen Zeichen gehörten
dazu einige, die schon sichere Lebensäußerungen des
Kindes betrafen: Tasten nach Pulsationen an der vorgefallenen Nabelschnur, an der Fontanelle oder an Händen
und Füßen. Es wurde sogar empfohlen, nach dem Schlagen
des Herzens zu tasten, sofern man mit dem Finger dorthin
gelangen könnte (BERNSTEIN) oder durch Einführen der
Hand in die Gebärmutter zu prüfen, ob das Kind an dem
Finger saugte (SCHÜTZEN). —
Diese Untersuchungen dienten noch nicht dazu, eine
Gefährdung des Kindes rechtzeitig zu erkennen, um
das kindliche Leben noch retten zu können.
Als Zeichen einer Gefährdung des Kindes galt bei den
Hebammen schon früh der vorzeitige Abgang von
Mekonium. Er wurde bereits 1679 im Hebammenlehrbuch
von VÖLLTERN als sicheres Todeszeichen erwähnt. Sehr
bald wurde Mekoniumabgang nur bei Schädellagen als
ungünstiges Zeichen gewertet. 1798 untersuchte GEHLER
die Bedeutung des vorzeitigen Abganges von Mekonium
genauer. Er wies darauf hin, daß man auch Konsistenz,
Geruch und Menge des Mekoniums beachten müßte.
An der prognostischen Beurteilung des Mekoniumabganges änderte sich im Laufe der Zeit nur wenig
(SCHWARTZ 1858 und HEYNE 1896). Die Theorie über den
Mechanismus des Abganges wechselte jedoch. VÖLLTERN sah
die Ursache 1697 in der Todesangst des Kindes,WEissENBORN
1780 in einer Kolik, die das Kind überfiele, GEHLER 1798
erwähnte schon die „Zusammendrückung des Gehirns" und
SCHWARTZ sprach von der „asphyctischen Intoxikation".
Am 26.12.1821 las KERGARADEC in Paris sein: „M6moire
sur i'Auscultation appliquee a l'Etude de la Grossesse".
Aufgrund dieses Vortrage wird er allgemein als Begründer
der geburtshilflichen Auskultation bezeichnet. Man findet
J. Perinat. Med. 3 (1975)
Gültekin-Zootzmann, History of monitoring the human fetus
in der Literatur jedoch die Namen einiger Ärzte, die als
Vorgänger KERGARADECS auf diesem Gebiete gelten. Es
handelt sich um die französischen Ärzte des 17. Jahrhunderts LE GOUST, LUSSAUD und MARSAC, die den Herzschlag des Kindes im Mutterleib mit dem „Klappern
einer Mühle" verglichen. — Der Anatom WRISBERG
schilderte die Möglichkeit, etwas über die Frucht zu erfahren, indem man die Wange auf das entblößte Abdomen
der Frau legte. — Francois Isaac MAYOR empfahl bereits
1818, das Ohr auf den Bauch der Mutter zu legen, um
festzustellen, ob das Kind lebte oder nicht. Wenn das Kind
noch lebte, könnte man seine Herztöne hören.
Der französische Arzt KERGARADEC beschrieb in seinem
Vortrag vor der Acadomie royale de medecine 1821 und in
seiner Schrift 1822, wie er dazu kam, die kindlichen Herztöne zu hören. Bei dem Versuch, die Bewegungen des
Fruchtwassers mit dem Stethoskop zu hören, fielen ihm
Geräusche auf, die an das Ticken einer Uhr erinnerten. Er
erkannte, daß es sich hierbei um die Pulsationen des kindlichen Herzens handelte. Nachdem er seine Entdeckung
durch Untersuchung anderer Schwangerer bestätigt fand,
zog er Schlußfolgerungen für die Praxis daraus. So erwähnte er bereits die Bedeutung von Veränderungen der
Herztöne in Stärke und Frequenz bei der Beurteilung des
Gesundheitszustandes des Kindes. KERGARADECS Untersuchungen zur geburtshilflichen Auskultation waren schon
so umfassend, daß sie in den folgenden Jahren von anderen
Geburtshelfern bestätigt wurden, aber kaum neue Gesichtspunkte dazu kamen.
