insr obstetrics 
AS PBACTISED 1ST GERMANY. PALPATION IN OBSTETRICS 
M 
AS PRACTISE!) IN GERMANY. 
By James R. Chadwick, M.D. Harv., Boston. 
Attention has of late been called to the 
abdominal examination and manipulation 
of the pregnant woman as performed in 
Germany, and more especially in Vienna. 
An attempt to state in detail the method 
there employed, and to consider some of 
its effects upon obstetric teaching and prac- 
tice, may not be out of place. 
The subject is one which is almost ignored 
in American and English textbooks, and is 
but imperfectly taught in the German trea- 
tises. The \ ienna School probably makes 
more of this method than any other, but, 
unfortunately, the works of the Professors, 
Carl Braun and Joseph Spaeth, are so old, 
that the views of the writers have in many 
respects changed since these were pub- 
lished, and the books cannot, therefore, be 
regarded as reliable exponents of the au- 
thors’ opinions at the present day. 
From the verbal teachings of the various 
professors must therefore be drawn the in- 
spiration which should guide the pen of one 
who ventures to detail the procedure fol- 
lowed, and the results claimed for this 
method of practice. That the latter are 
very great and essentially practical, I would 
insist upon from the outset, as proved to 
me from personal observation in the clinics 
of Vienna and Wurzburg. Direct applica- 
tion has been made to the above-mentioned 
professors and to their assistants, to have 
all dubious points in their teachings settled. 
In thus laying before his professional 
brethren in America the details and advan- 
tages of a comparatively unappreciated sub- 
ject, the writer will readily be pardoned if 
he recounts, in extenso, the steps to be 
taken and the inferences to be drawn in all 
circumstances. That the promised results 
are not to be gained by an inexperienced 
hand, must be realized, from the outset, by 
such as may make a practical use of the 
following pages. Let those who choose to 
test the value of this method, not condemn 
it, if they cannot leave the first or even the 
twentieth bedside, with “ Yeni, vidi, vici ” 
upon their lips. 
Abdominal examination consists in in- 
spection, percussion, auscultation and pal- 
pation. 
Inspection of the abdomen informs us as 
to its volume and form ; the tension of its 
walls—the discoloration and scars upon its 
integument—the changes of the umbilicus 
—the impediment to respiration, and con- 
dition of the ribs ; sometimes shows us the 
movements of the child or of flatus—the 
twitching of the abdominal muscles—and 
occasionally a thrill from pulsation of the 
aorta. 
Percussion informs us as to the consist- 
ence of the contents of the abdomen, giv- 
ing the size and height of the womb, as 
well as, imperfectly, the nature of its con- 
tents, the presence of ascites, flatus, or a full 
bladder. 
“ The object of auscultation is to recog- 
nize the foetal heart-sounds, and the mater- 
nal vascular murmurs, and to distinguish 
them from the transmitted heart-sounds of 
the mother—from the spontaneous move- 
ments of the foetus—from the umbilical mur- 
mur—from the gurgling of gases, and the 
splashing of fluids in the intestines—and 
from the aortal pulse.” [C. Braun.] 
I shall confine myself to this brief defini- 
tion of the scope of these first three divi- 
sions, in regard to which American prac- 
tice does not materially differ from the Ger- 
man, and shall proceed at once to the sub- 
ject of this paper— 
Palpation, in its two-fold Application to 
Diagnosis and Treatment. 
For the purposes of diagnosis, palpation 
is the determination of the volume, consist- 
ence, form and position of the uterus—the 
size, position, presenting part and sponta- 
neous movements of the foetus—the pre- 
sence of more than one foetus, or of com- 
plicating abdominal or pelvic tumors—the 4 
life of the foetus—the transmitted thrill of 
the aortal pulse—the fulness of the urinary 
bladder—the presence of ascites, and, in 
some measure, the question of a previous 
birth, by the sense of touch through the ab- 
dominal walls. 
Preliminaries.—The woman, to be ex- 
amined, should be flat upon her back on a 
bed; her legs should be drawn up, and her 
head supported, in order to relax the ab- 
dominal muscles and integuments. Corsets, 
drawers, and all constricting bands about 
the abdomen or chest should be removed. 
A sheet should cover the lower extremities, 
and the night-dress or chemise be drawn up 
under her breasts, thus leaving the abdo- 
men alone exposed. Should modesty re- 
quire, the sheet, being the cleaner and 
looser of the two, may be brought up over 
the abdomen, though this will interfere, 
somewhat, with a satisfactory examination. 
The physician’s hands should be warm. 
Manual of Palpation.-—Standing upon the 
right of the woman, the physician lays his 
hands upon her abdomen, and proceeds to 
explore its contents, as revealed to the 
touch. This is performed by moving the 
hands, step by step (so to speak), over its 
surface, while they are rounded over the 
inequalities, made prominent by pressure, 
so as to form an idea of the configuration 
of what is within. This is best effected by 
a general “ pawing ” motion, during which 
the hands are kept nearly flat upon the ab- 
domen, the pressure upon which is not con- 
stant in any one spot, for a rocking motion 
is imparted to the hands by alternate flex- 
ion and extension of the wrist and of the 
metacarpo-phalangeal articulations. The 
hands are, during this action, either moved 
along side by side in the same region of 
the abdominal surface, or at opposite sides 
of the abdomen ; then the one steadies the 
uterus and foetus, while the other studies 
their angles and form. The latter course 
is most useful, when the abdominal contents 
are very movable. 
When it is wished to test the consistence 
or mobility (including ballottement) of the 
underlying parts, tlie very tips of the fin- 
gers of one hand should, first, be placed 
gently upon the abdominal integument, al- 
most perpendicular to it, and then, by a 
forcible thrust downwards, be brought up 
against the parts below. As this should be 
a shove rather than a blow, it may best be 
executed by an action from the elbow, with 
stiff' but slightly-flexed wrist and hands. 
