1847]: The Uterine Souffle or Blowing Sound. 499 Dubois. To apply the term pulsation to the sound is surely very inaccurate; seeing that there is a total absence of any impulse or beat accompanying it. It is a something to be heard, not to be felt. It has usually the character of a soft intermitting puff; at other times it resembles the whistling of the wind through an ill-closed window, only that it is saccadé and not continued; while in other cases it is of a graver note, and is not unlike the vibrations of a bass string, or the cooing murmur of a dove. But, whatever be the character of the sound, it is invariably isochronous with the pulse of the mother, and never with that of the fœtus. There is no point of the uterine globe accessible to the stethoscope, in which this sound may not be heard. It is, however, over the lateral regions of the womb that it is usually most readily perceptible; but Dr. Depaul is not prepared to say whether it be more frequently present on the right, or on the left, side. Hohl says on the former; Naegele on the latter, admitting, however, that he has found it on both sides at the same time, and occasionally over every part of the uterus. Out of 295 cases in which pregnancy exceeded the fifth month, our author heard a distinct souffle on each side of the uterus, at a little distance from the crural arch in 182. It was discoverable on one side only in 27, and over the fundus of the organ in 43. In 18, the stethoscope could not be placed over any point of the uterus without the sound being readily met with; and, in 12, it was audible at three distinct points, viz. the fundus, and the parts immediately above the crural arch on each side. When the pregnancy was less advanced, Dr. Depaul has given the following results of his experience. In 4 cases where pregnancy had not exceeded the end of the 3rd month, the souffle was heard in the median line above the pubis. In 13 cases, in which pregnancy had advanced another month, it occupied the same region: the ste thoscope, it should be stated, required to be pushed somewhat forcibly towards the pelvis to discover it. In 3 cases, in which gestation was about the same period, it was heard on each side. Lastly, in 16 out of the 27 cases, in which pregnancy had reached the end of the fifth month, the sound was perceptible over every accessible part of the uterus; but it was nevertheless easy to determine that it proceeded from the lateral regions. By the fourth proposition, the reader will perceive that Dr. Depaul confirms the accuracy of Dr. E. Kennedy's assertion that, the uterine souffle may be heard before the end of the third month, a period considerably earlier than that which has been fixed by most writers. The usual belief is, that it is not discoverable before the end of the fourth month; and, as a general remark, this is doubtless quite true. M. Bouillaud and one or two other writers have, it is well known, attributed the blowing sound of pregnancy to the pressure of the enlarged womb upon the iliac arteries, and the consequent partial obstruction to the easy flow of blood through them. On this point our author thus comments:→ 66 Although I entirely repudiate the doctrine in question, I am ready to admit the possibility of the production of a blowing sound from the cause mentioned, having met with several examples of the kind in my own practice. In these cases, the phenomenon exists also on one of the sides of the uterus; I have never met with it on more than one side in any single case; and, in general, it is upon that which corresponds with the lateral inclination of the organ, when it does exist. It is, like the genuine uterine souffle, completely isochronous with the maternal pulse, and, like it, follows all its changes; but it presents a constant character which will readily serve to distinguish the one from the other. We have now no longer a souffle without pulsation; on the contrary, what is present is a pulsation accompanied by a more or less intense souffle; but I have never met with this last so extended as to render the perception of the first at all difficult. Moreover, while the position of the woman, and consequently that of the womb, has no influence upon the genuine uterine souffle, the other, on the contrary, is modified and may even cease altogether." Dr. D. alludes, also, to the occasional transmission of blowing sounds which originate from the heart itself of the mother; but no attentive auscultator can ever confound these with the souffle of pregnancy; for the force or distinctness of the former always increases as we recede from the uterine region towards the cardiac, while that of the latter is diametrically opposite in this respect. As an illustration of the tenth proposition we may adduce the following case. Dr. Depaul was summoned to attend a young lady, pregnant with her first child; she considered herself to be at the full period. Upon making an examination however, Dr. D. was surprised to find the uterus so little developed; for its fundus scarcely reached beyond the umbilicus. He therefore suspected either that his patient had made some fault in her reckoning, or else that the fœtus had been dead for a length of time. The fresh details now mentioned by the patient seemed to confirm the latter idea. On repeated auscultation, no fœtal tictac was ever discoverable; but a remarkably strong blowing sound, becoming sometimes of a sibilant character, might be heard over the side of the uterus. Dr. D. communicated his opinion to the husband; and the event proved how completely accurate it was. On the discharge of the liquor amnii, which was sanguinolent and fætid, the fœtus was quickly