fear various and worse evils from the milk of unhealthy and unclean nurses?

Dr. W. C. Cutler, of Chelsea, being much interested in this unique case, had a photograph taken on the eighth day, from which he had the accompanying cut made, and, through his kindness, we are able to reproduce it for the benefit of our readers. It represents the right thigh and part of abdomen of the child. ED.

PHYSICAL

EXAMINATION OF THE ABDOMEN AS A MEANS OF DETERMINING THE POSITION OF THE CHILD IN UTERO.

BY G. R. SOUTHWICK, M. D., DRESDEN, GERMANY.

In this short article neither the differential diagnosis of pregnancy from the various forms of abdominal tumors will be considered, nor the operations of external manipulation. Its aim is to call attention to a method scarcely mentioned in most of the text-books on midwifery used in the United States. The reason of this may be that these are usually English works, and external examination is not common in the English school. In Germany, all patients admitted to lying-in hospitals are examined in this manner. Valuable information as to the position, condition, and size of the child can be obtained some time before labor, and, according to recent writers, mal-positions rectified. It is also very useful during epidemics of zymotic diseases, or in cases of danger of infection through other causes. Vaginal examination gives more information regarding the mother, abdominal regarding the child; and the two combined will often enable the accoucheur to form an opinion at a much earlier period in labor than if used separately. Mal-positions, as in transverse presentation, may be detected, and, if version be decided upon, the time of operating can be selected, instead of being compelled to turn with a shoulder driven down in the brim, the membranes ruptured, and the uterus contracted, -conditions which make it a dangerous operation, especially in unskilful hands.

There is an objection raised that it requires an expert to practise external examination successfully. Where the uterus is tightly contracted, the woman long in labor, or an excessive amount of fat present, the method is often difficult. In the majority of cases, however, when the uterus is relaxed and the physician knows what to look for, where and how to find it, the task is an easy one. Especially, if it be compared to that of distinguishing, per vaginam, the anterior or posterior position of the occiput.

It may be objected, moreover, that women will not submit to it. The examination need not be painful, nor should enough force be used to make it so. There is little exposure, and it seems hardly probable that a sensible woman would refuse that which might be the means of relieving her from much suffering. The best literature recently published on this subject will be found in Schroeder's "Text-Book of Midwifery," 1882, — I believe the last edition is not yet translated, Playfair's "Science and Art of Midwifery," 1881, "Monographs," by Dr. Paul F. Mundé, of New York, reprinted from the American Fournal of Obstetrics, and by Pinard of Paris. The last is probably the most complete.

The patient must lie on her back, the thighs partially flexed, and the bladder emptied. All clothing must be loosened, particularly corsets, or anything forming a tight band about the body. The abdomen should be bare, as anything between it and the hands greatly increases the difficulty of distinguishing clearly the parts. If the patient gives trouble by holding her breath and contracting the recti muscles, she may be instructed to keep her mouth open and breathe naturally, or kept in conversation during the examination.

The child may be felt at the sixth month, but the most favorable time for determining its position is during the last month of pregnancy, before strong labor pains have commenced. The means at our command for diagnosis are, inspection, mensuration, percussion, palpation, and auscultation. By inspection, we notice the size and contour. A large uterus may contain, Ist, a large amount of amniotic fluid (Hydramnios), so distending the organ that it cannot contract to advantage, thus giving rise to a common cause of tedious labor; 2d, plural pregnancy ; 3d, a very large child. A large uterus may be simulated by one of ordinary size with thick, fat abdominal walls, or by pregnancy complicated with extra or intra uterine tumors. The normal contour is oval and a little prominent. A very prominent uterus may be the result of relaxed abdominal walls and a thinning or separation of the recti muscles. It may even overhang the pubes. The uterine axis is thus thrown out of relation to that of the vagina, forming an acute angle with it. The force from above, chiefly from the diaphragm, is directed against the back of the fundus uteri instead of the upper surface. The acuteness of the angle is thereby increased, the presenting part driven against the sacrum instead of in the axis of the parturient canal, and a very tedious labor results. A prominent uterus often indicates a contracted brim, which the head cannot easily enter. There is usually seen associated with it a transverse furrow in the abdomen, midway between the pubes and umbilicus.

This

furrow may be simulated by a distended bladder; but if the golden rule be followed, of keeping the bladder empty during labor, such a mistake will not be made. The indication for treatment is to restore the uterine axis to its normal relations. This is best accomplished by a well-applied binder, which raises the uterus to and keeps it in its proper position. In the case of contracted brim, steadying it so the patient can use all her strength to the most advantage, and drive the head if possible into the pelvis.

In plural pregnancy the diameters of the uterus are enlarged, its surface somewhat flattened from side to side, and sometimes a furrow or depression is seen. When the long diameter of the child is not parallel with that of the uterus, or in other words, when there is a transverse presentation, the transverse diameter of the uterus will be lengthened according to the position of the child.

Mensuration is of little practical service except in pelvic deformity. Attempts have been made to ascertain the length and size of the child by a pelvimeter, so constructed that one pole is applied to the os, the other to the fundus uteri. It is very useful in determining the period of pregnancy. At the fourth month the fundus is at the symphysis pubis; at the fifth, between it and the umbilicus; at the sixth, at the umbilicus; at the seventh, midway between the latter and the ensiform cartilage; at the eighth, at the ensiform cartilage; in the ninth month the fundus sinks again between the latter and the umbilicus. Perhaps it may be easier to remember that odd months are half-way points between the symphysis, umbilicus, and ensiform cartilage.