In order to examine the presenting part of 
the foetus, two other procedures are com- 
monly followed. In the first, the right 
hand of the investigator, with thumb ab- 
ducted, is laid, palm downwards, upon the 
abdomen immediately above the symphysis 
pubis, the thumb being near the middle of 
the left Poupart’s ligament, and the fingers 
at the same point on the other side ; the 
ring and middle finger come chiefly into 
play. The thumb and fingers are then 
thrust downwards into the abdomen, and 
approximated, until they grasp between 
them the presenting part of the foetus. The 
distinguishing characteristics, of a present- 
ing head or breech, may best be brought 
out by giving the part a sort of shake, 
with loosely grasping hands, by which it 
is tossed to and fro between the thumb and 
fingers. 
The second method, of palpating the pre- 
senting part, is by laying the two hands 
flat upon the opposite sides of the abdomen, 
the points of the fingers being directed to- 
ward and lying just above the middle of 
Poupart’s ligaments on each side ; they are 
then thrust downwards and inwards to- 
wards the cavity of the pelvis, until they 
come upon and hold between them the pre- 
senting part. This method is rarely resort- 
ed to, unless the previous one yields an 
ambiguous or negative result. The ex- 
aminer is by it enabled to explore deeper 
in the pelvis, and thus often reach a deep- 
seated head, which would not be accessi- 
ble to the former procedure. 
No force, sufficient to cause the woman 
any real pain, need ever be employed dur- 
ing these manipulations. 
Attention to the minutiae enumerated 
above is of importance, for a promiscuous 
punching will not only subject the woman 
to much discomfort and pain, but will also 
excite reflex contractions of the abdominal 
or uterine muscles, and thus defeat the ob- 
ject in view. 
At the Bedside.—While facing the wo- 
man, the obstetrician lays his hands, with 
the fingers directed toward her head, upon 
the opposite sides of her abdomen, to make 
sure that the long axis of the foetus corre- 
sponds to the longitudinal axis of the ute- 
rus ; in other words, that he has a longi- 
tudinal position before him. This proved, 
he proceeds to estimate the period of the 
pregnancy by defining the height to which 
the fundus uteri rises. This may be done 
by depressing, as far as possible, the ulnar 
border of the left hand above the fundus, 
and measuring, while it is closely applied 
to the latter and in a perpendicular position, 
its distance from certain fixed points. The 
right hand should be occupied in support- 
ing the body of the uterus, should it incline 5 
to fall away from the median line of the 
body. 
The Period of the Pregnancy is determin- 
ed chiefly from the height of the fundus, 
which depends, in the later months, almost 
entirely upon the size of the foetus. The 
measurement of the abdominal circumfe- 
rence gives no data, as proved by Ilecker, 
Spiegelberg and Richelot, who, for exam- 
ple, found, for the tenth month of preg- 
nancy, variations of 88-116 cm. (II.), 84- 
108 cm. (S.) and 82-113 cm. (R.). 
In transverse and twin pregnancies, this 
manner of diagnosticating the period gives 
untrustworthy results, for then the long 
axis of the uterus will be the transverse, 
and, in consequence, the fundus will not 
attain to the same altitude. The general 
size of the child or children, the size and 
hardness of the head or heads, and the 
testimony derivable from the vaginal ex- 
amination, and from the statements of the 
mother, must then be relied upon. 
of the second trimester it has reached the 
height of the umbilicus, and at the end of 
the third that of the ensiform cartilage. 
The altitude attained by the fundus at the 
end of the several months of each trimes- 
ter corresponds to. the other lines of the 
scale. 
The distance between each of these lines 
is about equal to the breadth of two fin- 
gers, whence the common saying that the 
fundus stands “ two fingers above the sym- 
physis pubis, two fingers below the navel/’ 
&c., indicating the end of the fourth and 
the fifth lunar months respectively, and 
so on. 
During the tenth lunar month, the uterus 
is generally supposed to be settling into 
the pelvis; therefore, although it has been 
increasing in size, the fundus has really 
been sinking from its position at the end of 
the ninth month. This descent is, however, 
far from constant, and should not be al- 
lowed for, until further abdominal and va- 
Lunar months. 
3d Trimester 
Capable of life. 
2d Trimester 
1st Trimester.. 
The following are the rules to be observ- 
ed in making the calculation. 
The line connecting the symphysis pubis 
to the ensiform cartilage is supposed to be 
crossed, at right angles, by six equidistant 
transverse lines; two intersecting each of 
the spaces from the pubes to the umbilicus, 
and from the umbilicus to the tip of the 
ensiform cartilage, and one passing through 
each of the last two points. 
The normal term of gestation, 280 days 
(reckoned from the commencement of the 
last menstruation), is then divided into ten 
lunar months; these, exclusive of the 
tenth month, are arranged in trimesters. 
During the first trimester the fundus uteri 
is rising to the level of the pelvic brim, and 
is not accessible to palpation; at the end 
ginal examination has confirmed the suppo- 
sition. A complete descent of the uterus 
would, consequently, carry the fundus, in 
the course of the tenth lunar month, through 
the various altitudes, through which it had 
passed in its ascent during the ninth, and 
bring it finally, at the end of the tenth, to 
the level at which it stood at the end of 
the eighth. This is exceptional, so that it 
is more correct to place the normal height 
of the fundus, at the end of the tenth month, 
somewhere between the lines corresponding 
to the end of the eighth and ninth months, 
with the proviso that the fundus will not 
infrequently be found as high as the line of 
the ninth month. 
In estimating the period of pregnancy, 
no mention has, thus far, been made of the 6 
other less reliable, but not unimportant, 
data to be obtained from palpation. These 
will be more fully described in other con- 
nections later, and will here be only men- 
tioned as they successively appear in the 
several months. 
4th lunar month.—The uterus is felt as a 
rounded, elastic tumor, above the symphy- 
sis pubis, and continued into the pelvis; 
its consistency is soft, and in multipara 
often uneven. It may be a little harder in 
several places adjoining the foetal parts, but 
the latter are not distinctly felt. Ballotte- 
ment through the abdominal walls is very 
rare. 
5th lunar month.—Uterus a little to one 
side of the median line, generally to the 
right. Spontaneous movement of the foe- 
tus, and abdominal ballottement rarely felt. 
(Foetal heart sounds, in rare cases, heard on 
auscultation.) 
6th lunar month.—Foetal parts, and, con- 
sequently, the presentation can commonly 
be made out. Spontaneous movements 
felt. (Foetal heart-sounds heard.) 
