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A TREATISE

ON

OBSTETRIC AUSCULTATION


NAEGELE









A TREATISE


ON


OBSTETRIC AUSCULTATION.



A TREATISE


ON


OBSTETRIC AUSCULTATION.


BY

DR. H. F. NAEGELE.


TRANSLATED FROM THE GERMAN
BV

CHARLES WEST, M.D.

GRADUATE OF THE UMVERSITY OP BERLIN.


LONDON :

HENRY RENSHAW, 356, STRAND ;

CARFRAE AND SON, EDINBURGH; AND FANNIN
AND CO., DUBLIN.

1839.




«



LONDON:

HRINTKD BY IBOTSON AND PALMER,
SAVOY STREET.


ADVERTISEMENT


BY THE

TRANSLATOR.


The treatise by Dr. Kennedy on the Signs of
Pregnancy, is the only work in our language
devoted to a consideration of Obstetric Ausculta-
tion : inost English writers on Midwifery dismiss
*the subject with very few words, or pass it over
altogether without notice.

It is hoped that the following pages may lead
to a higher estimate of the value of the stetho-
scope, and to a better acquaintance with its
employment, both during pregnancy and at the
period of labour. They present the results of
six hundred observations, which add some new
facts to our stores of knowledge, and afford a
most valuable confirmation of many others with
which we were previously acquainted.


iv ADVERTISEMENT BY THE TRANSLATOR.

This Translation was undertaken at the sug-
gestion of Dr. Rigby, to whose many friendly
offices I am much indebted, and for which I
gladly seize this opportunity to tender my most
sincere thanks.

It was in the Lying-in Hospital at Dublin that
I became practically acquainted with the value
of obstetric auscultation ; and I cannot omit to
acknowledge, in connexion with this circumstance,
how much I owe, in every department of mid-
wifery, to the instruction of Dr. Kennedy, and
with what pleasure I recal the time when every
day gave me the benefit of his teaching, and the
enjoyment of his company.

CHARLES WEST.

40 , Craven Street, Strand,

Jidy, 1839 .


CONTENTS.


l'agü

Advertisement by the Translator . . . iii

INTRODUCTION.

GENERAL OBSERVATIONS ON THE EMPLOYMENT OP AUSCUL-


TATION.

j I. Difficulties of acquiring a knowledge of

auscultation . . . . 1

II . Advantages of mediate auscultation . 3

III . The stethoscope . . . .5

IV. Disturbing influence of external noises . ib.

V. — VII. Of the best position of the person to be

examined ; of her dress ; and of the
posture of the practitioner . . 6


PART I.

Remits of the auscultation of women during pregnancy, and
in labour.

§ VIII. Classification of the different sounds heard
in the abdomen of pregnant and partu-
rient women . . . .10


VI


CONTENTS.


CHAPTER I.

OF SOUNDS PnOCEEDING FROM THE MOTHER.


A. Of the Uterine Sound.

Page

IX. Its character . . . .12

X. Situation where it is perceptible . . 14

. XI. Period at which it becomes audible . 15

XII, Modification which it undergoes during

labour . . . . .16


XIII. Reasons for calling it the uterine sound . 17

Ji, Of some other Sounds occasionally heard in the abdomen of
pregnant women, but not resulting from pregiuincy,

XIV. Of the pulsations of the maternal heart,

of the beatings of the aorta, of the iliac
arteries, &c. . . . .26

CHAPTER II.

OF SOUNDS PROCEEDING FROM THE FOETUS.

A. Of the pulsations of the fatal heart.


XV. Their character . . . .28

XVI. Their frequency . . .31

XVII. Their relation to the uterine sound . 34

xviii. Situation where they are audible . . 4i

XIX. Period at which they become audible . 45

XX. Influence of natural labour upon the pulsa-
tions of the foetal heart . . .47


CONTENTS.


Vll


B. Of the sounds produced by the moiemenis of the foetus.

Eage

XXI. Their character, time when they become

audible, &c. . . . .50

C. Of the sounds produced by the umbilical cord.
x.xir. Their character; how to be distinguished

from other sounds . . .51

XXIII. Circumstances favouring their production . 55

PART II.

Deductions from the results of auscultation,
CHAPTER I.

VALUE OF AUSCULTATION IN DETECTING PnEONANCY.

$ XXIV. Estimate of the value of the different sounds

in determining the existence of pregnancy 58
XXV. Signs of simjile and compound pregnancy . 61
XXVI. Of an error in diagnosis to which ausculta-
tion may lead, and how it is to be avoided 66

CHAPTER II.

