AUSCULTATION OF THE ABDOMEN.
Such are the sounds of the foetal heart, which in the second half of pregnancy are readily recognizable by their frequency, double beat, and the fact that they are not synchronous with the rhythm of the mother's heart; further the umbilical souffle, which is not infrequently mistaken for the second sound of the fatal Heart, but which is a certain sign of pregnancy, and finally every sound which accompanies the movements of the foetus. Aside from pregnancy sounds are also heard, such as: the maternal heart beat, the pulsation of the abdominal aorta, sounds due to passage of flatus through the intes tines, to the mixture of ascitic fluid and air, and finally the sound result ing from the rubbing together of raw surfaces.
Auscultation is practised with the patient in the dorsal position, with the thighs slightly approximated—marked flexion of the thighs interferes with the examination—and her body elevated enough not to cause the examiner to bend over too much. Auscultation may be direct by the ear against the abdomen covered by a towel, or else, and this is preferable, by means of a stethoscope. The instruments devised for vaginal auscul tation are rarely useful. We must be careful to apply the stethoscope evenly to the abdominal walls, and not to press on it overmuch, else faint murmurs may be Auscultation of the abdominal organs is practised too little, and yet it affords us most valuable information. The most important of the auscultatory sounds, the so-called placental souffle—which is considered by many, Naegele in particular, to be characteristic of pregnancy—is a more or less loud rhythmical murmur, synchronous with the maternal pulse, and is heard not only during pregnancy, but also in case of the large majority of abdominal tumors. According to Winckel and to Spencer Wells it is heard over fully one-half of the solid tumors of the uterus, and much less frequently over ovarian cysts; still Winckel recognized it in a case of cyst of the ovary adherent to the omentum. A similar murmur
has also been heard over the spleen (Winckel, Birch-Hirschfeld), over retro-peritoneal tumors (Winckel), and latterly over a carcinoma of the liver (Leopold). It has never as yet been heard over tumors of the kidney. Since, however, this murmur is not constant, and since its ab sence is not specially important, its diagnostic value is not very great. There is difference of opinion in regard to the cause of this murmur. The researches of Veit, Martin, Pernice, Winckel, and others, have fairly well established the fact that the source of the murmur is in the arteries, although the mechanism of its production has not as yet been proved. Furthermore, the nature of the murmur, its systolic increase, and frequently its continuous buzzing character, and its presence over localities where there are no large arteries, make it likely that it may also be produced in distended capillaries (Leopold).
It is often important to determine whether the murmur is over the tumor itself or in its neighborhood. Changes in position of the patient or of the tumor give us information on this point, as also compression of the vessel above the site of auscultation. Any murmur which arises in the pelvic arteries follows their course, while a murmur in the tumor is generally spread over a wide surface. The maternal heart-beat and the pulse in the abdominal aorta, which is often to be seen and to be felt, should not be confounded with the above murmur. The question as to whether a murmur is isochronous or not with the maternal pulse, is de cided by comparing it with the pulsation of the radial artery.
The gurgling murmurs which accompany the presence of gas and of fluid in the intestine, as also the so-called succussion murmur, are of special diagnostic value, and in addition the rubbing, creaking sounds which point to roughening of the parietal peritoneum, and of the organs lying in contact with it.