Percussion is of little value. Sometimes an area of increased dulness may be found over the child.

Palpation gives the most reliable information. The most im portant points to be learned are the positions of the head, breech, and feet. The operator should take care that his hands are well warmed, otherwise he might cause a contraction of the uterus, which greatly hinders success. He stands at the side of the patient, facing her. Placing his hands flat on the sides of the abdomen, gently pressing them togther and combining pressure with a slight side-to-side movement, he finds a long_body, one side of which gives more resistance than the other. This is the body of the child, usually nearly parallel with the long axis of the uterus; the side of greatest resistance is the back. He will next proceed to examine the ends of this body. Changing his position to the opposite direction and placing his fingers on each side and just behind the symphysis pubis, he presses backwards and inwards, endeavoring to bring their ends together. In doing so he will probably find between them a smooth, hard, round

mass, somewhat larger at one side, and lying in a transverse or oblique position in the pelvis. This is the head. This is the head. It may also be found by facing the patient and pressing the thumb and forefinger of one hand in behind the pubis, thus grasping the head between them. The physician again faces the patient, and tracing the back upwards examines the other extremity. If it be a breech, he will find a large, firm mass, lacking the globular, regular shape and stony hardness of the head. If the abdominal walls are thin, he may be able to find the cleft of the nates. Sometimes he can trace the thigh, and feel the depression between it and the body. Occasionally, by thrusting the fingers quickly and deeply into the abdominal wall over the breech, he will find it rebounding; in other words, ballotment will be perceived. This is more often found with a small fœtus and much liquor amnii. To one side of this body, in the upper half of the uterus, he will find one or two small projections, easily movable, and sometimes giving a little blow against the examining hand; these are the feet. Frequently the woman may complain of a small tender spot there, and tell you it is the place she has lately felt the child. It is important to bear in mind, considering the child's attitude in utero, that the feet must always be opposite to the back, and consequently on the side opposite the occiput. Occasionally small parts are felt in the lower part of the uterus, not necessarily on the same side as the feet; these are the hands or elbows. A uterus containing a dead foetus has often a relaxed, soft feeling, very different from the resistance given by one containing a living child.

Auscultation vies with palpation as a means of physical diagnosis. Some think that more positive information can be gained by the latter than with the former. The three chief sounds heard are those of the foetal heart, the funic souffle, and the uterine souffle.

The foetal-heart sounds are heard as early as the eighteenth week and distinguished by rapidity and a distinct double beat. It is always well to compare it with the maternal pulse at the same time. If the latter be very rapid, it might closely simulate, through the aorta, those of the foetus, but would lack the double beat. The frequency of the beat ranges from a little below one hundred and twenty to a little over one hundred and sixty per minute. They are increased by foetal movements and uterine contractions. It is said by some, that in a large proportion of cases one can tell the sex by the number of beats; that in females they are more rapid; that with a foetal heart beating one hundred and forty-four or more to the minute, we may predict a female, and if under one hundred and thirty-two, a male. If an examination is made for this purpose, it should be done before

labor has commenced and before palpating, as these will increase the number of beats. Have examined a very large number of cases with respect to this sign, and question very much if it is at all reliable. I have counted distinctly one hundred and sixty beats per minute, and a male child was born; again, I have counted one hundred and twenty beats, and a female was born. It is said the number of beats depends more on the size than sex; that males have a slower beat because they are larger. I have not made sufficient examination of this to express any opinion. Sometimes the existence of twins can be determined by a stethescopic examination. If two hearts can be heard at opposite points on the abdomen, if they are not synchronous in action,—and this fact is established by two observers, examining simultaneously, -twin pregnancy may be diagnosticated, otherwise not with certainty. The foetal heart may be heard in a limited or extensive area on the abdomen. This will be in proportion to the surface of the child's body in contact with the uterus; consequently, with a very small child or a large amount of liquor amnii, it will not be so distinct. Foetal-heart sounds, growing weak or irregular, indicate its life is in danger. As a rule, the sounds are heard most distinctly on the same side as the child's back. An exception to this is in face presentations. Here the sharp-pointed chin is felt, a sulcus between it and the breast, which is thrown forward against the uterus. The sounds are usually reflected from the back, as the small parts of the child being flexed in front of it prevent the breast coming in contact with the uterine wall. They are heard most often a little below and to the left of the umbilicus, corresponding with the first position. The funic souffle is supposed to be caused by the friction of the blood in passing through the funis. It is a blowing sound or murmur. The impulse is synchronous with the foetal heart, but not double. It is not always heard, and when distinct, is said to indicate the cord is around the neck, and that the sound arises from increase of friction. But it should be remembered that it may arise from any pressure on it, for the same reason.

The uterine souffle, also known as the placental souffle, is usually heard most distinctly in either inguinal region, and in advanced pregnancy is not heard over the fundus. It is very variable, from a soft, cooing murmur to a harsh, rasping sound. It is distinguished from the foetal sound by being synchronous with the maternal pulse, and differs from arterial by the absence of impulse. A very similar sound is heard sometimes with uterine tumors, and thus it might be an aid to diagnose them from similar tumors of the ovary. It was called the placental souffle because it was supposed to indicate the site of the placenta; but, as it has no fixed relation to the latter, being heard at various places