OF AUSCULTATION AS A MEANS OF DISTINGUISHING THE
POSITION OF THE FIETUS AND THE SITUATION OF THE
PLACENTA.

xxvn. General signs of the position of the foetus . 70
Signs of first and second vertex present-
ations . . . . .71

Of an exception to the general rule . 7li


vm


CONTENTS.


Pago

XXVIII. Of tbe position of the foetus in tho early


months of pregnancy . . .74

XXIX, Signs of a face presentation . . 75

XXX. Signs of a breech presentation . . 76

XXXI. Signs of a preternatural presentation •. 77

xxxii. How the situation of the placenta may be

ascertained . . . . ib.


xxxiii. Varieties in the situation of the placenta . 78

Peculiarities of the uterine sound connected
with the occurrence of hajmorrhage, and
with morbid structure of the placenta . 8 1

XXXIV, On the relation between the position of the

child and the situation of the placenta . 83

CHAPTER III.

INFOnMATION WHICH AUSCULTATION AFFORDS WITH REGARD
•lO THE LIFE OF THE CHILD DURING PREGNANCY, OR IN
LABOUR.

XXXV. Auscultation affords the only certain means

of deciding this question . . 83

XXXVI. On the death ofthe foetus during pregnancy,

and its influence upon the uterine sound 84
xxxvii. On the death of the foetus in consequence

of protracted labour . . .91

Influence upon the action of the foetal heart,
of rapid labour with violent uterine
action . . . . .94

On a peculiarity in the uterine sound occa-
sionally observed in Protracted labour . 96


CONTENTS.


IX


I’u«o

XXXVIII. On the death of the foetus in hour com-
plicated with prolapsus of the umbilical
cord . . . . .99

On marginal insertion of the umbilical cord
as a frequent cause of its prolapse . 104
xx.xix. On the death of the foetus from premature

escape of the liquor amnii . . 106

CHAPTER IV.

value of auscultation in operative midwifery.

XL. Its value in determining when manual inter-
ference is necessary, and what instru-
ments ought to be employed . . 110

xLi. Its value with reference to the treatment of

cases of prolapsus of the cord . .118




INTRODUCTION.


GENERAL OBSERVATIONS ON THE EMPLOYMENT
OF AUSCULTATION.

§

The auscultation of pregnant and parturient
women is attended with difficulties precisely
similar to those which retard the student’s acqui-
sition of skill in manual exploration. In both,
the necessary dexterity can be obtained only by
long-continued practice, with adequate oppor-
tunities for observation ; and as the practitioner
of midwifery will be unable to satisfy himself
about many very important occurrences until
his sense of touch has been much exercised, so,
before he can venture to rely upon the informa-
tion which his ear affords, his sense of hearing
must have undergone long schooling. Perhaps,


B


2


indeed, even more diligence and patience are
requisite in the latter, than in the former mode
of examination ; and he who is not possessed of
at least a moderate amount of persevering atten-
tion, can never succeed in gaining such a know-
ledge of auscultation as will enable him to apply
it successfully in detecting pregnancy, or in
ascertaining the different phenomena which take
place during labour. This knowledge may be
acquired in lying-in hospitals incomparably
better than elsewhere, though persons may both
learn auscultation thoroughly, and employ it
skilfully, without having had greater opportu-
nities than those presented to them in private
practice.

Some persons have asserted, that it is necessary
to possess a more than usually acute sense of hear-
ing, in order to practise obstetric auscultation
with success; this, however, is by no means indis-
pensable, for the ear will become so expert by
frequent exercise, as at length to detect the most
delicate variations of sound. One circumstance
which greatly facilitates the acquisition of skill
in this method of examination, is, a previous ac-
quaintance with the use of the stethoscope in
detecting diseases of the chest ; yet, it should


3


always be borne in mind, that the former is
attended with far greater difficulties than the
latter. Persons are very apt to forget this fact,
and to feel disappointed with the slowness of
their progress : let them console themselves with
Laennec’s assurance, that “ L* etude de ces pk4.no-
menes demande incomparahlement plus d’attention
que celle de tons ceux que presentent les maladies
de la poitrine.”