*lth and 8th lunar months.—All the parts 
of the foetus gradually become more mani- 
fest to palpation. Foetus gradually loses 
its extreme mobility. Head increasing in 
hardness, as well as in size. 
9th lunar month.—The foetus, constantly 
gaining in size in proportion to the uterus, 
obliges the latter to conform more and more 
to its shape. Ballottement of the head 
commonly felt. 
10£7i lunar month.—Uterus generally de- 
scends into the pelvis, by which the pre- 
senting part of the foetus becomes more or 
less immovable, and the fundus is caused 
to fall more forward, by which a flattening 
of the epigastric region may ensue. 
All these signs are to be earlier and more 
easily obtained in multipart than in primi- 
parae, owing to the greater tension of the 
abdominal walls in the latter. The foetus 
is, of course, supposed to be alive. 
This method of determining the period of 
the pregnancy will be found, in general, 
satisfactory, despite its manifest imperfec- 
tions. Three points are important in ap- 
plying it, however :—that the foetus should 
not be in a transverse position ; that the 
fundus should be in the middle line of the 
body; and that the bladder should be 
empty ; it being evident that a dilatation 
of the uterus in a transverse direction 
would shorten its vertical axis, that any 
deflection of the womb from the median 
line of the body would lessen its apparent 
height, and that a full bladder might pre-1 
vent the uterus from sinking to its proper 
level in the pelvis. 
Fulness of the rectum is said to affect, in 
some measure, the height of the fundus 
uteri, but is rarely taken into account. The 
thickness of the abdominal walls is also to 
be considered and allowed for; it is deter- 
mined by taking up a fold between the 
thumb and fingers. This gives another in- 
dication, for it has been proved that the 
amount of adipose tissue in the walls de- 
creases with each successive pregnancy. 
Deformity of the pelvis, of the vertical 
column, or of the thorax, an unusual 
amount of amniotic fluid, and the presence 
of complicating tumors may lead us astray, 
unless such conditions are discovered and 
allowed for. 
Having thus settled, preliminarily, the 
duration of the pregnancy, subject, how- 
ever, to modification or correction after the 
vaginal examination, the physician proceeds 
to diagnosticate the position and present- 
ing part of the foetus, and to detect any 
abnormal condition that may exist. If the 
urinary bladder is full, it will be felt as a 
more or less prominent, elastic tumor, im- 
mediately above the symphysis pubis, and 
must be evacuated. 
The consistence of the abdomen varies 
with the nature of its walls, and more es- 
pecially of its contents. The walls, when 
fat, will be soft to the feel, even when some- 
what distended ; yet in pri mi parse, in whom 
the walls are fatter than in multiparse, they 
are apt to be very tense towards the end 
of pregnancy, owing to the unusual dila- 
tation. 
The uterus is felt as an elastic, more or 
less firm bladder, rounded above and pro- 
longed downwards into the pelvis. Toward 
the end of gestation, it assumes more near- 
ly the ovoid form of the foetus ; it never, 
however, quite loses a slight antero-poste- 
rior groove in its fundus, the last trace of its 
formation by the union of Muller’s ducts; 
this is more marked during a contraction. 
Its shape when pregnant (and uncontract- 
ing), or dilated from other cause, is ac- 
knowledged to be chiefly dependent upon 
its contents. Up to the seventh or eighth 
lunar months the uterus is so distended by 
the proportionately great amount of liquor 
amnii, that the foetus floats free of its walls, 
and does not mar the symmetry of its 
rounded outline. After that time, however, 
the relation of the foetus to the fluid is 
gradually reversed, and the uterus assumes, 
in a measure, the form given it by the 
foetus. 7 
Peculiarities of the Foetal Parts.—The 
two great extremities of the foetus, as it 
lies doubled up in the uterus, are the head 
and the breech; they are recognized by 
their individual peculiarities, and by the 
rounded terminal character common to both. 
The head is felt as a round, hard body, 
entirely free from angles or even promi- 
nences, more movable than the breech, and 
more or less isolated (because of the hol- 
low at the neck) from the neighboring re- 
sistant points. When the head is freely 
movable, one of its chief distinctive fea- 
tures is its ballottement, or quick rebound 
upon the exploring fingers, after a sudden 
push. The sensation imparted to the hand, 
in this case, is peculiar and characteristic, 
being such as is caused by a hard ball float- 
ing in a liquid. Its rebound is quicker and 
more bouncing than that of the breech— 
which alone could resemble it—because it 
swings from the body by the flexible neck, 
and thus describes the arc of a small circle 
only, whereas the breech, when thus pro- 
pelled, describes an arc of greater radius, 
and is restrained by the inflexibility and 
greater inertia of the body, as well as the 
more extended surface which it exposes to 
the resistant action of the fluid ; for these 
reasons the rebound of the breech is slower 
and less sudden than that of the head. 
This peculiar feel is enhanced by the differ- 
ent consistence of the two parts, the head 
being hard and bony, whereas the breech is 
soft and fleshy. As the size of the head 
increases, this ballottement is less mark- 
ed, but as its bones gradually become more 
ossified, with the increase in size of the 
foetus, what is lost in mobility is gained in 
hardness. 
The breech is known by its being directly 
continuous with the back, by not being 
symmetrically round but somewhat point- 
ed (the tuberosities of the ischia), by not 
being hard, and by not rebounding sudden- 
ly upon the fingers after a blow (ballotte- 
ment). 
The back is recognized by the long, un- 
interrupted resistant surface it presents to 
palpation. It is said that the spinous pro- 
cesses of the vertebrae can, in some in- 
stances, be felt; if so, the occurrence must 
be of extreme rarity. 
The small extremities—the legs and arms 
—are generally detected as small, irregu- 
larly shaped bodies, easily pushed about by 
the hands, often spontaneously changing 
their positions, and frequently dealing 
blows to the hand of the observer. 
