Evory Kennedy.

Observations on obstetric auscultation, with an analysis of the evidences of pregnancy, and an inquiry into the proofs of the life and death of the ftus in utero online

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OBSERVATIONS



OBSTETRIC AUSCULTATION,



WITH

AN ANALYSIS

O F THE



EVIDENCES OF PREGNANCY,



AN INQUIRY INTO THE PROOFS OF THE LIFE AND
DEATH OF THE FCETUS IN UTERO.



By EVORY KENNEDY, M.D.,

Licentiate of the King and Queen's College of Physicians in Ireland, Lecturer on

Midwifery, and ttie Diseases of Women and Children, at the Richmond

Hospital School, and late Assistant to the Dublin Lying-in Hospital.



WITH AN APPENDIX CONTAINING LEGAL NOTES,
By JOHN SMITH, Esq.,

BARRISTER AT LAW.

WITH NOTES AND ADDITIONAL ILLUSTKATIONS,

By ISAAC E. TAYLOR, M.D.



NEW-YORK: }%^.)^^/
J. &, H. G. LANGLEY, 57 CHATHAM-ST.

18 4 3.



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CONTENTS



Pago

Dedication . . . . vii

Editor's Preface . .9

Dedication . . . % . . . . . . 11

Evidences of Pregnancy . . .... . .1

Divided, first, into those ascertained through the representa-
tion of the individual supposed pregnant ... 5

Rigor coittis and general excitement 8

Pelvic and lumbar pains 9

Morning Sickness, &c . '9

Menstrual suppression . 10

Sympathetic mammary pains . . . . . .20

Cerebral sympathies, vitiated tastes, cramps, &c. . . 21
Alvine and urinary excretions ..,.*. 22

Quickening 23

Divided, secondly, into those sensible to the medical atten-

dant 30

Tangible Evidences 31

Those ascertained per vaginam, as the state of the hymen . 31
Changes in the os uteri (Levret's test) . . . .35

Development of the neck 36

Tilting up of the fcetus {abattement) . . . . .43
Those ascertained through the abdomen, abdominal en-
largement 45

Percussion . . , 49

Active motions af the foetus 52

Passive motions (ballottement) 54

Visible Evidences . . 58

Mammary development, formation of areola, &c., and se-
cretion of milk 58

Emerging of umbilicus, abdominal fissures . . . .64
Countenance, discoloured skin, spots, jaundice, &c. . . 64

Swelled limbs, varicose veins, &c 65

M. Nauche's urinary test 66

Audible Evidences .71

Auscultation, mediate and immediate . . . .73

Wrisberg's test 75

Placental souffle 78



IV CONTENTS.

Page
How produced « . , 78

Dr. Haus's riews 84

Laennec's and Corrigan's explanation of bruit de soufflet . 87
Possible sources of deception in exploring for a placental

souffle . . .88

Practical benefits deriyed from the placental souffle . . 94

Foetal heart . . 103

Extent of its pulsation, on what depending . . . 104

Its frequency and varieties . . . . . .107

Remarkable connexion between vascular system of mo-

ther and foetus • . . 108

Situation of foetal heart Il5

Period of its detection . 118

Its utility as an evidence of pregnemcy .... 127

Difficulties attending its detection * . . . . 131
Funic pulsation and souffle . . v . . . 137

Compound Pregnancy 147

Popular signs of twins 147

Signs afforded by auscultation 149

Utility of auscultation where a doubt exists of a second

child remaining in the uterus ...... 152

Singular case in which a child was heard to breathe and cry

in the womb 159

Complicated Pregnancy 161

Pregnancy complicated by the co-existence of an inordinate

secretion of liquor amnii 161

of air and hydatids in the uterus 164

of structural disease of the uterus . . . .165

of abdominal and pelvic turnours, tympanites, and as-

cites ......... 166

Pseudo.Pregnancy 176

Actual pseudo-pregnancy depending on extra-uterine or-

gauic alteration or disease, as ascites .... 178

tympanites abdominalis . . .. . .. ^ .181

visceral enlargement, ovarian development, &c. . . 184
Depending on fimctional changes of the uterus, as retention

of menses ......... 187

menorrhagia, dysmenorrhea, &c. . . . . . 192

Depending on structural disease of the uterus . . . 193
Upon intra-uterine growths, as moles . . .. ^ . 196