§ II-

Auscultation of the abdomen, as of the chest,
may be practised either with the unaided ear, or
by means of the stethoscope : both methods have
had their warm advocates, and much controversy
has arisen respecting their comparative advan-
tages. An undue importance seems to have
been attached to this question, for a person may
succeed in either way in ascertaining the exist-
ence of pregnancy, or in distinguishing the oc-
currences which take place during labour. The
employment of mediate auscultation, however,
has many circumstances in its favour ; its supe-
rior delicacy must be obvious to all ; and it often
happens that no sound is audible except in some
part of the abdomen, such as the hypogastric, or


4


inguinal region, which it would be impossible to
auscult without the stethoscope. But, indepen-
dently of the needless indelicacy of applying the
ear to the abdomen of the patient, the practitioner
who does so must place himself in a position often
exceedingly incommodious, and likely to occasion
congestion about the head. Nothing interferes
so much with the successful employment of this
mode of examination as an inconvenient posture ;
and it is useless to continue listening to the
abdomen after our ear has become red, and the
beating of the arteries of the tympanum per-
ceptible. Moreover, if the ear is applied directly
to the abdomen, the number and variety of the
sounds heard is very confusing, while the stetho-
scope has the great advantage of limiting and
isolating the field of observation. Another
benefit which attends the use of this instrument
is, that by means of it a moderate degree of
pressure may be exerted upon the abdomen of
the patient ; and this is often very necessary, if,
in addition to her not being far advanced in
pregnancy, her abdominal integuments be loaded
with fat, or if her uterus contain an unusually
large quantity of liquor amnii.


5


§ UI.

Various instruments have been recommended
as possessing peculiar advantages for obstetric
auscultation ; and the most dissimilar materials
have been employed in the construction of
cylinders or cones, which were either hollow, or
solid, or otherwise modified in shape, according
to the fancy of the different inventors. This,
however, is not the place for a critical examina-
tion of these instruments ; which, indeed, is the
less important, since the auscultation of the
abdomen may be practised almost equally well
with any stethoscope.*

§ IV.

A person but little versed in ausculation will
find it necessary to have the room perfectly quiet ;

• We are in the practice of employing Piorry’s stetho-
scope, slightly modified. It is a cylinder made of any firm
wood, from seven and a half to eight inches (Parisian mea-
sure) long, from six to seven lines thick, and with a bore
of four lines in diameter : one extremity expands into a
conical cavity one inch four lines deep, and one inch four
lines in diameter at its base ; while an ivory ring two lines
high is attached to the other end, and to this ring an ivory
ear-piece is screwed which is two inches in diameter, and
plane on both sides.

B 3 .


6


but, by degrees, as he becomes more familiar
with the sounds heard in the abdomen of preg-
nant women, external impressions will cease to
distract him, and he will at length be able to
carry on the examination without difficulty, even
though persons may be conversing together in
the same apartment. The period of digestion
should also be avoided by the beginner, since
the noises then heard in the intestinal canal are
very likely to disturb and perplex the unprac-
tised ear.


§ V.

In order to examine the abdomen with the
stethoscope, the patient should lie on her back,
upon a moderately high bed, her head supported
by a pillow, and her arms stretched out by her
side : the whole uterine region is thus rendered
accessible to the stethoscope, while the intestines
lying on either side of the abdomen, or pressed
towards the spine, seldom if ever interfere with
the examination. Although these are generally
the most favourable circumstances- for practising
auscultation, yet there are cases (to be hereafter
more exactly described) in which it is advanta-
geous to turn the patient more or less on her
side.


7


It is likewise exceedingly important for making
an accurate examination, that the posture of the
practitioner should be such as he can maintain
for several minutes with ease to himself, since it
is often necessary to prolong the auscultation for
a considerable time, or, at least, to interrupt it
only by very short pauses. Perhaps the least
weariness will be felt by kneeling on a cushion
at the bed-side of the patient. It is furthermore
desirable to acquire the practice of hearing with
equal facility with either ear ; for prolonged
exercise of one ear renders it red and painful,
and compels us to desist from our examination.

Any one who attempts to auscult a patient
while standing or sitting, labours under very
great disadvantages ; for not merely is the per-
ception of sounds thereby rendered more difficult,
but the position in which he is forced to place
himself is exceedingly incommodious, and many
parts of the abdomen of the patient are rendered
quite inaccessible to the stethoscope.

§ VI.

Although a practised ear will detect the dif-
ferent sounds through the ordinary dress of the
l>atient, \ et it is always desirable that she should


• «


be thinly clad ; it will therefore he found a
useful plan, to direct her to roll up her under
garments so that nothing but the gown and shift
maybe interposed between the stethoscope and the
abdomen ; for woollen stuffs interrupt the exami-
nation by the rustling noise which they occasion.
Patients in labour may be examined in their
night-dress, the bed-clothes having been turned
aside from the abdomen ; but no case can occur,
in which exposure of the person is either neces-
sary or justifiable.