The momentary application of cold to the 
abdomen is said to increase these spontane- 
ous movements of the foetus; it is incon- 
ceivable that the cold itself should penetrate 
to the foetus and excite the unwonted ac- 
tivity, especially if we are to believe 
Hebra’s statement, made in my hearing, 
that a thermometer, placed between the 
teeth and cheek, is pot sensibly affected by 
the continued application of ice to the 
cheek externally ; that the reflex nervous 
current, which might be excited in the wo- 
man, in such a case, could have an effect 
upon her uterus, and thus indirectly produce 
an impression upon the foetus, is within the 
bounds of reason, though improbable. I 
have had no opportunity of verifying the 
truth of this assertion as to the application 
of cold. 
At the Bedside.—Having first established 
the longitudinal or transverse position of 
the foetus, and the period of the pregnancy, 
the next step is to decide upon the presen- 
tation which we may have before us. 
Longitudinal Positions.—The head is first 
to be sought for, and will commonly be 
found, by suitable palpation, over the sym- 
physis pubis ; not unfrequently, it lies some- 
what to one side, especially in the earlier 
months of pregnancy, when it is less crowd- 
ed down into the pelvis by the pressure of the 
fundus uteri upon the breech. If not disco- 
verered over the symphisis pubis, the head 
must be located in the vicinity of the fundus. 
One extremity of the ovoid having been 
found, the other, the breech, is to be 
searched for. It must lie in the opposite 
vertical half to that in which the head lies. 
The presenting part, whether head or 
breech, may be above the brim of the pel- 
vis, where it will be freely movable, and 
easily accessible to palpation ; or it may 
have descended into the pelvis, and become 
more or less fixed, in proportion to the 
depth to which it has sunk, and its size rela- 
tively to that of the pelvis. In the latter 
case, the presenting head may still be reach- 
ed by palpation, or often the neck only, 
which can be recognized by its appearing, 
when grasped, too small to be either the 
head or the breech. The bimanual method 
of examining the presenting part may, in 
cases of “ deep-seated head/’ be resorted 
to with success. When the breech has de- 
scended into the pelvis, the part seized by 
the hand is not small, but, consisting, as it 
does, of the body and perhaps the legs, it 
is as large and may even be larger than the 
breech itself. Bimanual palpation will 
here only confirm the deep seat of the breech. 
The remaining regions of the abdomen 
are then to be explored to determine in 
which direction the back is turned, and in 8 
which quarter the small extremities lie. 
The bac/c is commonly directed either to 
the right or the left side of the mother, 
and may be recognized rather by the 
greater resistance, imparted by it to the 
lateral half of the abdomen in which it is 
located, than by its long, resistant surface 
being absolutely felt, though this last may 
often happen. 
In the opposite, lateral half of the abdo- 
men, the limbs are to be sought for, both 
by deep pressure, and by a passive laying 
on of the hands. 
Transverse Positions.—In these the head 
and breech are first to be distinguished from 
each other as they lie in the opposite later- 
al segments of the abdomen. 
The back and limbs are then felt for, with 
a view to determining whether the former 
is turned more to the front, or more to the 
back of the mother. No presenting parts 
will be detected, an arm or a leg being too 
small to be appreciable by palpation. All 
these signs of the position of the foetus 
may not be elucidated in every case, but 
enough will almost invariably be made out 
to enable us to decide upon the presenta- 
tions and positions, recognized in the clas- 
sification adopted. The examiner should 
not, however, be satisfied until he has tried, 
at least, to obtain each of the data given 
above. 
Before giving the classification, I must 
apologize for substituting the English term 
“ presentation ” for the exact translation 
of the German word “ lage,” which would 
be " position.” This is all the more to be 
deplored, for “ position ” [lage] seems 
(though I have been unable to verify the 
fact) to have been specially chosen, be- 
cause of the importance accorded in Ger- 
many to external examination, in which 
the presenting part plays but a subordinate 
role. The danger of being misunderstood, 
from the use of the term “ position ” in a 
more restricted sense in English and Ame- 
rican treatises, seems to justify this change. 
As no two schools in Germany have the 
same classification, that used in Vienna 
will be given, because, in my opinion, it is 
the simplest and best. 
The 3d and 4th occipital presentations, 
of English and American authors, are desig- 
nated as abnormal “ rotations ” of the other 
two occipital presentations. 
After the vaginal examination, in breech 
presentations, more exactitude is some- 
times gained by accepting knee and foot 
presentations, as subdivisions of the first; 
very little stress is, however, laid upon this 
point, as it is devoid of all practical worth. 
(The German names are added, to aid 
such as may occasionally refer to German 
text-books.) 
Classijication of Presentations and Positions 
of the Vienna School. 
I.—Longitudinal Presentations. 
[Langenlage.] 
Head. 
(Kopflagc.) 
Breech. 
(Steisslagc.) 
Occipital. 
(Schadel- 
lage.) 
Face. 
(Gesichts- 
lage.) 
i-t Back toward left side. 
(Rocken nach links.) 
Back toward right side. 
(Racken nach rechts.) 
2(j Back toward right side. 
' (Rocken nach rechts.) 
i Back toward left side. 
' (Rocken nach links. 
2(j Back toward right side. 
(Rocken nach rechts.) 
Back toward left side. 
' (Rocken nach links.) 
Oblique presentations (schieflage) al- 
ways change into longitudinal or transverse. 
II.—Transverse Presentations. 
[Querlage.l 
lst. 
Head in left side. 
(Kopf links.) 
2d. 
Head in right side. 
(Kopf rechts.) 
9., Position 
(Stellung) 
9j Position 
“Q (Stellung) 
1c:f Position 
lst (Stellung) 
Position 
ASl (Stellung) 
Back backwards. 
(Racken nach hinten.) 
Back forwards. 
(Rocken nach vorne.) 
Back backwards. 
(Rocken nach hinten.) 
Back forwards. 
(Rocken nach vorne.) 
It will be observed that this classification 
and nomenclature are the direct result of 
the prominence given, in Germany, to the 
external examination, as all the different 
presentations and positions can be deter- 
mined, exclusively, from the data thus fur- 
nished. From this are the diagnoses made, 
and then later confirmed, made doubtful, 
or, in rare cases, refuted by the vaginal 
examination. The division is extremely 
simple, and has been proved to give all the 
indications of real importance in practice. 
