The Physician and Surgeon

A JOURNAL OF THE MEDICAL SCIENCES.

BY A. H. STEINBRECHER, M. D., DETROIT, MICHIGAN.

WHEN called to a case of labor we feel more or less anxious. This feeling changes to one of satisfaction after making an examination and feeling the resistant surface of the head through the os uteri. But we often encounter some considerable difficulty in making this examination, especially in primiparæ, due to the irritable condition of the external genitals in displacement of the uterus and consequent difficulty in reaching the os, and frequently to the disinclination of the patient to permit an examination.

It has happened to me when this condition existed before the os uteri had dilated, and before the presenting part had engaged, that in making an examination I had diagnosed a vertex presentation which afterward proved to be the breech. An error of this kind might prove very disastrous to the reputation of a physician under certain circumstances. This error could not occur if we would, as a matter of routine in every case, employ external palpation and auscultation of the abdomen as an adjunct to internal examination. Obstetricians like Leopold, Credé, Olshausen and Winckel lay great stress on an external examination; in fact go so far as to say that in a normal case of labor internal examination is unnecessary.

While auscultation is being performed all clothing should be removed from the abdomen of the mother. The unaided ear or the stethoscope may be used. In my opinion the monaural stethoscope is to be preferred. By this method we obtain the sounds referable to either mother or child. Those of the mother are the uterine vascular murmur, uterine bruit. It is a simple blowing sound synchronous with the maternal pulse and heard loudest over the lower lateral walls of the uterus, ceases at the height of a pain, and can be heard as early as the fourth month of pregnancy, and is one of the important features in the differential diagnosis of other abdominal tumors. Other normal maternal sounds that can be heard are the pulse of the aorta, the heart sounds, intestinal sounds due to the movement of gases and fluids in the intestines.

The sounds referable to the child are the fœtal heart sounds, which give us a very good idea as to the position, presentation, and condition of the child, aid in making the diagnosis of multiple pregnancy, and warn us of impending danger to the child.

The fetal heart sounds are heard toward the end of the fourth and the beginning of the fifth month of pregnancy, ranging from one hundred and ten to one hundred and sixty beats per minute; at term averaging from one hundred and thirty to one hundred and forty-four beats per minute. It is most distinctly heard at that part where the left side of the child is nearest to the uterine walls. The sounds are distinguished from the maternal heart sounds by their frequency, • and that the intensity of the maternal heart increases from below upward, while the fœtal sounds are more distinct from above downward, as it is possible in pathological conditions of the mother that the frequency may be the same in both. Some authorities claim that the sex of the child may be recognized in utero by the frequency of the fœtal heart sound. Ziegenspect, of Munich, has upon investigation found the average heart beat in the male to be one hundred and thirty-six, in the female one hundred and thirty-nine, per minute.

In my opinion one of the chief indications for a thorough knowledge of auscultation is in those cases when the child's life is in danger, and in order to recognize this condition an examination at least every half hour or hour should be made in order to ascertain the frequency and condition of the fœtal heart sounds. If we find a decline in the fetal sounds below one hundred beats, not only during a pain but also in the interval, or a continuous well-marked rise above one hundred and sixty beats per minute, with weakened impulse, the indications are to deliver as soon as possible either with the forceps or version, otherwise the chances are that the child will be still-born. Another sound referable to the child is the umbilical souffle, a short blowing sound synchronous with the fœtal heart, usually heard over the child's back near the fœtal heart.

Abdominal palpation enables the physician to appreciate the size of the uterus and determine how far pregnancy has advanced; the presence and number of children in utero; the position and presentation of the child if in the transverse or long axis of the uterus; where we will find the head, breech, back, and feet. It enables him to modify the position if necessary, and helps him to ascertain whether the presenting part lies at the brim or is already engaged and fixed within the pelvis; whether the child be small or large, and whether the pelvis be deformed. It also aids in diagnosing existing diseases of the uterus and its appendages. Some of the obstacles to obstetric palpation are, fluid in the abdominal cavity, tenderness and inflammatory condition of the abdominal viscera, the presence of abnormal abdominal fat, the involuntary contraction of the abdominal muscles. The woman should be placed in the dorsal position with the thighs and legs flexed upon the abdomen-slightly rotated outward. The clothing being removed from the abdomen, the physician's hands previously warmed, he stands at either side of the patient, facing her, placing the extended

hands, palmar surface, flat upon the abdomen. Being careful that all manipulation be made between uterine contractions, the hands now gently glide upward toward the fundus, and you are enabled to determine whether the child lies in the transverse or long axis of the uterus by feeling the head or breech, and you will also gain an idea of the size of the child and the length of time of pregnancy. From the fundus the hands glide over the side of the abdomen. On one side will be felt the small parts or extremities, usually the feet. These are recognized by their small size and irregularity of contour and the freedom in which they change their position. The hands next glide downward until you reach the pelvis. It is now advisable for the obstetrician to change his position so that his back will be toward the face of the mother. With the fingers directed toward the symphysis and gently pressing down into the pelvis, he endeavors to grasp the presenting part. If he feels a hard globular body it indicates the head, if it feel softer in consistency, probably the breech; or does the head or breech feel thicker, less distinct, and softer than normal? if so it is probably a placental attachment. If he fails to feel the head or breech over the brim it is probably a transverse position.