CONTENTS. V

Pago
hydatids, hydrometa, and tympanites uterinus . . . 198

Nervous or Ideal Pseudo-Pregnancy 202

Premeditated or simulated Pseudo-Pregnancy . . . . 206
Motives for having recourse to this deceit .... 207

Joanna Southcott's case 210

As a plea in bar of execution in criminal cases . . . 211
Case of Margaret Mackessy, tried at Limerick, March,

1831 . . .212

Anomalies of our law as regards quickening in these cases . 214
Case of Catherine Smith, tried at Carlow, January, 1830 . 215
Objections to the present jury of matrons system . .218

Case of Mary Wright, and Norwich jury of matrons . . 220
Pseudo-pregnancy resorted to for the purpose of imposition

in livil cases 223

Writ de ventre inspiciendo 224

Inquiry into the Proofs of the Life and Death of the Foetus in

Utero 225

Causes of child's death 226

Importance of ascertaining whether the child be ahve dur-
ing pregnancy 227

Maternal evidences of its death ; general health . . 230

State of the breasts . • . . . . . .231

Flaccidity, with sense of falling and coldness in abdomen . 232
FcBtal evidences ; child's motion ..... 233

Evidences afforded by auscultation ; foetal heart . . . 237

Placental souffle 241

Cases by Dr. Wm. Stokes, M. Kergaradec, Dr. Breheret,

and M. De Lens 247

Importance of ascertaining whether the child be alive or

dead during labour 249

Causes of child's death in labour 252

Merat's experiments 253

Popular signs of child's death in labour ; falling of abdo-
men, and absence of child's motion .... 255

Foetid discharge 256

Discharge of meconium 258

State of the head in dead fcEtus 258

State of the arm ; abrasion of cuticle, «&:,c. &c. . . . 261
Want of contraction of sphincter, and action of jaws . . 262
Absence of pulsation in funis 262



yi CONTENTS.

Page
Importance of ascertaining the life or death" of the child

in labour 264

Utility of auscultation in this respect 265

Position in which foetal heart is perceptible in different
stages of labour, in natural presentation .... 266

In presentation of the arm, breech, foot, &c. . . . 267

Difficulties attending exploring in cases of labour, from

uterine action ; distention of bladder .... 270

Extension of the maternal heart's action and aorta ; irre-
gularity of foetal heart's action ; muscular irritation . . 271

Cases illustrative of benefits of auscultation in pronouncing
on the vitality of the child 272

Apphcation of the stethoscope to detect the heart's action
in still-bom children . . . . . . . 280



APPENDIX.

LEGAL NOTES.



Offences against the fostus in utero considered with reference
to the supposed importance (in point of law) of ascertain-
ing the period of quickening. Note [A] .... 285

The plea of pregnancy in stay of execution considered in the

same point of view. Note [a] 293

The writ de ventre inspicieyido considered in the same point of
view. Note [B] i ... 301



FRANCIS E. BERGER, M.D.,

&c. &c. &c.



My Dear Sir,

There is no one whose name I can with
so much pleasure, and propriety, prefix to the following
pages as your own. Permit me, then, in testimony of your
public worth, and private virtues, the high esteem in which
your character is held, and my grateful remembrance of a
series of kindnesses bestowed, which can never be repaid
nor forgotten, to inscribe them to you.

Yours, most truly,

Isaac E. Taylor.

New. York, April 11, 1843.



EDITOR'S PREFACE.



As the Profession in this country have not through the
numerous republications been presented with any work
on Obstetric Auscultation, the Editor has been induced to
enter upon the present undertaking with the hope of provid-
ing for the obstetric student, that which he regarded as a
desideratum in the profession — especially as only short
notices have been given on this subject, in the late English
publications, that have been republished in this country.

Since the publication of the author's work, much valua-
ble information has been elicited, and the editor has en-
deavoured to adduce all that relates to this point up to the
present period, together with the results of his own expe-
rience. He has also ventured to draw comparisons between
pregnant and non-pregnant females — primiparse, and those
who have borne children, which may possibly be accepta-
ble to the younger members of the profession, and to those
whose minds have not yet been directed to this subject.
He has also enlarged more fully on other late signs of
pregnancy, which have received but a passing notice from
the author.