Before reviewing the signs yielded by 
palpation, in each of the presentations and 
positions, I must briefly refer to the assist- 9 
ance furnished, in this respect, by another 
mode of examination. 
Auscultation of the Foetal Heart.—This 
may be performed, with the ear applied to 
the integument of the abdomen, through 
the medium of a sheet, or, better still, by 
means of a stethoscope, because this in- 
strument may be applied to any part of the 
abdomen, without necessitating a con- 
strained posture, or a congested head, on 
the part of the auscultator ; it is open to 
only one objection, that the woman’s abdo- 
men must be laid bare. 
It has been proved that the foetal heart- 
sounds are, almost invariably, best heard 
through the back of the foetus, hence at 
that part of the abdominal surface of the 
woman beneath which the back lies. This 
is based upon the fact that the back is 
generally forced, by the motions of the foe- 
tal extremities, into immediate apposition 
with the uterine walls, hence the distance 
through the back to the auscultator’s ear 
is less than through the breast; moreover, 
a considerable layer of fluid is apt to inter- 
vene between the breast and the uterine 
walls, a condition peculiarly unfavorable to 
the transmission of sound. 
This rule has but one recognized excep- 
tion, though, of course, unusual circum- 
stances may render it unreliable. In face 
presentations, from the unnatural position 
of the head, the occiput being pushed back 
upon the vertebral column, the dorsum of 
the foetus is separated from the uterine 
walls on that side, and the breast is thrust 
forward against them on the other, thus re- 
versing the ordinary condition of things. 
Here the heart-sounds will best be heard in 
that region of the abdomen nearest to the 
breast of the foetus. In all other presenta- 
tions, the spot at which the foetal heart- 
sounds are heard with the greatest dis- 
tinctness, will always guide us to the posi- 
tion of the back. If the back of the foetus 
is directed toward the back of the mother, 
the heart-sounds will be but faintly audible, 
if at all. During contractions of the uterus, 
the foetal heart-sounds are never heard. 
It will now be seen how auscultation of 
the foetal heart-sounds will confirm or re- 
fute the data, furnished by palpation, as to 
the lay of the back. 
Signs Obtained in each of the Presenta- 
tions and Positions through Palpation and 
Auscultation. ls£ Occipital.—Head over 
the pubes. Breech in fundus uteri. Back 
in left side of abdomen, small extremities 
in right. Foetal heart-sounds in left lower 
segment of abdomen. 
2d Occipital.—Head and breech as above. 
Back and foetal heart-sounds in right side, 
small extremities in left. 
ls< Face.—Head over pubes, somewhat 
to left. Breech in fundus somewhat to left. 
Small extremities in right side, also foetal 
heart-sounds. 
2d Face.—Head over pubes, somewhat 
to right. Breech in fundus, somewhat to 
right. Small extremities and foetal heart- 
sounds in left side. 
Oblique are merely divergencies from 
one or another of the occipital or transverse 
presentation, hence the signs will be but 
modifications of those found in these pre- 
sentations. 
ls£ Breech.—Breech over pubes. Head 
in fundus uteri. Back in left side of abdo- 
men, small extremities in right. 
2d Breech.—Breech and head as above. 
Back in right side, small extremities in left. 
ls£ Transverse.—Head in left side, breech 
in right. 
ls< Position.—Back forwards. Small ex- 
tremities backwards. Heart-sounds heard. 
2d Position.—Back backwards. Small 
extremities forwards. Heart-sounds not 
heard, or but very faintly. 
2d Transverse. — Head in right side, 
breech in left. 
ls£ Position as in first transverse. 
2d Position as in first transverse. 
The Diagnosis of Twins is, in general, 
very uncertain, and, in primiparae, rarely 
successful. A depression running across 
the abdomen is rather the exception than 
the rule, and, even if present, is not con- 
clusive. Up to the tenth lunar month, the two 
foetuses are so movable that they yield but 
few data on which to base a diagnosis. 
During the tenth lunar month the following 
signs, if satisfactorily made out, will justify 
us in pronouncing in favor of twins, yet 
there is no condition in midwifery which so 
frequently baffles the skill of the most ex- 
perienced obstetricians as this. 
1st. The recognition, by palpation, of 
several similar large foetal parts (head or 
breech). Perhaps, while one is deep in the 
pelvis, two others may be felt through the 
abdomen. 
2d. The recognition, by palpation, of nu- 
merous, small, movable, foetal parts (legs 
and arms), or their spontaneous motions in 
several regions of the abdomen. 
3d. The exact diagnosis, by palpation, of 
position of each foetus. 
4th. The immobility of the presenting 
part (as revealed by palpation and vaginal 
examination), especially after evacuation 10 
of the liquor amnii, while the parts felt 
through the abdominal walls are very 
movable. 
5th. The perception, by auscultation, of 
the foetal heart-sounds at two opposite sides 
of the abdomen, while they are inaudible in 
the intervening space. 
6th. A striking want of accord between 
the presenting part (as revealed by palpa- 
tion and vaginal examination) and the place 
of the heart-sounds. 
In general, an unusual size of the abdo- 
men, a lateral distention of the uterus, the 
sensation, by the mother, of foetal motions 
in many regions are signs of subordinate 
value, but should, at least, raise suspicions 
of a multiple pregnancy. 
The Signs of Extra-uterine Pregnancy re- 
vealed to palpation vary so greatly in dif- 
ferent cases, that scarcely any rule can be 
given for them. The chief peculiarity is 
the presence of two abdominal tumors, one 
being the foetus with its enclosing cyst, in 
which, early in the pregnancy, movable, 
resistant parts may be felt, and later even 
the presentation, &c., of the foetus be de- 
termined ; the second tumor is the uterus, 
somewhat enlarged, but not so much so as 
the supposed duration of the pregnancy 
would require. Until the foetal parts, or 
their motions, can be made out, or the foetal 
heart-sounds can be heard, extra-uterine 
pregnancy cannot be diagnosticated, by ex- 
ternal examination, from any other cystic 
tumor. 
Complications of Pregnancy revealed by 
Palpation. 