Neben einigen kritischen Stimmen (v. SIEBOLD und DUGES)
wurde die Bedeutung dieser Entdeckung allgemein anerkannt. Die ersten Schriften über die geburtshilfliche
Auskultation in Deutschland erschienen schon 1823 von
Adam ULSAMER und C. J. HAUS aus Würzburg. Es wurde
beschrieben, welche Schwierigkeiten die Auskultation dem
Ungeübten bereitete, wie charakteristisch die kindlichen
Herztöne aber waren, sobald man sie einmal gehört hatte.
Es wurden auch die ersten Fälle beschrieben, in denen man
sich in der Praxis auf den Zustand der kindlichen Herztätigkeit verließ. In den folgenden Jahren erschienen zahlreiche Schriften über die geburtshilfliche Auskultation.
Zwei besonders umfangreiche waren die von HOHL 1833
und DEPAUL 1847.
Unterschiedliche Ansichten gab es zur praktischen Durchführung der Auskultation. So wurde sie an der stehenden
Frau mit bedecktem Abdomen durchgeführt von einigen
Geburtshelfern für „anständiger" gehalten (ULSAMER,
141
HAUS), oder es wurden die Vorzüge der unmittelbaren
Auskultation gegenüber der mittelbaren erörtert (ULSAMER).
Auch wurden eigene Stethoskope konstruiert und ihre Vorzüge beschrieben (HOHL, DEPAUL).
In den nach 1850 erschienenen Arbeiten zur Überwachung
des Kindes durch Beobachtung seiner Herztätigkeit
tauchten jetzt neue Fragen auf wie: Veränderung der
Herztöne durch Wehen, durch kindliche Bewegungen oder
durch Pulsfrequenz oder Temperatur der Mutter.
SCHWARTZ (1858) ermittelte eine „individuelle Normalfrequenz" zu Beginn der Geburt, um die Veränderungen
der Herztöne später beurteilen zu können. Er beobachtete
Frequenz, Stärke und Rhythmus der Herztöne und untersuchte den Einfluß der Wehen. Dabei stellte er fest, daß
eine Veränderung der Herztöne bis in die Wehenpausen
hinein ungünstig zu beurteilen wäre. Zu ähnlichen Ergebnissen kamen HÜTER, KATZ, LUDWIG und ZIEGENSPECK. — SEITZ untersuchte 1903 in seiner Habilitationsschrift die Veränderung der Herztätigkeit bei einer Gefährdung des Kindes. Er fand, daß sich die Herztöne vom
Beginn der Geburt bis zu ihrem Ende während der Wehe
zunehmend verlangsamten. Je mehr sich diese Verlangsamung in die Wehenpause hinein erstreckte, desto stärker
wäre die Bluterneuerung des Kindes behindert und desto
mehr sein Leben gefährdet. Bei der pathologischen Verlangsamung der Herztöne unterschied er drei Stadien bis
zum Absterben des Kindes. Für ihn war das Verhalten der
Herztöne des ungeborenen Kindes allein der ausschlaggebende Indikator, die Gefährdung des Kindes frühzeitig
zu erkennen.
Es wurden nun auch Methoden zur genaueren Untersuchung der Herztätigkeit entwickelt. Dazu gehörten:
Verstärkung der Herztöne, ihre graphische Darstellung
und das fetale EKG. SCHÄFFER entwickelte 1923 ein Verfahren, die kindlichen Herztöne während der Geburt laut
hörbar zu machen. PESTALOZZA zeichnete 1891 die Herztöne mit Hilfe eines Sphygmographen auf. Weitere Methoden der graphischen Darstellung stammten von SEITZ,
HOFBAUER und WEISS, SCHWARZ, BERUTI und RECH.
Die Amerikaner SAMPSON, McCALLA und KERR leiteten
1926 ein Phonokardiogramm mit Hilfe eines elektrischen
verstärkenden und filternden Stethoskops und eines
Saitengalvanometers ab. Der erste Versuch, ein fetales
EKG zu schreiben, stammte von CREMER aus dem Jahre
1906. Bei der abdominal-vaginalen bzw. rektalen Ableitung
mit einem EiNTHOVEN-Saitengalvanometer erhielt er
Andeutungen eines fetalen EKGs.