Should he be chargeable with deficiencies, notwithstand-
ing his earnest solicitude to supply all that is essential to the
subject — his short-comings will he hopes meet with indul-
gence. He trusts nevertheless that the object which he has
felt anxious to accomplish, may tend to a wide diffusion and
more correct opinions, than have hitherto prevailed in the
profession, and that society may reap advantage from his
labours.



JOSEPH CLARKE, Esq. M.D.,

HONORARY FELLOW OF THE COLLEGE OF PHYSICIANS, SENIOR VICE-
PRESIDENT OF THE ROYAL IRISH ACADEMY, ETC.



Sir,

Admiration of those talents which have
enabled you to confer such benefits upon society, through-
out a professional career of extraordinary duration and
celebrity, veneration for active philanthropy, and strong
feelings of personal regard, induce me to dedicate to
you the following Treatise. The importance which you
attached to the subject was influential in directing my
attention to its investigation. Anxiously hoping that you
may not consider as valueless the results of that investi-
gation,

I have the honour to remain,

Your faithful and obedient servant,
EvoRY Kennedy.




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OBSERVATIONS,

(fee (fee.



CHAPTER'!,



EVIDENCES OF P R-E G N A N C Y.

If we for a moment consider the responsible task the
medical adviser is occasionally called upon to perform,
vi^hen desired to pronounce on the existence or absence
of pregnancy ; that peace of mind, domestic- happiness,
character, property, nay, even life itself, may be sacri-
ficed by inaccuracy in his diagnosis ; we shall find ample
reason to question, whether there be, in the broad field
of medical science,-any subject which more calls for the
attention of the practitioner, as well from its importance
as from the difficulty so frequently attending its investi-
gation.

Every medical man, at all conversant with midwifery
practice, knows how often he is required to give an opi-
nion in cases of doubtful pregnancy, by his ordinary pa-
tients, who are naturally anxious to be acquainted with
their real situation ; and he also well knows what dissa-
tisfaction and want of confidence his refusal to give a
decided answer on this subject frequently engenders.
How much is his embarrassment increased, when he is
1



2 EVIDENCES OF PREGNANCY

called on to decide in those cases where private character
or public justice is at stake, and in which, from their
very nature, must be expected nought but concealment
and misrepresentation !

It is a matter very easily proved, that difficulties in
this respect do, and by no means very unfrequently, meet
us in our practice. It shall be our endeavour to explain
upon what these depend, to canvass the means at pre-
sent relied upon for meeting them, and to offer some in
addition, which may guide and assist us in overcoming
them.

The appearance of a distinct treatise having such
objects in view may to some seem superfluous ; these
subjects having been treated of at large in all the stand-
ard works on Midwifery. They have, however, and that
very lately, engrossed the attention of some of the most
eminent writers in that department ; and the candid opi-
nion of any man who will be at the trouble to consult
such, must be, that the subject still demands elucidation.
If it were necessary, the testimony of numberless authors
could be adduced to corroborate this statement ; but
every individual possessed of even a moderate opportuni-
ty of observation must bear witness to its correctness,
and agree in thinking that the diagnostic signs of preg-
nancy are still very obscure, particularly in some of those
cases where their assistance is most required ; as, for
instance, where pregnancy is simulated by, or compli-
cated with, other altered or morbid conditions, and where,
with a view to treatment, diagnosis is a matter of the ut-
most importance : while candour obhges us to admit, not
only that in such cases mistakes too frequently occur,
but that they are occasionally productive of the most
mischievous consequences.



EVIDENCES OP PREGNANCY. 3

In this state of acknowledged deficiency in our diag-
nosis, more than ten years have elapsed since the atten-
tion of the profession was directed to auscultation by
Dr. Kergaradec, who published some cases proving its
utility in this respect: yet, strange to say, notwith-
standing the splendid results which have, in the course
of a very few years, attended its employment as a diag-
nostic means in other branches of jphysiological and pa-
thological investigation, auscultation in pregnancy has
heretofore either escaped the notice of authors, and been
altogether passed over in the systematic and other works
on midwifery which are daily issuing from the press, or
else has been noticed in so cursory a manner as to prove
that it had not engrossed the attention or undergone the
scrutiny due to so useful and so interesting a discovery.