§ vn.

After the practitioner has placed himself in a
convenient posture at the bed-side of the patient,
he should next smooth the clothes over her body,
so as to obtain an even surface on which to place
the stethoscope. The pressure of the ear upon
the instrument will generally suffice to maintain
it in its position, or it may be held between the
thumb and fore-finger of one hand. The other
hand will serve the examiner to lean upon ; or he
may use it to feel the patient’s pulse ; or, placing
it on the abdomen, he may endeavour to steady
it by gentle pressure ; but he should especially
guard against using force either with the hand


f


9


or with the stethoscope, since not only does it give
the patient pain, but it may cause some violent
movement of the foetus, which would excite its
circulation, and render it impossible to count the
frequency of the pulsations of its heart.




PART I.


Results of the auscultation of women during preg-
nancy and in labour.

§ VIII.

Various sounds may be heard in the abdomen
of a person during the latter months of pregnancy,
some of which proceed from the mother, others
from the foetus.

It must not, however, be supposed, that all
sounds distinguishable in the abdomen of a preg-
nant woman are indicative of her condition, for
many of them are also present in persons who
have never been impregnated. Thus, the pulsa-
tions of the patient’s heart, the respiratory mur-
mur, especially when altered by disease, the
beating of the aorta and of the iliac arteries, and
noises caused by flatus in the intestinal canal, are
as often heard in the abdomen at other periods,


11


as during that of utero-gestation. But, beside
these, there is one sound characteristic of preg-
nancy, and which, proceeding from the uterus,
and being caused by the circulation of blood
through its substance, may be very appropriately
called the Uterine sound.

Furthermore, our ear assures us of the exist-
ence of pregnancy, by detecting the following
signs, which result from the presence of a child
in the uterus ; namely, the beating of the heart
of the foetus, the movements of its limbs, and the
pulsations of the umbilical cord.

Each of these signs of pregnancy deserves
a distinct consideration. It will be best to begin
by examining the uterine sound, and afterwards
to investigate such as proceed from the foetus,
while the different noises which have been alluded
to as not dependent on pregnancy, may receive
a cursory notice, as far as they are of importance
to the practitioner of midwifery.


12


CHAPTER I.

OF SOUNDS PROCEEDING FROM THE MOTHER.

/

A. Of the Uterine Sound.

IX.

The circulation of the blood through the uterus
produces a single, whizzing, or humming sound,
which differs in its apparent distance from the
ear of the observer, is always synchronous with
the pulse at the wrist, and changes with every
alteration that the pulse undergoes, becoming
slower, quicker, or intermittent, in accordance
with the changes in the maternal circulation.*
This sound bears a considerable resemblance
to that bellows- sound sometimes heard in the

* Hohl, in his valuable work, (Die geburtshülßiche Explo-
ration, 1 Theil, das Hören, Halle 1833,) has stated, that the
uterine sound coincides with the maternal pulse not merely
in rhythm, but also in strength and fulness, weakness or
smallness ; this, however, is far from being the case, for the
former often seems to the ear very distant and feeble, at a
time when the mother’s pulse is very strong and full.


13


heart or arteries when any mechanical obstruc-
tion is presented to thecirculation. The similarity,
however, is far from complete, for the ordinary
bruit de soufflet is much less shrill and loud than
the uterine sound; which indeed varies so much
in tone and intensity in different persons, and
even in the same individuals at different periods,
that it is difficult to say with what it may be
most aptly compared. Sometimes it resembles
the blowing of the wind; at other times the deep
sound caused by the vibration of the string of a
violoncello ; while occasionally it is like the
highest tones of a violin.

The resemblance of the uterine souffle to the
ordinary hncit de soufflet, and its isochronism
with the maternal pulse, have induced some per -
sons, overlooking tbe fact that it communicates
no shock to the listener’s ear, to apply to it the
inappropriate name of a pulsating sound.

It is worthy of observation, that the uterine
sound varies in its intensity at the same part of
the abdomen within a very short time : occasion-
ally, indeed, it disappears completely in perfectly
healthy women, without any evident cause. In
some of these cases, the sound has merely
changed its position, and become distinctly audible

c


14


in a part where it had never before been heard,
while, in other instances, it leaves its old situation
for a time, and cannot be detected in a new one.
Some exceedingly rare cases have occurred, in
which a living child was born, although this
sound was not audible at any period during preg-
nancy or in labour.


§ X.