Schlüsselwörter: Auskultation (geburtshilfliche), Geburtshilfe, Herzfrequenz (fetale), Medizingeschichte, Mekonium,
Tod (fetales), Überwachung (Spätschwangerschaft).
Resume
Etüde historique sur la surveillance du foetus humain
Les «signes de vie ou de mort» d'un foetus mentionnos
dans les anciens manuels d'obst&rique servaient d'indication
pour savoir si le foetus vivait encore ou non et si on
pouvait mettre un terme par Perforation a une naissance
J. Pcrinat. Mcd. 3 {1975)
difficile pour sauver la mere. Parmi ces nombreux signes
goneraux, certains concernaient les manifestations extorieures et süres de la vie du foetus: palpation des pulsations au cordon ombilical saillant, ä la fontanelle ou aux
mains et aux pieds. II otait meme recommande de palper
les battements du coeur dans la mesure ou on pouvait y
parvenir avec le doigt (BERNSTEIN) ou d'examiner en
142
introduisant la main dans Futorus si Fenfant sugait ledoigt (SCHÜTZEN). Ces examens, toutefois, ne permettaient pas encore de dotecter a temps un p6ril menagant le foetus, donc de le sauver.
Depuis longtemps deja, on avait reconnu comme signe de
danger pour le foetus la perte prematuree de meconium
qui etait signalee des 1679 comme un Symptome mortel
certain dans le manuel d'obstetrique de VÖLLTERN. Peu
apres eile n'apparaissait plus que comme un Symptome
dofavorable dans les positions du sommet. En 1798,
GEHLER analysa avec plus de precision la perte prematuree
de meconium en insistant sur les facteurs de consistance,
d'odeur et de volume. Depuis, on n'apporta guere de
modification ä la valeur de pronostic de ce Symptome
(SCHWARTZ 1858 et HEYNE 1896). Seule la theorie sur le
mecanisme meme de Fecoulement se modifia au cours des
ans. VÖLLTERN en voyait la cause en 1697 dans l'angoisse
mortelle du foetus, WEISSENBORN en 1780 dans une colique
du foetus; GEHLER parla en 1798 de «compression du
cerveau» et SCHWARTZ d'«intoxication asphyxique».
Le 26.12.1821, KERGARADEC donna lecture a Paris de son
«Memoire sur l'auscultation appliquee a Fetude de la
gtossesse» qui lui valut d'une fagon generale la reputation
d'initiateur de Fauscultation obstetricale. On trouve
toutefois dans la litterature les noms de quelques medecins
consideres comme les predecesseurs de KERGARADEC dans
ce domaine. II s'agit des medicins frangais du XVIIeme
siecle LE GOUST, LUSSAUD et MARSAC qui ont compare le
battement du coeur foetal au «tic-tac d'un moulin». —
L'anatome WRISBERG decrivit la possibilite d'apprendre
quelque chose sur le foetus en mettant la joue sur Fabdomen
nu de la femme. — Frangois Isaac MAYOR a recommande
des 1818 de mettre Foreille sur le ventre de la mere pour
savoir si Fenfant vivait ou non selon qu'on entendait ou
non les bruits du coeur foetal. Le medecin francais KERGARADEC expliqua dans son expose a FAcademie royale de
medicine en 1821 et dans un article paru en 1822 comment
il reussit a entendre les bruits du coeur du foetus: en
essayant de «sonder» les mouvements du liquide amniotique
a l'aide du stethoscope, il pergut des sons ressemblant au
tic-tac d'une montre et dans lesquels il reconnut les pulsations du coeur foetal. Sa decouverte s'etant confirmee a
la suite de Fexamen d'autres femmes enceintes, il en tira
les consequences pour une application pratique. C'est ainsi
qu'il precisa la signification des changements de Fintensito
et de la frequence des bruits du coeur pour le diagnostic de
Fetat de sante du foetus. Les etudes de KERGARADEC sur
Fauscultation obstetricale etaient dejä si etendues qu'elles
ont fait autorite au cours des annees suivantes ä Fexception
de quelques critiques (v. SIEBOLD et DUGES).
