The bruit do souffle, uterine murmur, then it produced in the walls of the uterus itself and is synchronous with the radical pulse. It can be heard in chlorotic females in whom no pregnancy exists, in cases of fibrous tumor and vesicular tumor of the uterus, and in males,. As a sing of pregnancy its value is very differently estimated by different authors, some giving it much more importance than others do. It can only serve to render probable the existence of pregnancy; since it may exist independently of pregnancy and does not always accompany it. No proof of he life or death, or position of he child can be obtained from the uterine murmur;l nor whether the uterus contains a double foetus or only a single one. (*For a fuller elucidation of this subject, compare Tyler Smith, Lecture VIII., and Cazeaux, on Signs of Pregnancy.) Where we are certain the female has no disease, the bruit de souffle becomes of some importance as a sign of pregnancy.
In auscultating the abdomen for the purpose of discovering the signs of the pregnancy; it should be remembered that the uterine murmur nay be first distinguished at about the fourth or fifth month, or at whatever time the uterus rises out of the pelvic cavity; and that the being of the foetal heart may be discerned in the course of the fifth month; so that in most cases the examine may expect to meet with both classes of sounds. The bruit de souffle coming first in order of time may severe to render pregnancy probable; while the clearly distinguished beating of the foetal heat not only renders absolutely certain the presence of a living foetus, but affords some indications as to is position in the womb, and its healthy condition.
Auscultation in the earlier months of pregnancy can only be accomplished by placing the female upon he back; later she may lie on her side, sit, or be examined standing. It is always best to use the stethoscope, which should be placed at once, first on the left side,, low down; then in the same region on the right side if necessary. Thus by applying directly to the place where the pulsations are most usually to be found we escape annoying he female by searching at random. It is important for the physician to avoid stooping too much, which in many cases will cause such a pressure of blood in his head as to prevent him from hearing at all. By using the stethoscope the examiner will avoid all danger of confusing the uterine s sounds by th fraction of his ear upon the abdomen; and at the same time relieve his patient from the close personal contact which to many females is a very serious annoyance. In cases in which the mother had already recognized the foetal movements, the stethoscope should be applied exactly opposite to the side where these are most distinctly felt. For the upper and lower extremities of the foetus which cause the ‘motions, being folded upon its abdomen, a nd the pulsations of the foetal heart being most distinctly perceived from the back if will be evident that if the motions e felt in the left side of the abdomen of he mother, the sounds of the foetal heart will be plainest on the right side, and vice versa. Before the first month, however, pulsations are usually most plainly discernible on the in median line, from the pubis to the umbilicus.
In addition to the uterine murmur, or as it is termed by some, the bruit placentaire and the beating of the foetal heart, certain ‘sounds of the displacement of the foetus, have been distinguished by auscultation; and at a period even prior to the uterine murmur. These sounds consist of shocks, sometimes quick, like a light tap,. and at other times more like a heavy plunge; and there are also friction of he foetus over he inner surface of the uterus. Some have even believed they could distinguish the pulsations over the funis itself, in cases where the parietes of the abdomen were extremely thin. But both these class of sound, while they possess at the least very little or practical diagnostic value, require for their successful discovery more protracted opportunities for auscultating the particular case, and greater skill and more extended experience in auscultation in general, than usually fall to the lot of the young physician, at least in private practice.
STATEMENT OF THE PRINCIPAL SIGNS OF PREGNANCY; Showing the time and order of their appearance; condensed from Cazeaux.
FIRST AND SECOND MONTHS-Suppression of the menses; usually from the first of conception; some exceptions, which however are less numerous in the later months. Morning sickness, nausea and vomiting, and other gastric disturbances; sometimes flattening of the hypogastric region depression of the umbilical ring. Enlargement and tenderness of the breasts; increase in the size of the uterus. It slightly descends, and becomes less movable.
THIRD AND FOURTH MONTHS.-Towards the close of the third month the fundus uteri rises to the level of the superior strait. About the end of the fourth month it reaches midway in the space between he umbilicus and the pubis. Vomiting and other gastric derangements. A small protuberance in the hypogastric region. By abdominal palpation a round tumor may be detected, of the size of a child’s head. Less depression of the umbilical cicatrix. Increased enlargement of the breasts; the nipple appears more prominent and the areola slightly discolored, especially in primiparae. In the fourth month the cervix uteri appears elevated, and directed backwards and to the left side. The orifice of the os tincae is more softened; in multiparae it is patulous, admitting the finger; in primiparae, it s closed and rounded. Kiestein in the urine.
FIFTH AND SIXTH MONTHS.-Towards the close of the fifth month the umbilicus is one finger’s breadth below the umbilicus; and the same distance above at the end of the sixth month. The gastric disturbances generally disappear. The sensation of “quickening’ may be experienced about the sixteenth or eighteenth or eighteenth week that is about the beginning or middle of the fifth month. Then the movements of he foetus itself begin to be noticed. The abdomen becomes still more enlarged. the umbilical depression is nearly effaced. The uterine murmur may be heard. And soon after the heating of the foetal heart may be distinguished. Ballottement may be performed. The discoloration of the areola becomes deeper. Kiestein in the urine. The inferior half of the intra-vaginal portions of the cervix uteri is softened. In multiparae the finger can penetrate the cavity of the neck, which in primiparae remains closed at its orifice, through softened.
SEVENTH AND EIGHTH MONTHS.-The fundus uteri is four fingers breadth above the umbilicus at the seventh month; and five or six at the eighth. Dilatation of the umbilical ring; pouting of the navel. The movements of the foetus are more sensibly felt. The sounds of the foetal heat are more clearly distinguished. Ballottement, which is easily performed in the seventh month, becomes obscure in the eighth. the softening of the cervix is ovoid and shortened; tin multiparae it is conoid, and so patulous as to admit the whole of the first phalanx of the finger, while at the upper portion of he neck it is remains closed. The areolae become darker. The breasts become more fully developed, and there is a show of milk. Kiestein still appears in the urine.
NINTH MONTH.-First Fortnight.-The fundus uteri reaches the epigastric region ad (on the right side) presses the inferior margin of the false ribs. Difficulty of respiration. the abdomen is still more enlarged; the skin is stretched and very tense. The foetal movements are active. The sounds of the foetal heart are head. In primiparae the cervix is softened and its external orifice slightly opened. In multiparae the finger may penetrate its entire cavity to the os internum, which remains closed.
Second Fortnight-The fundus uteri sinks down a little. The vomitings are less troublesome; and the respiration easier. Walking becomes difficult. Frequent and sometimes ineffectual efforts to urinate. In multiparae the internal orifice is dilated, and the finger may reach the naked membranes. In primiparae the entire cervix is expanded, the os externum remaining closed. Hemorrhoids; varices; and oedema of he lower limbs and even of the vulva.