This sound is far from being limited to one
particular spot : in one patient, it will be found
confined to the lower part of the uterus ; in a
second, diffused over the whole organ ; while it
would not be possible to point out any part of the
uterine region accessible to the stethoscope,
where it has not in some case or other been
heard. It is usually, however, audible in one or
both inguinal regions, whence it generally ex-
tends eitlier towards the hypochondrium, or
more forward towards the umbilicus, though it
seldom passes the mesial line. But, whatever
may be the situation it occupies, it will almost
always be heard over a surface fully equal to,
and often greatly exceeding in size, the circum-
ference of the placenta.


15


§ XI.

The uterine souffle is seldom sufficiently dis-
tinct to be clearly recognised before the fourth
month of pregnancy ; as is shown by the fact,
that while it was audible in twenty out of thirty-
five patients at the fifteenth week of utero-gesta-
tion, it was heard in three only at the fourteenth
week. Sometimes, indeed, it cannotbe detected till
the beginning of the fifth month, or the middle of
pregnancy ; but it can always be distinguished
several weeks sooner than the pulsations of the
foetal heart.

When it first becomes audible, the uterine
sound is feeble, * diffused over the whole of the
small uterus, and most distinct just above the
pubes ; but, as the uterus rises with the advance
of pregnancy, the sound is heard higher up, and

• It is a common practice with the student, when examin-
ing women in the early months of pregnancy, to press the
stethoscope deeply into the abdominal integuments, under
the erroneous impression that he will thus hear with greater
facility. This should be avoided ; for not only is it need-
less, and likely to put the patient to pain, but, in some
instances, premature labour has followed soon after examin-
ing a patient with the stethoscope, and has appeared to be
altogether the result of roughly-conducted auscultation .


16


generally becomes most intense at the sides, even
if it should not be confined to that situation.
Changes in its intensity during the second half
of pregnancy are far from common; sometimes it
does become louder as the end of utero-gesta-
tion approaches, but there are equally numerous
instances of a decline in its strength with each
succeeding month.


§ XII.

The uterine sound rises in frequency during
labour synchronously with the pulse of the par-
turient woman : in some cases its loudness is
increased, while in others there does not occur
any change in its intensity. During the acme
of each pain, it generally becomes inaudible in
the fundus and body of the uterus, though it may
still be heard in the inguinal region. Hohl *
has asserted, that the access of each pain is an-
nounced by an increased intensity or greater
loudness of the uterine sound, or by certain
modifications in its tone, which he represents as
following a regular order ; but the most careful
examination of a great number of women has not
verified any of these statements.

• Loc. cit. p. 104, et seq.


17


It has been already mentioned, that in some
rare instances the uterine sound is inaudible
during the whole labour.

The same pain which expels the child, usually
detaches the placenta, and is then immediately
followed by a cessation of the uterine murmur;
but if any interval should elapse between the
two processes, the sound will continue to be
heard until the separation of the placenta has
been effected. From this, however, it must not
be inferred that the sound ceases because the
placenta is detached, but rather because the
contraction of the uterus, and the consequent
diminution in the calibre of its vessels, limit the
quantity of blood which that organ receives, to
a supply adequate for it only in the unimpreg-
nated state.


§ XIII.

The term uterine sound not being that com-
monly employed, it will be necessary to state
why it has been thought proper, in this treatise,
so to designate the sound treated of in the fore-
going paragraphs.

This name was chosen in preference to those

c 3


18


hitherto in vogue,* from a supposition that the
sound not only proceeds from the mother — not
from the foetus — but that it has its seat in the
uterus, and is produced by the alterations the
uterine vessels undergo during pregnancy ; all
which opinions are supported by the following
circumstances.

First. — The perfect isochronism which exists
between this sound and the pulse of the mother,
and the fact that all changes in the movements
of the maternal heart, as the acceleration, re-
tardation, or intermission of its pulsation, com-
municate themselves to the uterine sound, both
point to its origin in the vascular system of the
mother : while its independence of the foetal cir-
culation is shown by the fact, that, although in
some rare cases it has been found more frequent
than the pulsations of the foetal heart, no instance

* Kergaradec, who inclined to the opinion that the
placenta had some share in the production of this sound,
called it Battemens simples avec souffle, (see his Memoire
sur V auscultation appliqtiee ä /’ etude de la grossesse, See.
Paris, 1822, p. 30.) Soon afterwards De Lens named it
Pulsations placentaires, (see his Observations Additionelles,
in Kergaradec, p. 39) ; and, since 1822, it has been
commonly called Bruit placentaire. Souffle placentaire.
Placental sound.