Les premiers articles sur Fausculation obstotricale en
Allemagne parurent des 1823 sous les noms de Adam
ULSAMER et C. J. HAUS de Wurzbourg. Ils decrivirent les
difficultes de Fauscultation pour un non-initie, mais aussi
combien les bruits du coeur foetal etaient caracteristiques
Gültekin-Zootzmann, History of monitoring the human fetus
des qu'on avait roussi ä les percevoir une fois. On presenta
egalement les premiers cas ou l'activito cardiaque foetale
decida de Fintervention pratique. De nombreux articles
parurent les annose suivantes sur l'auscultation obstotricale,
dont deux particulierement importants de HOHL en 1833 et
DEPAUL en 1847.
Les avis differerent sur Fapplication pratique de Fauscultation. Certains obstetriciens considorerent «plus correct»
de laisser la femme dans la position debout et Fabdomen
couvert (ULSAMER, HAUS), ou discuterent des avantages de
Fauscultation directe sur celle indirecte (ULSAMER). On
mit egalement au point divers stothoscopes, avec description
de leurs avantages respectifs (HoHL, DEPAUL).
Dans les travaux parüs apres 1850 sur la surveillance du
foetus par l'observation de son activite cardiaque, on releve
des questions de ce genre: modification des bruits du
coeur par les douleurs d'accouchement, par les mouvements du foetus ou par la frequence de pulsation ou la
temperature de la mere. SCHWARTZ communiqua en 1858
une «frequence normale individuelle» au debut de F
accouchement pour servir de base aux altorations successives des bruits du coeur dont il observa la frequence,
Fintensite et le rythme sous Finfluence des douleurs du
travail. II en conclut le pronostic defavorable d'une alteration des bruits du coeur qui se prolonge jusque dans les
interruptions des douleurs. HÜTER, KATZ, LUDWIG et
ZIEGENSPECK parvinrent a des conclusions analogues. —
SEITZ examina dans sä these d'agregation en 1903 les
modifications de Factivite cardiaque comme facteur de
risque pour la vie du foetus. II etablit que le ralentissement
des bruits du coeur allait croissant durant le travail du
debut de Faccouchement a son terme. Plus donc ce ralentissement se prolonge dans les arrets du travail, plus le
renouvellement du sang foetal se trouve entravo et la vie du
foetus en danger. II distingua trois phases de ralentissement
pathologique des bruits du coeur jusqu'a la mort du foetus.
Le comportement des bruits du coeur du foetus restait
pour lui le seul indicateur determinant pour dotecter a
temps le danger menagant la vie du foetus.
Des methodes furent alors mises au point pour Fexamen
plus procis de Factivite cardiaque, dont FampHfication des
bruits du coeur, leur enregistrement graphique et Felectrocardiogramme foetal. SCHÄFFER doveloppa en 1923 un
procede destine a rendre audibles les bruits du coeur que
PESTALOZZA enregistra en 1891 a l'aide d'un sphymographe.
D'autres methodes de diagramme ont et6 egalement elaboroes par SEITZ, HOFBAUER et WEISS, SCHWARZ, BERUTI,
BENATT et RECH.
Les Americains SAMPSON, McCALLA et KERR ont obtenu
en 1926 un phonocardiogramme a l'aide d'un stethoscope
61ectrique amplificateur et filtrant et d'un galvanometre
d'Einthoven. Le premier essai d'enregistrement d'un
electrocardiogramme foetal remonte ä CREMER en 1906
par la derivation abdomino-vaginale ou rectale a l'aide
d'un galvanometre d'EiNTHOVEN.
Mots-cles: auscultation obstetricale, coeur foetal, histoire de la madicine, meconium, mort foetale, obstetrique, soins
prenataux.
J. Perinat. Med. 3 (1975)
Gültekin-ZootJsmann, History of monitoring the human fetus
143
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