On the necessity which exists for accurate knowledge
on the subject of the life or death of the foetus in utero^
and the total-inefficiency of the means which have hitherto
been in use to assist us in forming our decision on that
point, it is unnecessary to dwell, as every tyro in mid-
wifery must be aware of the former, and every individual
who has practised must have had painful experience of
the latter. One of the objects of this treatise is, if not
to supply this deficiency, at least to lessen the difficulties
which so frequently meet us under such circumstances.

In turning my attention at first to the investigation
of the subject, I was merely actuated by a wish to obtain
a more accurate method of deciding in cases involved in
doubt and uncertainty. Having with this view instituted
a series of experiments, and carefully noted the pheno-
mena that presented themselves, and that in an ample
field for observation, I found my trouble fully repaid by
the experience thus acquired of the advantages of aus-



4 EVIDENCES OF PREGNANCY.

cultation, as it not unfrequently enabled me to pronounce
with a certainty which actual demonstration could alone
warrant in those very cases in which, without it, had I
formed any opinion, I should have done so with extreme
hesitation. The benefit derived from it must explain my
motive in drawing the atterftion of the profession to what
must be pronounced as an improvement of practical utility
in midwifery. It is not meant, in recommending auscul-
tation, to do so to the exclusion of those means already
relied on, nor to ascribe to it any undue merits, which
would totally frustrate the object of the author in recom-
mending it, as by thus "loading it with pieces of super-
fluous armour, which encumber rather than defend," he
would undoubtedly bring it into disrepute.

To such as object to it, because opposed to all inno-
vation, I would merely repeat the words of one of our
patriarchs on midwifery, Mauriceau : " I desire, if you
mean to profit by my book, you will read and examine it
without critical envy, free from all pre-occupation that
may obscure your judgment, and hinder your acknow-
ledging the truth of what I profess to teach ; therefore,
follow not such as condemn a conception when they un-
derstand it not, and believe it false because it is new."
Whilst one can freely enter into, and commend the feel-
ings of such as are deliberate in forming opinions upon
reputed improvements in science, and particularly in
medicine, it cannot be denied that there are few things
which injure and retard science more than scientific in-
credulity ; and if we inquire into its cause, we shall not
unfrequently find it arise from feelings directly opposed
to philosophy and moral principle. I say so much, be-
cause there are, even at the present day, some who not
only deny the utility of auscultation as a means of diag-
nosis, but even attempt to turn it into ridicule.



EVIDENCES OFPREGNANCY. 5

Pregnancy has been defined as that state in which a
woman is when she has conceived, and which is hmited
by the period of conception, constituting its commence-
ment, and that of dehvery or abortion, its termination.
The ovum may be situated within or without the uterus,
thus giving rise to the denominations uterine and extra-
uterine pregnancy. As a useful practical division of this
subject, we shall here adopt the French plan, and con-
sider pregnancy under the heads simple, compound, and
complicated. The first occurs when there exists but one
foetus ; the second, when there are two or more ; and
the last, when there is a complication from the co-exist-
ence of one or more, with disease either of the uterus or
some of the neighbouring parts, rendering diagnosis in
these cases doubly difficult from the contradictory symp-
toms which attend them. The consideration of pseudo-
pregnancy, which may be defined as that condition simu-
lating pregnancy by the presence of the symptoms usually
accompanying this state, shall afterwards demand our
attention.

Innumerable are the symptoms of pregnancy as men-
tioned by all those authors who have treated upon this
subject. Our more particular attention shall be directed
to such as are generally looked upon as most deserving
of confidence, at the same time that the others shall not
be passed over altogether unnoticed. As the motley way
in which we generally find them enumerated by authors
tends rather to embarrass than to elucidate the subject,
with a view to facilitate their consideration they shall be
arranged under distinct heads. The least objectionable
and the simplest division appears to be the classing them
into those signs which are evident to the medical atten-
dant, and with which he can of himself become ac-



O EVIDENCES OP PREGNANCY.

quainted, and into those which from their nature are re-
stricted in their recognition to the individual supposed
pregnant, and with which the attendant can only become
acquainted through her representations.