19


was ever yet observed in which the two sounds
were synchronous.

Second. — The situation in which this sound is
heard, the period at which it becomes evident,
and the time of its disappearance, are all in
favour of its origin being in the uterus, and not
in any other abdominal organ. It is probable
that the uterine sound might be heard soon after
conception, at which time the vital action in the
uterus seems to be so much increased, if it were
possible to bring the stethoscope near that organ ;
but its position in the pelvic cavity at the com-
mencement of pregnancy, as well as the thick
layer of fat just above the symphysis pubis,
afford no opportunity for so doing. As the
uterus, however, rises out of the pelvis in the
fourth month of pregnancy, the stethoscope
placed just above the pubes is brought into close
proximity to its fundus, and this sound may then
be detected ; it being usually first audible in the
linea alba, where the abdominal parietes are
thinnest. As the uterus gi’adually rises, the
sound accompanies it ; and sometimes it
may be heard in the eighth month of preg-
nancy, extending from the symphysis pubis
to the epigastrium ; but this has been the case


20


only where the placenta was attached to the
fundus uteri, and other circumstances concurred
to favour the diffusion of the sound. After the
birth of the child, and the expulsion of the
placenta, the sound in the uterus generally
ceases ; though exceptions to this are sometimes
met with in the case of women who have already
borne children and are subject to severe after-
pains : in them a slight murmur may, from time
to time, be detected in the uterus for a short
period after delivery, but disappears as soon as
the after-pains have subsided.

Third. — The assertion, that the vascular
system of the uterus is the seat of this sound,
and that the changes which the uterine vessels
undergo are its cause, is supported by the re-
semblance which exists between it and the
bellows-sound, frequently heard in other parts
of the vascular system, especially in cases of
aneurysmatic dilatation of the vessels.

Although, as has been already observed, the
similarity between the uterine sound and the
bruit de souffle sometimes audible in the heart
and arteries, is far from complete, yet, according
to the statement of some recent observers, there
is a sound which bears the most exact re-


21


semblance to it, namely, that heard in varix
aneurysmaticus — a disease in which a direct com-
munication exists between the blood in the vein
and that in the artery. The chief point to be
borne in mind, in order to explain how the sound
is produced in these cases, is, that one column of
blood, moving quickly, passes out of the dilated
artery into the dilated vein, where it comes in
contact and eventuallymixes with another column
of blood travelling more slowly through the vein.
Paul Dubois* was the first to call attention to this
analogy between the uterine sound and that pro-
duced by varix aneurysmaticus ; and Hohlf sub-
sequently asserted their perfect resemblance.
The next question will naturally be, whether,
since the sounds are similar, a resemblance in
structure does not also exist between the organs
that produce them ? Dubois, whose experiments
prove, to say the least, an exceedingly easy
transition of injected fluids, or of air, from the
arteries into the veins, has answered this question
in the affirmative, and compares the structure of

• De I'application de Vavicultation ä la pratique des ac-
couchemens ; rapport fait ä VAcadimie de M^decine(29 Nov.
1831.) Extrait des Archives G£n6rales de Med., p. 26.

t Loc. cit. p. 76, 157, 158.


22


the uterine walls to a tissue, naturally formed, of
varicose aneurisms. Hohl agrees with him in
this opinion ; but, going even further, he assumes
the existence of the so-called placenta uterina to
be fully proved, and imagines that the com*,
munication between arteries and veins takes
place there, not by anastomosis, but through the
medium of large cells ; in which he follows the
opinion of Meckel. Were this really the case,
no more apt comparison of the structure of the
uterine vessels could be found, than that with the
varix aneurysmaticus ; oi*, to speak more strictly
in the language of modern surgery, the aneurysma
varicosum. Such an analogy between these two
structures would serve excellently well to ex-
plain the occurrence of the uterine sound, while
the conclusion would naturally follow, that “ the
pulsation is heard only at that part of the uterus
to which the placenta is attached;”* and not
merely would the term placental sound be justi-
fiable, but there would be no reason for substi-
tuting for it another name.

Since, however, the doubt, whether the struc-
ture of the uterus does really resemble a tissue
of varicose aneurisms, is by no means solved,

* Hohl, 1. c. p. 154.


23


and since the investigations with regard to the
arrangement of vessels in the uterus, and the
connexion between it and the placenta, are far
from concluded, it will be better, leaving un-
touched the questions of the existence of an
uterine placenta, of the sinuses of Meckel, &c.,
to show why such a structure, even though it
were actually demonstrated, would not suffice to
explain the occurrence of this sound.