expelled. It was in a semi-putrid state, and seemed to have been dead for two or three months. The placenta was the seat of old and serious changes. This case is but one out of a very large number of similar ones, which have occurred in our author's experience. The only other remark that we have to make respecting the uterine souffle is, that it becomes much less distinct during the presence of a labour pain, and that it will often disappear altogether when the contractions of the uterus are strong, more especially of the liquor amnii has already been discharged. Our next enquiry is about the still more important sign, afforded by the transmission of the sounds of the foetal heart through the uterine and abdominal parietes. The conclusions, which our author has drawn from all his elaborate researches upon this highly interesting point, are these: 1. The discovery of this auscultatory phenomena preceded that of the uterine souffle, and we owe it to M. Mayor.* While the claim of the eminent surgeon of Geneva to the merit of this discovery cannot be denied, it is nothing but fair to M. Kergaradec to state that he appears to have been entirely ignorant of it when, in December 1821, he read before the Academy of Medicine his important memoir, announcing the existence of a fœtal as well as of a uterine sound in the latter months of pregnancy. 1847] The Cardiac Pulsation of the Fœtus. 501 2. Although there has never been any dispute as to its seat, and as therefore the name given to it is not of much consequence, it seems preferable to adopt that of the double cardiac pulsation (doubles battements du cœur de l'enfant). 3. Resembling in some degree the tictac of a watch, it consists of two pulsations that are quite distinct, and, in general, without the admixture of any blowing sound or murmur. 4. Nevertheless, a blowing or a rubbing sound may accompany it; but such an occurrence is rare, nor does it at all indicate the state of health of the child. 5. The double foetal pulsation may often be heard earlier than is usually supposed. It is frequently discoverable by the end of the fourth month, and occasionally at three months and a half, or even earlier. I have adduced facts which incontestably prove that it may be heard at the end of the 12th, and even of the 11th, week of pregnancy. (This is however of rare occurrence). 6. The absence of the fœtal pulsations is an exceptional occurrence in the three last months* of gestation, unless indeed the fœtus has ceased to live. They were absent, or could not be heard, in 8 only out of 906 women who had advanced to this period. 7. The point of the uterus where they are best heard varies with the period of pregnancy, and still more according to the situation of the child. 8. The spot, which corresponds to the heart, is that which transmits them most forcibly; but, starting from this spot as from a centre, they may be perceived over a greater or less extent; and sometimes they exist, with a variable intensity, over every part of the uterus that is accessible to the stethoscope. 9. In the normal condition, their frequency always exceeds that of the maternal circulation. 10. This frequency is nearly the same at different stages of gestation; it is therefore an error to state that it goes on diminishing in proportion as the pregnancy advances to its completion. 11. The uterine contractions have an obvious, but usually only a very transitory, influence upon the fœtal pulsations. 12. Their force becomes greater as pregnancy advances; but a good deal in this respect depends upon the circumstances of each case. 13. Moral emotions experienced by the mother have no direct influence on the life of the fœtus. 14. Disturbances of the maternal circulation act only consecutively on the foetal circulation. 15. In my opinion, it is impossible to confound the double pulsations of the fœtus with any other sound which may be heard in the abdomen of a pregnant woman. 16. Their presence certifies not only the existence of pregnancy, but also the life of the foetus. In several passages of our author's work it is stated that, in the latter half, or four months and a half, of pregnancy, the absence (or inability to detect the presence) of the foetal tictac is quite the exception. 17. They may be discovered at a period of pregnancy, when all the other modifications or phenomena lead to but a mere probability. 18. Their absence, ascertained upon several occasions by an experienced observer, will never mislead; and, in every case, this circumstance has a value above that of all the other signs which are usually regarded as indicative of the death of the fœtus. 19. Two double pulsations, distinct and not isochronous, warrant with certainty the diagnosis of a twin-pregnancy. 20. If three such pulsations, each having a peculiar rhythm, were present, it might be possible to recognize a triple pregnancy. 21. The discovery of a fœtal circulation, when at the same time it is known that the uterus cannot contain the product of conception, would suggest the existence of an extra-uterine pregnancy. But, as yet, this is a mere matter of rational conjecture. 22. It is undeniable that, in an immense majority of cases, provided the pregancy be sufficiently advanced, it is quite possible to ascertain with precision how the child lies in reference to the inlet of the pelvis, and the relations of its different parts both with the inlet and with the walls of the uterus. 23. For this purpose, it is not sufficient to make out with certainty the existence of the double pulsations at any one point of the uterus; the exploration must be general, for it is necessary to ascertain what I have called the summum of their intensity. 