In the first vertex position, when the hands are pressed down into the pelvis they meet with a hard body. There is no similar body in the fundus of the uterus, therefore the head must be below and the breech must be above. If the left hand, which is on the left side of the abdomen of the patient, goes deeper in the pelvis than the right hand before it meets with resistance, then the occiput is directed to the left and in front, and if in following up along the left side of he abdomen, the hand meets with greater resistance than on the right side, then this would indicate the presence of the back. The feet or small parts are felt on the right side, and their movements can be noticed on inspection. On auscultation the fœtal heart sounds can be heard to the left and midway between the umbilicus and left anterior superior spine of the ilium.

In the second position the head is found below in the pelvis, the right hand going farther down than the left, which meets with the resistance of the frontal bone. The back and breach are felt on the right side. The feet or small parts on the left side. The fœtal sounds are heard on the right side midway between the right anterior superior spine of the ilium and the umbilicus.

In the third and fourth positions of the vertex we ascertain the presentation to be the head, but here in the third position the hand which depresses the abdominal walls on the left side meets with the most opposition on account of the prominence of the forehead.

In the fourth position the right hand meets with the greatest resistance; in the third we seek the back on the right side, in the fourth on the left side, of the abdomen, but as it is turned backward the resisting plane is narrower. In order to feel the back, we place the woman on her side. The small parts are felt on the opposite side. The fœtal heart sounds in the third position are heard on the right side, in the fourth position on the left side midway between the umbilicus and anterior superior spine of the ilium.

In face and brow presentations we feel the head below over the brim of the pelvis, but in these cases the head rises much higher and is more easily felt than in any of the vertex cases. Early in labor, there exists between the back and the head a deep furrow, into which the finger sometimes easily penetrates. This prominence of the head and the presence of this furrow is the distinguishing feature of a face presentation. In the first and fourth positions of the face the breech is to be felt on the left side and the small parts on the right side; in the second and third positions the breech is felt on the right side and the small parts or feet on the left side: but as a rule combining auscultation with palpation makes the diagnosis of a face presentation comparatively easy. In flexed cephalic presentation the fœtal heart sounds are heard where the back of the child is, in face cases. However, they are transmitted not by the back but by the anterior fœtal surface. This disagreement between palpation and auscultation suggests a face presentation, therefore in the first and fourth face presentation the fœtal heart sounds are heard on the right side; in the second and third on the left side midway between the umbilicus and the anterior superior spine of the ilium.

In breech presentations when the fingers are pressed into the pelvis they do not meet with the hard resisting surface of the head, but the presenting part feels softer and its outlines are much less distinct. On palpating the fundus we feel the hard, movable head above and the resisting back below. This may be felt on the right or left side, either anteriorly or posteriorly; the small parts or feet are felt on the opposite side. The heart sounds are most distinctly heard above the umbilicus, in the first position, to the left; in the second position, to the right.

Transverse presentations are not difficult to diagnose if the back is directed to the front, but may become so in the dorso-posterior position. In the first place the outline of the uterus is altered; its longer axis does not coincide with the axis of the superior strait, but is directed transversely or obliquely. On palpating the uterus we find that the pelvis is empty. We find the hard movable head either in the right or left iliac fossa. The breech can be felt on the opposite side usually higher up, so that the child lies obliquely. The small parts correspond with the breech. If it be a dorso-anterior position the back can be felt above the symphysis. If the head be on the left side the right shoulder presents; if the head be on the right side the left shoulder presents. In the dorso-posterior position it is just the opposite. The fœtal heart sounds are most distinctly heard in the median line below the umbilicus. In no other presentation is a knowledge of external palpation so important as in this, since an early recognition will warn us to preserve the integrity of the membrane as long as possible; will indicate to us which hand to employ in making podalic versionthe left hand if the head is felt in the left iliac fossa and the small parts on the right side; the right hand if the fœtal head is felt on the right side and the feet on the left.

In twin pregnancy the abdominal tumor may be larger and more irregular in contour. If one child lies back of the other the diagnosis may be difficult, but if we can feel one head over the brim of the pelvis and one in the fundus of the uterus, with the corresponding small parts above and below, the diagnosis is comparatively easy, particularly if this can be confirmed by two heart sounds. In the latter case we will get the fœtal heart sounds of one child above, the fœtal heart sounds of the other child below, the umbilicus, that is, providing both children are living.

Abdominal palpation is useful in some of the obstetrical operations, such as