The Death of the Foetus during pregnancy 
can never be recognized with certainty, but 
may be suspected from the following signs : 
the general flabbiness, and want of fixed 
shape of an abdomen, which had previous- 
ly been firm and resistant, as well as diffi- 
culty in defining the outline of the uterus ; 
the impossibility of feeling the spontaneous 
movements of the foetus (very unreliable); 
the softness and non-resistance of the foetal 
parts, and their remaining passively in any 
spot into which they are pushed ; the non- 
ballottement and soft feel of the head. 
Confirmatory evidence is derived from 
the fact that the foetal heart sound, which 
have been audible to a skilled anscultator, 
can no longer be detected in any region of 
the abdomen. (The heart sounds are best 
heard when the back is directed forwards, 
and the limbs backwards and out of reach, 
and vice versa.) 
The Size of the Foetal Head relatively to 
that of the pelves. This, in all cases of 
narrow or deformed peltis, is of the utmost 
importance as determining, whether the de- 
livery should be left to the course of nature, 
or whether manual or instrumental inter- 
ference is called for. The size and hard- 
ness of the head may be presumed from the 
general size of the foetus, and estimated di- 
rectly by palpation. The head can seldom 
be fairly grasped, and its dimensions arriv- 
ed at, except when over the pubes, and 
even then, it requires long and constant 
practice, to enable its size to be calculated 
with any degree of accuracy. 
Hydrocephalus is diagnosticated from the 
large size, and the abscenco of the usual 
hardness, of the head, as well as from its 
remaining above the pelvic brim, in spite 
of strong uterine contractions, when pre- 
vious easy births, or an exact measurement 
has established the normal dimensions of 
the pelvis. 
Contractions of the uterus are plainly de- 
tected through the abdominal walls, and 
their character determined. The different 
conditions of fnertia, atony, exhaustion, 
paralysis either general or partial, and te- 
tanus, of the uterus during delivery, are 
thus recognized, and appropriately treated. 
Colicky pains, from contractions of the 
uterus before the full term, may be distin- 
guished from other similar pains and proper 
means be taken to avert a threatening abor- 
tion or miscarriage. 
Retroversion of the pregnant uterus is 
commonly first indicated by retention of 
urine, and colicky abdominal pains ; on pal- 
pation the bladder will be detected, extend- 
ing often as high as the umbilicus. The 
uterus will be out of reach. 
Rupture of the uterus, during natural de- 
livery, occurs, according to C. Braun, from 
the violence of the contractions, and is lo- 
cated, transversely, at the junction of neck 
and body. It can only be certainly diag- 
nosticated from the vaginal examination, 
but may be suspected from the sudden ces- 
sation of pains, previously severe, from the 
great change in the position of the foetus, 
and the retreat of the presenting part, from 
the recognition of the contracted uterus 
as a hard turner upon one side, and from 
the greater distinctness with which the 
foetus having escaped into the peritoneal 
cavity, is felt. When the foetus does not 
thus escape, the fundus uteri commonly 
falls to the opposite side to that in which 
the rupture has taken place, owing to the 
local paralysis of the latter. The abdomen 
becomes large, and fluids collect in its 
deep parts. 11 
Tumors, such as fibroids, ovarian cysts, 
&c. The former will often mar the sym- 
metry of the uterine contour, and may then 
be carelessly taken for the small extremi- 
ties, or even a second foetus ; their persis- 
tence in one spot, in spite of manipulation, 
and their possible want of accord with the 
position of the foetus will dispel the illu- 
sion. Ovarian cysts can generally be made 
out as distinct elastic tumors, separated 
from the uterus by a well-marked furrow. 
Hindrances and Expedients. 
Tension of the abdominal walls, when 
due simply to the unusual dilatation as of- 
ten happens with primiparse, may general- 
ly be overcome by attention to the details of 
examination, given in the early pages of 
this paper. Yet this condition will occa- 
sionally prove so obstinate as to render pal- 
pation fruitless. Percussion may then be 
resorted to. 
Muscular contractions of the abdominal 
and uterine walls. The latter are involun- 
tary and unavoidable, unless through the 
delicacy of the explorer’s touch. The in- 
tervals between the spasms must then be 
made the most of. The abdominal muscles 
are, for the most part under the influence 
of the will, and should but rarely prove an 
obstacle to their examination. The wom- 
an’s attention may often have to be distracted 
by conversation, or better still, she should 
be required to hold her mouth open, or to 
count in order to prevent her straining. 
Hydramnios may cause such distension 
of the uterus as to interfere seriously with 
palpation. The uterus will then be large 
and symmetrical, even yielding fluctuation 
in extreme cases. The foetus is freely mov- 
able, and ballottment easy. The foetal 
heart sounds are weak or unheard. Too 
small an amount of liquor amnii, on the 
other hand, will allow the uterus to cling 
to the foetus before the contractions, and 
enable a long and tedius first stage of labor 
to be foreseen. 
Tenderness of the abdomen is rarely so 
great as to interfere, seriously, with careful 
palpation, through a circumscribed spot 
may be rendered so sensitive, from the con- 
tinual kicking of a lively child, especially 
if it be against the ribs, as not to bear the 
least touch. Cases, of which I have seen 
one, occur occasionally, in which, at any 
time during the early months of pregnancy, 
an hyperaesthesia of the peritoneum is ex- 
cited by spasms of the uterus ; many of the 
local symptoms of a subacute peritonitis, 
such as pain,extreme tenderness on pressure, 
&c., are present, with entire absence of 
the constitutional disturbance, effusion and 
other diagnostic symptoms of such a condi- 
tion. The true nature of the affection has nev- 
er been satisfactorily shown, so far as I can 
learn. It is pleasant however to feel that 
this state will improve with time and treat- 
ment, and have no prejudicial effect upon 
the regular course of the pregnancy, pro- 
vided abortion is, at the time, guarded 
against. Such a complication would evi- 
dently prevent all palpation, as might also 
a true circumscribed peritonitis, such as 
is caused by the bursting of the cyst in ex- 
tra-uterine pregnancy. 
Adipose tissue, when deposited, in great 
amount, in the abdominal walls, adds great- 
ly to their thickness, and may thus form 
a serious hindrance to abdominal examina- 
tion. No change occurs in the uterine 
walls from successive pregnancies, except 
a little unevenness of surface in some in- 
stances. 
