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we have had no opportunity of ascertaining its powers in this respect, the determining of which would require a series of experiments, carefully conducted, and on a large scale."
Should any of our readers wish to learn more respecting the evidence of our Irish brethren about the Ledoyen fluid, they cannot do better than consult the capital article in the last number of our Dublin contemporary, from the pen of the editor. It exposes, with a not-unjust severity, the system of bold and braggart assertion which Colonel Calvert has thought fit to employ, in puffing off the nostrum which he has taken under his im. mediate protection.
Of the two preparations, which have now been brought before the attention of our readers, we are strongly inclined to believe that Sir W. Bur. nett's will be found to be most generally and extensively useful. Future experiments, however, can alone decide the point, One thing is certain, viz., that it is much more potently antiseptic than its rival. And this is just what might, à priori, be expected; for we know that Chlorine and many of its compounds have a very marked influence on all sorts of decay ing matter, as well as upon most, if not all, offensive odours; whereas the action of the Nitrate of Lead appears to be limited to the neutralisation of ammoniacal and hydro-sulphuric gases. Some of our readers may perhaps remember that the late Professor Daniel was led, by the results of some experiments, to suppose that the waters of the estuaries and western seacoasts of Africa contained a large amount of the last-named gas--generated, it was presumed, by the action of decaying organic matter upon
the sulphates contained in the sea-water--and to throw out the hint that the existence of this deleterious gas in the atmosphere might be connected with the production of that pernicious miasm which infests the regions alluded to, and proves so destructive to human life. The accuracy of the above statement has, however, not been confirmed, we believe, by subse. quent researches, while the probability of the suggestion is at once set aside by what we know of the development of similar morbific malaria in other parts of the world. No observations, as far as we know, go to prove that there is a fixed connection between the production of any form of fever, and the mere presence of any chemical gas in the atmosphere. The bearing of this remark upon the alleged " disinfecting” properties of the Ledoyen and Burnett fluids, and more especially of the former, will be at once obvious. One remark more, and we have done. Let it never be forgotten that the possession of an efficient antibromic may lead to the very serious evil, in certain circumstances, of getting rid of a temporary nuisance, while the removal of the radical mischief is overlooked or nego lected. Dr. Smith and Messrs. Grainger and Toynbee have very properly dwelt, with marked emphasis, upon this point in their report; for, after all, cleanliness and free ventilation are the best sweeteners in the world.
1847] Depaul on Obstetrical Auscultation.
495 , t་༣་རྒྱུ ༔ ཙ, ཀན ཎ *,, ༔ , ; ༡ i《» 11 sing 101 BS TRAITE THEORIQUE ET PRATIQUE D'AUSCULTATION OBSTETRI.
CALE. Par J. A. H. Depaul, D.M., &c. &c. Octavo, pp. 400. Paris, 1847, Labé.
The subject of Obstetrical Auscultation has not attracted that notice and attention in this country which its importance demands. With the exception of Dr. Evory Kennedy, whose admirable volume contributed so much to diffuse a knowledge of it at the time of its publication, 1833, our obstetrical physicians have done but little to advance this most interesting branch of professional research, and, in this respect, have been greatly behind their brethren in France and Germany. The volume before us contains the results of our author's observations commenced ten years ago in the wards of the Maternity Hospital at Paris, under the guidance, we believe, of Professor Dubois, and steadily persevered in ever since both in hospital and in private practice. The author writes as one who is thoroughly acquainted with his subject, and his work is therefore likely to become, we should think, a manual of information on the subject of which it treats.
It is divided into two parts, the Historical and the Didactic. The first,
treatises and papers which have been published both in France and else where on the subject since the appearance of the admirable memoir of M. Kergaradec-unquestionably the true founder of obstetrical auscultation, although M. Mayor of Geneva had anticipated him in the discovery of one of its principal phenomena in 1822 down to the present time, with an analytic summary of the contents of the most valuable of these writings. To the intelligent reader this account will prove acceptable ; as it is not less instructive than interesting to trace the successive steps by which any branch of useful knowledge has reached to the status in which it now exists. We must, however, at once pass to the contents of the second or didactic part, which treats of the sounds that are discoverable in the abdomen during pregnancy, and the presence of wliich is more or less pecuá liar to, and characteristic of, this condition. There are, however, one of two prefatory observations that should be first briefly alluded to.