Hohl’s assertion, that the uterine souffle is
audible only over that part of the uterus which
corresponds to the insertion of the placenta, has
already been noticed. It is a statement entirely
at variance with daily observation ; for when the
uterine sound is to be heard at all, it may usually
be detected in both inguinal regions, from one of
which it will be heard extending forwards, or
upwards, with increased intensity. Often, indeed,
it is audible, not merely in the lower and lateral
parts of the uterus, or reaching over a larger
surface on the one than on the other side, but
diffused with equal loudness over the whole organ;
and it is almost always heard through a space
considerably larger than that portion of the uterus
to which the placenta is attached. The average
diameter of the placenta may be estimated at


24


about six or seven inches ; and in very many
cases, the uterine sound is heard distinctly over a
surface three or four times that extent.

Any person who will apply his stethoscope
along the course of Poupart’s ligament, may con-
vince himself that a souffle is constantly audible
in the lower part of the gravid uterus. But if
this be the case, there at once arises the question
how the phenomenon is to be explained, since it
is impossible to assume the existence of sinuses
in this situation. May it not be produced by
the uterine arteries before their entrance into the
womb ? for it is known that these vessels change
their character immediately on reaching the
broad ligaments ; that they become wider than
when given olF from the main trunks, and run in
a tortuous course before entering the substance
of the uterus. In further support of this view, it
may be observed, that, as a louder and more
extended souffle is heard on one side of the uterus
than on the other, so examination after death
often shows that the uterine vessels are larger
and more developed on the side to which the
placenta had been attached. The loudness of
the murmur at one part of the abdomen will often
enable a person to form an accurate conjecture as


25


to the seat of the placenta ; and surely no one
can feel surprised that the sound should be
loudest at that part of the uterus where the
placenta is attached, since thither, as to the
centre of the vascular activity of the organ, all
the largest vessels direct their course. Lastly,
if the causes above assigned for the uterine
murmur be correct, the occurrence of some
cases in which auscultation gives no satisfactory
information with regard to the seat of the placenta,
not merely ceases to excite surprise, but the
reasons for this deviation from the ordinary rule
at once become apparent.

Such are the facts which have been adduced to
prove that Hohl’s theory, even admitting it tobe
correct, is yet insufficient to explain this pheno-
menon ; and which also favour the opinion, that
it is produced by causes existing in the structure
of the uterine vessels, such as the tortuousness
of the arteries, and perhaps also the dilatation
of their cavities, and attenuation of their coats.
If they should be considered to afford sufficient
proof that this sound is often heard in places
which are distant from the insertion of the
placenta, and that, though it is frequently louder
near that part to which the placenta is attached.


D


26


still it is not produced by it, but has its seat in
the arteries of the uterus, — it will follow, of
necessity, that no name could be applied to it so
appropriate as that of the uterine sound.


J3. Of some other sounds occasionally heard, in
the abdomen of pregnant women, but not result-
ing from pregnancy.

§ XIV.

First of all may be noticed the pulsations of
the maternal heart, which are often audible over
a large part of the pregnant abdomen, probably
in a great measure owing to the sound being
conveyed by the intestinal canal distended with
gas. If the stethoscope be placed on the front
of the abdomen, where the uterus is in contact
with the abdominal parietes, these pulsations of
the heart cannot be heard, but are distinctly
audible at either side, (where the intestines lie
close to the uterus,) even as low down as the ossa
ilia. The importance of this phenomenon in
diagnosis will be hereafter spoken of more at
large.

The beating of the aorta, or of one or other


27


iliac artery, synchronously with the first sound
of the heart and the pulse at the wrist, is some-
times, though very rarely, heard. It occurs
only in hysterical or hypochondriacal patients, in
whose circulation irregularities of all sorts are
met with, as well as in persons labouring under
diseases of the heart.

Occasionally, especially when persons are suffer-
ing from catarrhal affections, the sounds produced
by respiration, as rhonchus sibilans, rhonchus
mucosus, puerile respiration, &c., are conveyed
to either side of the uterus by the same circum-
stances which rendered the beating of the heart
audible in this situation.

The rumbling of flatus in the intestinal canal
may be heard in the abdomen of many women
during pregnancy, as at other times, almost in-
cessantly ; and it may often be discovered, from
the situation in which it is heard, where the
uterus and where the intestines are in contact
with the abdominal parietes.


CHAPTER II.