24. In order that the diagnosis, founded on stethoscopic results, may have all the value that can be desired, it is proper that the examination be made, or repeated, at the time when an opinion is given; for it is not impossible, though unquestionably rare, that the fœtus when well developed may, by its own proper movements, modify its position and even its presentation. 25. As it is necessary, in ascertaining the progress of labour, that an examination be every now and then made by the vagina, so, but in a yet higher degree, it is indispensable, as respects the child, to discover at short intervals the state of its circulation. 26. The modifications, which may occur in the double pulsations, ought to be studied with attention; for, when they exceed certain limits, the life of the fœtus will be found to be compromised, 27. These modifications may be only transitory; and then, either they may be sufficient to produce a hurtful influence on the life of the child, and delivery alone can save it; or they may have created a merely temporary distress, which will speedily pass away and not require the interference of art. 28. However this may be, nothing will better enable the physician to appreciate these different conditions than the state of the fœtal circulation. 29. The changes or modifications, which indicate something serious, consist more especially in an irregularity of the pulsations, and in a marked diminution of their frequency and force. 30. Excessive acceleration never indicates any thing amiss; the beats may exceed 200 in a minute, and the child remain quite healthy. 31. The value of such-like facts will be appreciated when the choice of 1847) The Cardiac Pulsation of the Fatus. 503 an operation has become necessary a choice that must be founded on the combined interests of mother and child. 32. In the same measure as the discovery of the uterine souffle is of comparatively little value in practice, so that of the foetal cardiac pulsations possesses very great importance; no other sign or phenomenon can replace it as a means of exact diagnosis. On the subject of the seventh of these propositions, we find the following remarks : "As the double sound or tictac has its seat in the heart of the foetus, which, in the early months of pregnancy, enjoys a great mobility within the uterus, we can readily understand how it may be heard at very different spots in the hypogastric region at different times. Moreover, the considerable extent, over which it may be perceived, must serve to produce considerable differences in this respect. It may be said in a general way, that it is in the part of the organ which corresponds to the heart of the child that it will be found, and that from this spot it radiates-diminishing in intensity-over a space of from two to four inches square. In some cases, it extends over a large space at the full term of pregnancy; and it is not impossible but that it may be detected at every point of the uterine globe that is accessible to the stethoscope. The following, however, may be taken as the usual state of things. When it is first perceptible from the twelfth to the sixteenth week, it is by the fundus of the uterus, which then begins to exceed the pelvic inlet and can alone be explored, that it is transmitted. Most usually, it is by no means a matter of indifference in what way the pressure with the stethoscope is made. It is almost always necessary to give it a vertical direction, i. e. parallel with the axis of the uterus itself. Ás a matter of course, the bladder should always be quite empty at the moment of exploration. In proportion as the uterus rises above the pelvis, the preceding considerations are less frequently applicable, and then it is over one or other of the lateral regions of the organ that we may expect to find the sound; although it may be perceptible also upon the median region. According to my experience, however, this is of much less frequent occurrence than at an earlier stage of pregnancy. The explanation of the difference is probably this. From the fifth to the sixth month, the size of the fœtus is much more considerable, and the quantity of liquor amnii is proportionately less; hence there is more fixedness in the relations, and more facility to keep the uterine parietes in contact with certain regions of the fœtal ovoid. We shall presently see that these are not all equally capable of transmitting the cardiac sound. "But it is especially in the three last months of gestation that the influence of the conditions just mentioned becomes evident; and this in such a marked manner, that, if the exact position of the foetus were previously known, one might with almost complete certainty indicate the region upon which the stethoscope should be placed. The results of an extended series of observations warrant me in asserting that, in a large majority of cases, the double sound will be found along the trajet of a line which, extending from the left antero-superior spine, would terminate in the umbilicus; that, much less frequently, it will be found over the correspondent points on the right side; and that, much more rarely still, it will be found above the umbilicus, sometimes on the left and at other times on the right side. It is at this period also that it may extend from its point of departure over a considerable space, and that, in some instances, it is even discoverable over every accessible point of the uterus." Dr. Depaul has some very interesting observations on the independence of the foetal and maternal circulations, that well deserve to be attended to; but we must refer our readers to his work for particulars. We cannot, |