Dr. Depaul admits that the auscultation of pregnancy is attended with much more difficulty than that of thoracic diseases, and that skilt, however great, in the latter department of diagnostic enquiry will not suffice to ensure speedy success in the former. He has known more than one in stance of a diligent student not succeeding in distinétly making out the existence either of the uterine or of the fætal sound, until after several months' repeated trials. M. Dubois, now one of the best obstetrical aus. cultators in Paris, confesses that he had to serve a long apprenticeship (that is the word he uses himself) to the pursuit, before he acquired any. thing like confidence in the results of his observations. It is undeniable, however, that, notwithstanding the difficulties, it only requires persevering diligence, and the opportunity of a sufficiently ample experience, to enable any one to overcome them all, and to gain that readiness in discovering
the presence or absence of those important signs of the pregnant state, which the sense of hearing can alone discover. Dr. Depaul suggests that there should be a regular class for obstetrical auscultation in every good school of medicine ; nor do we see how the available and practical knowledge of it can ever be obtained save in this way. Certain it is, that no one will ever be able to instruct himself by the merely occasional opportunities afforded by private practice.
Besides the most perfect silence in the chamber, there are two or three other circumstances which the auscultator will find well to attend to. The rectum and bladder ought, if possible, to be empty at the time of the examination; for, independently of the sounds which may arise from the contents of these viscera, it is obvious that the distension of the abdomen, so produced, will prevent that ready pliancy and yielding of its parietes to the pressure of the stethoscope which it is often necessary to make, especially in the early months of pregnancy. Dr. Depaul prefers the recumbent to any other position for the
purpose of auscultatory examination of the uterus. The thighs ought to be somewhat bent, in order to relax as much as possible the abdominal muscles; in this way only, can the con. tour of the uterine globe be distinctly traced, and the stethoscope be applied to its lateral regions. The height of the bed, on which the woman lies, is a matter of some consequence to the physician; for, if it be too low, he will soon find that the fatigue of stooping will prevent him from continuing his examination so long as he might otherwise wish ; not to mention the headache and confusion of hearing which are apt to be produced thereby. Nothing should intervene between the instrument and the abdomen of the patient, but a soft handkerchief or chemise if this be thin and quite smooth ; but in obscure cases it is better to apply the instrument directly to the uncovered skin. The corset, or any other tight article of clothing, must have been previously removed.
Dr. Depaul, it should be here remarked, gives a decided preference to mediate over immediate auscultation in obstetrical examinations. The following passage contains his reasons for this purpose.
“ In the first place, immediate auscultation cannot be employed, with any prospect of advantage, in the early months of pregnancy, when the uterus is scarcely above the level of the pelvic entrance. The same will be the case in a somewhat more advanced period, when, although the organ is higher up, there are interposed between it and the abdominal parietes folds of intestine or other intervening substance. The naked ear cannot be employed without bringing a large extent of the abdomen in contact with the side of the face. From this circumstance result, first, the friction-sounds inseparable from so extensive a contact; secondly, (and this remark had not escaped the penetration of Laennec,) in order sufficiently to depress the parts that separate the ear from the uterus, it is necessary to employ a much greater degree of force, the consequence of which is that the physician thereby increases the sounds arising from the contraction of his own muscles; and thirdly, even when the pregnancy is far advanced, and especially when there is a tendency to the anterior obliquity of the uterus, there are certain points of it which cannot be conveniently explored, those, for example, adjoining the inguinal regions.
The great advantages of auscultation with the stethoscope are, that the sounds are thereby rendered more distinct and readily perceptible; that we can more easily determine their limits, as well as distinguish the one from the other; and, lastly, that we can with much greater accuracy appreciate their different shades or degrees 1847) The Uterine Souffle or Blowing Sound. 497 in point of intensity or force. This is not because the instrument adds aught to their intensity, but merely because it enables the physician to come within a shorter distance of their origin.”
In all the cases in which our author has succeeded in detecting the auscultatory signs of pregnancy in the very early months of pregnancy, it was with the aid of the stethoscope ; examination with the naked ear having proved quite ineffectual. He then adds :
« The pressure which is made with the ear necessarily bears upon a large surface, and this has many inconveniences. With the stethoscope, on the contrary, we act upon a limited point, and avoid all friction-sound. In the great majority of cases, moreover, we can, without effort or danger, remove or push aside the stratum of liquor amnii interposed between the fætus and the uterine parietes. This proposition will be received with doubt by those who are in the habit of believing that the uterus is quite distended with fluid during pregnancy. But this opinion is not correct. When the different evolutions which take place during pregnancy succeed one another with regularity, the uterus remains yielding and compressible at all the stages, and this too usually to a considerable degree. Very near the full period, one or two litres of liquid might still be added to the liquor amnii, before complete distension was produced. In several instances, where women have died near their full period but without being delivered, and where the ovum was in all its integrity, I have ascertained the truth of the assertion now made."