Ascites and Flatus may occur during 
pregnancy and prevent all access to the 
uterus through the abdomen. They are 
distinguished from each other by percus- 
sion and fluctuation. Graviditas nervosa 
is a form of the latter, which is often met 
with at the time of the grand climacteric 
and may then give rise to much doubt and 
distress. 
Internal and External Examination 
combined. 
Thus far external examination alone has 
occupied our attention, but we must not 
pass from the application of this to diag- 
nosis without a few brief words upon the 
effect of its combination with the internal 
examination. This method is superfluous 
after the presenting part is fixed or but 
slightly movable. When, however, it is 
freely movable, or when the foetus is too 
small to be made out by palpation alone, 
and again in complicated or obscure cases, 
this combination may be employed to great 
advantage. Before the uterus has risen 
above the brim of the pelvis, i. e. in the 
first three lunar months, a finger in the 
vagina and a hand upon the abdomen may 
hold between them the enlarged uterus, 
and from its size, growth, consistency, &c., 
distinguish it from other uterine as well as 
extra-uterine tumors. Soon after this pe- 
riod, the foetus or its head may often be 
first recognized by its bouncing from one 
to the other of the hands, when thus held, 
and made to strike it. 
Still later in the pregnancy, a hand upon 
the abdomen will often be required to bring 
down and retain the presenting part of the 12 
foetus within reach of the finger in the va- 
gina. This is especially useful in oblique 
presentations, where the presenting part 
lies in one of the iliac regions, and may be 
pushed down into the pelvis by a hand ap- 
plied outside of it. The same may be ef- 
fected in many transverse presentations. 
In determining the size of the foetal head, 
when presenting, this combined examina- 
tion will be manifestly advantageous, for 
the head can then be held between the 
hands, and its dimensions estimated with 
tolerable accuracy by an experienced ob- 
stetrician. 
As an assistance to vaginal examination, 
the left hand upon the abdomen is in 
such constant use in Germany that no 
student is ever allowed to omit it. It 
should not, then, be applied over the 
fundus utei'i only, and made to press 
the foetus down into the pelvis, but 
should be moved to various regions of the 
abdomen. When there is ‘any tendency to 
what is called “ hanging abdomen,” the 
hand will be more efficacious when pushing 
upwards from immediately above the sym- 
physis pubis. In the diagnosis of twins, 
some aid may be derived from noting 
whether a push, administered to the pre- 
senting part, is transmitted to the hand 
upon the fundus uteri and vice versa. 
Palpation in its application to Treatment. 
Version by external manipulation alone was 
first recommended by Wigand in 1807, and 
has given so much better results than the 
old method by internal manipulation, or the 
combined one more recently brought into 
notice by Braxton Hicks, as to be univer- 
sally given the preference in Germany. The 
fact that, if unsuccessful, it is perfectly 
harmless, and in no wise prevents the other 
modes of version being resorted to, raises 
it above reproach. Wigand himself says, 
“we should never neglect to try it,” and 
later generations but echo his opinion. 
The theory of the operation is merely to 
aid nature in her attempt to bring the foetus 
into the normal, i. e. longitudinal, position. 
It is, of course, derived from our observa- 
tion of the many transverse positions that 
change, in the last months of pregnancy, 
into longitudinal, or are converted into 
such, by the uterine contractions, after 
labor has commenced. 
The conditions most favorable to the ope- 
ration are thin, flabby, non-sensitive abdo- 
minal and uterine walls, considerable liquor 
amnii, and not too large a foetus ; these 
render the foetus accessible to manipulation 
and freely movable. 
During contraction of the uterus, and, 
with very few exceptions, after rupture of 
the membranes, nothing can be effected by 
external treatment. The most suitable time 
is when the membranes are still intact, and 
the uterus makes quite long pauses be- 
tween the contractions. A fully dilated os 
uteri is an advantage, for then, should ver- 
sion by external manipulation prove unsuc- 
cessful, and during the attempt the mem- 
branes be accidentally ruptured, version by 
internal manipulation may be undertaken, 
before the foetus has become fixed by the 
hugging of the uterine walls. This dilata- 
tion of the os uteti should, however, not 
be waited for, because the liquor amnii 
may escape at any moment, and thus the 
golden opportunity be irretrievably lost. 
As to the question whether any good re- 
sults from version during the last few 
months of pregnancy, in fact at any time 
before labor has commenced, I can only 
say that in Vienna the operation is now 
never performed at such times; Professor 
Spaeth has, in my presence, repeatedly 
pronounced any version, undertaken before 
labor begins, as useless. Its advocates 
elsewhere admit that the change in position 
is rarely permanent, and in these instances 
the operation, in all probability, but fore- 
stalls the working of nature. The proper 
time is as soon as possible after the first 
pains are felt. 
If, then, it is to be performed before the 
os uteri is dilated, and consequently before 
vaginal examination will yield reliable re- 
sults as to the presentation, the importance 
and even necessity of basing the diagnosis 
upon the data furnished by external exami- 
nation again asserts itself. 
Manual of the Operation.—The advaa- 
tage of having the woman upon the side 
in which the part to be brought down lies, 
and thus, by causing the fundus to fall to 
that side, directing the head towards the 
entrance to the pelvis* seems to me to be 
overbalanced by the difficulties of the ma- 
nipulation, and, especially, the impossibility 
of properly applying the force; the tendency 
of the whole operation is, moreover, to 
bring the fundus uteri into this desirable 
situation. I have seen the operation seve- 
ral times performed in the dorsal decubitus, 
and am satisfied of its superiority. This 
applies to the complete cro.-s presentation, 
and not to the oblique, where lateral decu- 
bitus alone, if properly chosen, will result 
in a longitudinal presentation of the foetus. 
Let the woman, therefore, be upon her 
back, and the physician upon that side of 
the bed in which the future presenting part 13 
lies, for the force will then be most com- 
fortably and efficiently applied. Either 
cephalic or pelvic version may be perform- 
ed, the rule being to bring down into the 
pelvis that end of the foetus which is near- 
est to it. If, however, the foetus is so 
movable as to render either an easy task, 
the head is to be chosen, from the lesser 
mortality attending those presentations. 
