Diagnosis of the Sex of the Fetus by Auscultation.
Within recent years an effort has been made to utilize the greater or less frequency of the festal heart-beats as a means of discovering the sex of the child. If the pulsations exceed 144 per minute, the child is, ac cording to Frankenhauser, a girl; if below 144 a boy. Dauzats says that more than 145 pulsations show the sex to be female, and fewer than 135 heart-beats render it probable that the sex is male. If the number ranges from 135 to 144, there is no certainty. These observations have not been confirmed, but Budin and Chaignot, as the result of renewed research, reached the following conclusions: 1. There is no constant relation, from a practical standpoint, between the number of festal heart-beats and the sex of the child; 2. If the pulsa tions are repeatedly counted, during the latter months, the numbers, at different examinations, are sometimes the same, but usually very different; 3. Variations•of from 15 to 20 pulsations occur in consecutive minutes without apparent cause; 4. There is no relation betteen the foetal heart beats and the weight of the foetus. Frequent pulsations do not point to a. small foetus, nor do less rapid pulsations prove the child to be of large size.
The discovery of the foetal heart-sounds thus enables one to affirm, in an absolute manner, not only the existence of pregnancy, but the possession of life on the part of the fcetus. The absence of the sounds proves that the foetus is dead, provided only that they have been repeatedly and plainly heard at an earlier date, for we have seen that sev eral circumstances might temporarily render the sounds inaudible. One can, moreover, by the aid of the heart-sounds, ascertain the existence of twin or of triple pregnancy. In case of twin pregnancy, one finds two maximum points of intensity, but this is not enough: The distance be tween these points must be considerable, and between them there must be a point of minimum intensity for both sounds, which should, however, augment in intensity in proportion as the auseultator approaches their respective maximum points. The two hearts must, moreover, have differ ent rhythms. In case of triple pregnancy, one finds three maximum points. Finally, one can ascertain, during parturition, whether the child be weak, or whether its condition be perfectly normal. When the child is well, the heart-beats only change during the pains. If, however, the child is suffering discomfort, the pulsations grow slower, less distinct and irregular. We have thus a certain criterion for the necessity of interven tion in the interest of the child.
Diagnosis of the Presentation, and of the Position.
Auscultation is of special use in diagnosticating presentations and posi tions. According to Depaul, the heart is so situated as to be nearer the cephalic than the pelvic extremity, and, since the attitude of the foetus is that of anterior flexion, the heart-sounds are most easily transmitted to the ear through the back. The point of maximum intensity will be over the foetal dorsal region, corresponding to the foetal pericardium. Now, if the foetus is presenting by the head, the point in question will always be below a horizontal line dividing the uterus in two equal parts. If the
pelvic extremity is presenting, the point will be above the line. The um bilicus can not serve as a landmark on account of its variable position. The line dividing the uterus into two equal parts sometimes passes above, and sometimes below the navel. This explains the errors of those ob servers who draw the horizontal line through the umbilicus. Ribemont has shown, by his recent researches, that the heart is situated at about equal distances from the cephalic and the pelvic extremity, and, although admitting the division of the uterus into two equal parts, he refers the difference as regards auscultatory signs, in the two cases, to the engage ment of the head, in cephalic presentations, and to the low position of the heart resulting from the descent of the trunk. In pelvic presenta tions, on the other hand, the heart is found at the upper part of the uterus. In head presentations, the maximum is below, in breech cases, above the horizontal line. If abnormal conditions, such as faulty inser tion of the placenta, deformity of the pelvis, an abnormally large head, or failure of the head to engage, detain the head above the superior strait, the heart-sounds are heard at a higher point. But, whatever Tarnier and Chantreuil may say to the contrary, we do not believe that the cardiac sounds are ever heard, in head presentations, above the level of the hori zontal line, as happens in pelvic presentations. To recapitulate: A. Head presentations; sounds heard below the horizontal line, dividing the uterus into two equal parts. B. Breech presentations; sounds heard above the horizontal line. C. Face presentations. Depaul denies that one can recognize face presentations by auscultation, and we believe that the diagnosis by means of auscultation, alone, is about impossible. If, how ever, we combine auscultation and palpation we may easily make the diag nosis. Let us remember that the point of maximum intensity corresponds to the foetal cardiac region, and that, in head presentations, the sounds reach the ear through the back. Now, as Tarnier remarks, in face pres entations, the head being extended, and the occiput in contact with the back of the fcetus, the back is no longer applied to the uterine wall, and the foetal dorsal region is no longer in close proximity to the uterine pari etes. The heart-sounds will, therefore, be directly transmitted to the ear through the foetal cardiac region. In this case, palpation and ausculta tion are at variance. While, for example, palpation shows the back to be directed toward the left, auscultation will give a maximum intensity at the right, at a point directly opposite to that where it should be found in a head presentation. Besides, as a result of the failure of the head to engage, the sounds will be heard higher, but will still remain below, or at least on a level with the horizontal line dividing the uterus into two equal parts. This disagreement between the results of auscultation and of pal pation will excite attention and elucidate the diagnosis.