We may observe that the stethoscope which Dr. Depaul always uses is one invented by himself, and which is now, he says, very generally used in Paris for obstetrical auscultation. A figure of it is given in his work. After these preliminary remarks, we now proceed to lay before our readers the pith and marrow of our author's very minute and accurate description of the different auscultatory signs of pregnancy; and this we shall do most correctly and briefly by first giving the conclusions, in wbich he has himself compressed and embodied the contents of each chapter, and then selecting a few passages from the main text to illustrate some of these conclusions at rather greater length. And first, of that sound which has its seat in the uterus itself, and with which the fætus has nothing directly to do.
1. The denomination of uterine souffle is preferable to any other term that has been proposed.
2. The uterine souffle does not resemble other blowing sounds that are perceptible along the trajet of arteries. Like them, indeed, it is isochronous with the contractions of the left ventricle; but it has characters peculiar to itself.
3. It varies exceedingly in respect of tone and persistance, and also as to the point of the uterus where it exists, &c. &c.
4. It has been demonstrated by incontestable facts that it may be perceived in the middle of the 11th, and even at the end of the 10th, week of pregnancy. In general, however, it cannot be discovered till somewhat later.
5. Its intensity goes on increasing until the end of the 7th month ; after this time it makes but little progress. Allowance must be made for individual differences.
6. It is produced in the arteries of the uterus, and may be heard over every point of the organ that is accessible to the ear or to the stethoscope.
7. It is in the peculiar arrangement of the arterial system of the uterus, and in the modifications to which it is liable from the active movements of the foetus, that we find the best explanation of its production, its irregularities, intermissions, changes in point of situation, &c.
“ด : 1 * 8. Many physicians have erroneously regarded it as a sure and certain sign of pregnancy. Taken by itself, it has not much more value than the other rational signs of this state: but, in connexion with some others, it gives an importance to them, while at the same time it acquires a very great value itself. 59. It cannot in the present day be denied that a sound, in every respect similar to the uterine souffle, may exist when the enlargement of the uterus is owing to'a cause altogether different from pregnancy.
10. The death of the fætus does not appreciably modify it ; & fortiori, it does not cease upon this event. We cannot, therefore, have recourse to it with advantage, if our object be to ascertain whether the child lives or not. :'3 1. II. Neither is it modified by the diseases which may attack the fætus during the course of intra-uterine life. ww112. If it be true that a direct relation generally subsists between the size of the placentu land! that of the child, we are not warranted in believing, as some writers would have us do, that we can judge of the strength and development of the latter by the intensity, or by any other character, of the uterine souffle. aw v...
To 918i 1.98 ** 13. As it is clearly established that there is no necessary relation be: tween the uterine souffle and the placenta, we can readily understand that the morbid conditions of the latter are not discoverable by any modifications of the former.
de notor: 14. For the same reason, this sound is incapable of giving us any precise 'notions as to the 'exact spot where the placenta is attached, and, if chance has sometimes seemed to warrant the idea in question, innumerable facts to the contrary have abundantly proved its general fallacy. -7 15. To pretend that, by the aid of this sign, we can form any rational conjecture as to the shape of the placenta, is an opinion altogether contra. dicted by experience, but which was, in some measure, the forced consequence of the erroneous doctrine that the uterine souffle was necessarily connected with the circulation of the placenta... 1./16. Neither can the presence of double pregnancies be ever made out by the existence of more souffles than one. Experience proves that two and even three distinct souffles may be met with, when the pregnancy is single; and anatomy, moreover, has shown that, in the majority of cases of twins, there is only one placentary muss.
17. The uterine souffle is of no utility in determining the situation of the child in the womb..
1:!; Hy-if: ;- r18. Lastly, it follows from all that has been now stated, that this sign is of very limited value in respect of its applications to practice." "With regard to the first proposition, Dr. Depaul remarks that, being convinced that the sound in question is not limited to the seat of the placenta, and that it does not necessarily arise from the circulation through its vessels, he objects to the appellation of placentary souffle which has been given to it by many writers, and prefers that of uterine souffle first proposed by M.