While facing the woman’s feet, the obstet- 
rician lays the palm of the farther hand above 
and outside of the part to be brought down, 
and endeavors to propel it in the direction of 
the entrance to the pelvis. With the other 
hand he is, at the same time, pushing and 
rubbing the opposite end of the foetus to- 
ward the fundus uteri. Great force should 
never be applied, but manipulation and 
friction during the intervals between the 
contractions, and steady pressure during 
the contractions, to prevent the loss of 
ground already gained, will generally effect 
the desired result. An assistant to work 
over one large extremity, while the opera- 
tor confines himself to the other, is often 
useful. An occasional pressure upon the 
lower end, in the direction of the long axis 
of the foetus, to start it out of the hollow 
in which it lies, is advisable. 
As the contractions of the uterus may, 
unaided, perform the version, we should 
never overlook the chance of success 
through their increased violence, due to the 
manipulations. It is even well at times to 
await the effect of these. 
If the end of the foetus approaches the 
pelvis, agreeably to our wishes, the pres- 
sure should be maintained, until we are 
satisfied that the part will remain in its new 
place, during the pauses as well as the con- 
tractions of the uterus. For this purpose, 
turning the woman upon the side, whence 
the presenting part has descended, is to be 
recommended. Should it even then not re- 
main fixed in the pelvis, it must be held 
there, until the os uteri is sufficiently di- 
lated to justify a rupture of the membranes; 
where absolutely necessary, this last 
may be done before the os is fully dilated, 
but ever with great circumspection. Pads 
and bandages, to keep the foetus in place, 
are of little avail. The moment the present- 
ing part is firmly engaged in the pelvis, the 
completion of the labor may be left to nature. 
Two conditions will contraindicate this 
method of version, a narrow pelvis and ne- 
cessity for a hasty completion of the deliv- 
ery ; in all other cases it should invariably 
be tried, provided the obstetrician is not 
called upon too late. 
To prevent haemorrhage, in cases of pla- 
centa prsevia, many authorities consider 
that the leg serves as a better tampon than 
the head, and that podalic version should 
then be elected. 
When the foetus is dead, great difficulty 
may be experienced in turning thus, be- 
cause of the want of firmness in the foetus ; 
as soon as this state is recognized, podalic 
version or decapitation may even be un- 
dertaken. 
In a premature birth, the version by ex- 
ternal manipulation will generally be easy, 
owing to the proportionally great amount 
liquor amnii. 
Matteiand Ilegar recommend the change 
of breech into head presentations, to which 
there can certainly be no objection, provid- 
ed it can easily be accomplished. 
In Germany it is never thought necessa- 
ry to employ an anaesthetic during this oper- 
ation. 
Before leaving the subject of palpation 
in treatment, I might be charged with over- 
sight, did I not mention the advantage of 
friction and manipulation to augment the 
intensity of weak uterine contractions, as 
well as the great acceleration to delivery, 
in cases of “ hanging abdomen,” from sup- 
porting, with the hands or a bandage, the 
fundus uteri, which, by its falling forwards, 
directs the presenting part against the 
promontory of the sacrum, and not into 
the entrance to the pelvis. 
I will not farther emphasize the importance 
of palpation in obstetrics, but trust that the 
persual of these pages has made the theory 
appear rational, and will persuade others to 
give it a fair trial in practice. 
In justification of the high value which I 
claim for my subject, I will append two or 
three opinions expressed by leading Ger- 
man obstetricians. 
Naegele and Grenser say “ this mode of 
investigation has a great value, and cannot 
be sufficiently recommended.” 
Schroeder, in the last edition of his treat- 
ise, expresses himself as follows: “ For the 
small practitioner, the determination of the 
foetal presentation from the external examin- 
ation, under ordinary circumstances, allows 
less opportunity for error, than the internal, 
when it alone is undertaken. The first 
should never be omitted, since the results 
derived from the internal examination are 
subjected, through it, to the most admirable 
test.” 
Ilegar of Freiburg goes even farther, and 
says, “ If the attention of our women was 
called to the great advantage of this (ex- 
ternal) examination, they would soon come 
to demand it. Pregnant women can be ex- 14 
amined much oftener and by more persons 
externally than internally. The chief cause 
of the many fatal results after transverse 
positions is, I am perfectly convinced, that 
the external examination is placed in the 
second line, and far too great a value at- 
tributed to the vaginal examination in the 
instruction of students and midwives. In 
theory, the importance of palpation has 
long been recognized, but, in practice, it 
is too little used, and in the schools for 
midwives especially, too little stress is laid 
upon the fact that this method of examina- 
tion is more important than the internal. 
Were this not so, then we should not be 
continually hearing of neglected transverse 
positions.” Can testimony be stronger! 
What then are the chief advantages which 
have compelled so strong expressions of 
opinion, in favor of palpation in obstetrics? 
1st. That, by it, the period of the preg- 
nancy may be approximately estimated. 
2nd. That the diagnosis of the foetal 
presentations and positions may be made 
during the later months of the pregnancy 
and the first stage of labor, when internal 
examination yields very meagre results. 
3d. That twins, extra-uterine pregnancy, 
the death of the foetus, the size of the foe- 
tal head, complicating tumors, and many 
other conditions may, by it, be recognized, 
long before the vaginal examination would 
reveal them. 
4th. That the external examination may 
be made many times, and by many persons, 
without any risk of doing harm. On this 
account it recommends itself especially, 
for purposes of instruction. 
In the way of treatment. 
1st. That version can be performed by 
external manipulation with much greater 
chance of success than by the internal, and 
with this gain to the mother that the danger 
of inflammation and rupture of the uterine 
walls is reduced to a miminum, that in case 
of haemorrhage or other threatening symp- 
tum, turning by external manipulation may 
be resorted to, if thought expedient, much 
earlier than the old method; and to the 
child that it thereby escapes the greater 
mortality attendent upon breech presenta- 
tions. 
The length of this paper bids me desist 
from considering the application of the 
combined method of treatment, and refer 
the reader to the able article by Braxton 
Hicks, published a few years since in the 
“ Transactions of the London Obstetrical 
Society.” 
Vevey, Switzerland, July 15, 18*72.