Of the evidence of the latter class, some depend
upon sympathetic, others upon mechanical causes. We
must bear in mind the fact, that the human frame is com-
posed of a variety of organs supplied with nerves enabling
it to perform a double function ; first, one by which it
maintains its connexion with the external world, receives
impressions, and performs certain voluntary and involun-
tary motions and actions ; and, secondly, one which
unites the parts of the animal frame, constituting it a
whole. This last quality, with which every part of the
body is more or less endowed, is termed sympathy. The
nearer animals approach to the most perfect state of ex-
istence, the more acute will be their sympathies ; or, in
other words, the more perfectly organized the animal is,
the more will the well being of the whole depend on the
right execution of each individual function. On the
other hand, in cold blooded animals, where each separate
part possesses a greater share of individual vitality, there
is much less sympathy between the different organs and
functions of the body ; and of course we find a less per-
fect general organization. Blumenbach explains this by
the proportion the brain bears in size to that of the nerves
proceeding from it, which in the inferior animals is much
smaller than in the higher classes.

Sympathy has a general and particular operation ;
genera], when the whole frame sympathises with an or-
gan ; particular, when one organ sympathises with an-
other. This sympathetic connexion is much more ob-
servable between some organs than others, and it is in



EVIDENCES OP PREGNANCY. 7

many latent until developed by a variety of causes, such
as newly acquired or periodic functions, and altered or
diseased actions. Sympathy between organs may be
mediate or immediate ; mediate when this peculiar con-
nexion or consent exists between two organs directly ;
immediate, when it exists through the intervention of a
third. The uterus furnishes us with examples of these
different kinds of sympathy, which become developed in
a most striking manner in pregnancy, and the diseases
most likely to be confounded with it ; they may, there-
fore, with justice be termed the sympathetic signs of
pregnancy. The sympathy existing between almost all
organs is reciprocal ; that this is particularly the case
with the uterus will be apparent, when we recollect how
frequently the uterus sympathises with other organs as
well as they with it. Of this fact we have abundant
proof in the frequency of the occurrence of abortion from
vesical, ahmentary, or even mental irritation, which in-
dicates the necessity of attending to this connexion as a
matter of paramount importance in treating such cases.

Tiedemann* has gone a considerable length in ex-
plaining the sympathies existing between the uterus and
other organs, by means of actual anatomical demonstra-
tions. He proves that the nerves of the uterus form six
plexuses, which he traces to the great sympathetic on
each side ; he describes them as soft and closely applied
to the coats of the arteries at their entering the sub-
stance of the organ, where they all at once disappear.

The first symptom mentioned by authors as indicating
pregnancy, is to be observed immediately on conception
taking place. It has been stated, that a peculiar sensa-

•Tabula Nervorum Uteri, T. Tiedemann, M. D., Heidelberg.



8 EVIDENCES OF PREGNANCY.

tion is experienced, described by some as a slight rigour,
by others as a spasm, followed by a feeling of indescrib-
able pleasure of some continuance, which is again suc-
ceeded by a sense of languor and depression. The ex-
citement into which the uterine system is thrown at the
time of conception may occasionally produce these symp-
toms, but by no means so frequently or decidedly as to
constitute a guide to us in determining on the existence
of pregnancy. Sensitive females have been known to
experience similiar sensations after each coitus, though
never becoming pregnant.

Conception is occasionally accompanied by a general
excitement of the system, attended with all the evidences
of increased vascular action, such as a quick pulse, heat
of surface, &c. ; this sometimes merges into a decidedly
febrile state, perhaps assuming a hectic form, attended
"with periodic exacerbations, succeeded by intervals of
exhaustion and debility, and even considerable emacia-
tion. This state, however, is rare, and only occurs in
females of a peculiarly nervous temperament, or when
the natural state of the system is altered by luxurious
habits or other causes. In such, impregnation, which
under other circumstances would have been attended
with scarcely any sensible change in the constitution, may
induce various morbid alterations, when the uterus, sym-
pathising with the vascular system generally, may pro-
duce the febrile state alluded to. The general febrile
state can be but little relied on as a symptom of preg-
nancy inasmuch as that in the great proportion of preg-
nant women it is not present, or if so, in but a trifling



Online LibraryEvory KennedyObservations on obstetric auscultation, with an analysis of the evidences of pregnancy, and an inquiry into the proofs of the life and death of the ftus in utero → online text (page 1 of 24)