OF SOUNDS PROCEEDING FROM THE FOETUS.

A. Of the pulsations of the foetal heart.

§ XV.

The sound which proceeds from the foetal
heart consists of a rapid succession of regular,
short, double pulsations, which resemble those of
the adult heart, but are, in most instances, twice
as frequent. Ever since the time of Kergaradec,
persons have been in the habit of comparing this
sound to the ticking of a watch ; but it so nearly
resembles the pulsation of the heart of a new-born
infant, that no considerable difference can be
detected between them, either in character or
in frequency.* The only difference between the

* It is a very good plan to let those who are commencing
auscultation listen, for a few times, to the chest of new-
btra children, in order that they may form some idea of the
sounds of the fojtal heart. Children one year old answer
almost equally well for this purj)Ose ; and those persons


29


two appears to consist in the fact that no re-
lation necessarily exists between the strength of
the sound and the development of the foetus; for,
though generally the strength of the heart’s
sounds corresponds to the degree of foetal de-
velopment, yet sometimes the reverse of this is
found to be the case, the heart’s pulsations being
indistinct in a very strong, well-developed foetus,
while they are remarkably loud and clear in
another which is young and feeble. This dis-
crepancy is no doubt in great measure owing to
the circumstance that the heart’s action is heard
through various media, which differ in thickness,
density, and conducting power, and that the
position of the foetus is not always equally
favourable to the transmission of sound. In the
great majority of these cases, the heart would
probably be found acting with a force exactly
proportionate to the age, and degree of strength,
and development of the foetus, if it were possible
to apply the stethoscope immediately to its chest.
It must, however, not be forgotten, that the
heart’s action is sometimes less distinct in a

who havo previously practised listening; to the heart of
infants, will leam to distinguish the pulsations of the foetal
heart in a very short time.

D 3


30


strong child than in a weaker one, although
circumstances may in both be equally favourable
to the transmission of sound. This, indeed, is
not an occurrence peculiar to the foetal state, but
is, also, occasionally noticed in adults.

But, independently of this, the action of the
foetal heart is subject to other apparent changes,
from a different cause. On listening attentively
for a considerable time to the same part of the
abdomen, the beating of the foetal heart is some-
times found to undergo a great and sudden
increase in intensity ; or, on the contrary, to
diminish in force just as rapidly, becoming so
feeble as to be almost inaudible. These changes
in the heart’s action, however, though so striking
as to have attracted the notice of Kergaradec,
last but for a moment, and are merely apparent ;
the movements of the foetus, and its consequently
varying distance from the uterine parietes, oc-
casioning the sounds to be heard sometimes with
greater, at others with less distinctness.

The pulsation of the foetal heart has just been
described as a short, quick, double beat, exactly
similar to that of an infant’s heart ; and this
character has been insisted on, as serving to
distinguish it from any similar sound heard in the


31


abdomen of a pregnant woman. Now, it oc-
casionally happens that only one sound is to be
heard, and consequently this diagnostic mark of
the action of the foetal heart is absent, some
circumstance having rendered the second sound
exceedingly weak, or quite inaudible. Hitherto,
no one has called attention to this peculiarity in
the heart’s action ; but it is very important that
it should be borne in mind, since forgetfulness of
it may easily lead a person into error.

§ XVI.

The frequency of the foetal heart’s pulsations,
as deduced from a comparison of six hundred
cases, averages one hundred and thirty-six strokes
in the minute. Most writers appear to have
estimated the rapidity of the action of the foetal
heart at too high a rate, for when the foetus was
healthy, it was never found to exceed one hundred
and eighty, though it sometimes sank to ninety
strokes in a minute, and varied from one hundred
and thirty to one hundred and forty pulsations in
most cases.

Although it may appear very rational to sup-
pose that an alteration would take place in the
rapidity of the action of the foetal heart with the
advance of pregnancy, and that its pulsations


32


would become slower, as they do in infantile life,
yet careful observation proves such a notion to
be erroneous ; while Dubois’* investigations verify
the opinion, that the rhythm of the heart’s pulsa-
tions continues the same at the end as it was at
the beginning of pregnancy.f Indeed, so far are
the pulsations of the foetal heart from becoming
diminished in frequency as the end of utero-
gestation approaches, that instances sometimes
occur of their rapidity increasing in the latter
months of pregnancy, and even continuing greater
for some months after birth than it was when the
heart’s action first became audible.

Irregularities in the rhythm of the heart’s
contractions are still more frequent than varia-
tions in their strength. Whenever the foetus

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