CLINICAL LECTURE 
ON THE 
DIAGNOSTIC VALUE 
OF 
ABDOMINAL PALPATION 
IN 
PREGNANCY. 
BY JAMES R. CHADWICK, M. D. 
Fellow of the American Gynecological Society, Boston, Mass. 
Reprinted from the American Practitioner, Nov., 1876. 
INDIANAPOLIS: 
JOURNAL COMPANY, PRINTERS. 
1876. DIAGNOSTIC VALUE 
OF 
Abdominal Palpation in Pregnancy. 
The history of the patient now before you has already sug- 
gested to your minds the probability that she is pregnant, 
but the menstruation has been habitually so irregular that we 
must all entertain some doubts as to the fact, and must be 
completely in the dark as to the period to which that state 
may have advanced. As your text-books give at great length 
the various signs and symptoms of pregnancy as taught by 
English, French and American obstetricians, I will devote the 
short time at our disposal to a minute exposition of the 
method and advantages of abdominal palpation, which has 
attained to a prominence and importance in Germany that 
are unknown and unappreciated in other countries. 
The other methods of abdominal examination are inspection, 
percussion and auscultation ; their objects may be briefly stated 
as follows: 
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 impe- 
diment to respiration, and condition of the ribs; sometimes 
shows us the movements of the child or of flatus, the twitch- 
ing of the abdominal muscles, and occasionally a thrill from 
pulsation of the aorta. 
Percussion informs us as to the consistence of the contents 
of the abdomen, giving the size and height of the womb, as 
well as, imperfectly, the nature of its contents, the presence 
of ascites, flatus, or a full bladder. 2 
The Induction of Premature Labour. 
France, when it was first suggested, in 1779, its introduction 
met with the strongest opposition from M. Baudelocque and his 
followers. The doctors of the Sorbonne declared it a violation 
of the laws of the Church. Gardien, Carpuron, and Madame La 
Chapelle firmly resisted it. They regarded it as immoral, barba- 
rous, and unjustiably endangering the life of the mother and her 
child. As late as 1827 it was stigmatised by the Academie Royale 
de Medecine as immoral. Professor Stoltz was the first in the 
country to practise it. He did so four years afterwards, in 1831; 
and in 1852, so great was the revolution of feeling, that the Aca- 
demic Royale de Medecine declared the operation not only to be 
not "immoral"-the term applied to it twenty-five years pre- 
viously-but to be justifiable, as being less fatal to the mother, 
and offering a mode of delivery in contraction of the pelvis, 
certain haemorrhages, and tumours which are irreducible and 
irremovable. 
In Germany, the celebrated Carl Wenzel, of Frankfort, was 
the first to declare himself favorable to the operation. In Italy 
it met with very little opposition, and now for some time past 
the practice has been universally accepted. 
Denman* states that Dr. Savage performed it successfully on 
a lady of title, who had given birth to four dead children after 
very difficult labours ; and Dr. Leef gives the details respecting 
a patient with deformed pelvis, in whom he induced labour no 
less than fourteen times. In one case only was the child born 
alive. The contraction was too great to admit of the operation 
being delayed beyond the seventh month. For some years after 
the recognition of the system, the only plan adopted was that 
of evacuating the liquor amnii by puncturing the membranes, 
and this method had been handed down from the ancients, by 
whom it was practised in the earlier months of pregnancy, in 
order to prevent disfigurement, as Ovid gives it,J " that the 
belly may be without the blemish of wrinkles." Tertullian§ 
describes the instrument employed thus-"There is also a probe 
of bronze, by which the destroying is done in a secret, criminal 
manner; they call it by the Greek term, that is 
to say, the murderer of the living infant." 
This, then, which hitherto had been used but for criminal 
purposes, was introduced as a legal practice, but only in cases 
of deformity of the pelvis. 
During the present century, however, numerous plans have 
* 'Introduction to the Practice of Midwifery,' 6th edit., 1824, p. 293. 
f ' Clinical Midwifery,' 2nd edit., 1848, p. 81. 
J 'Ut careat rugaruin crimine venter.'-Ovid, Amoves, 2, 14, 7. 
§ ' Est etiam seneum speculum,' &c.-Tertullian, Liber de Anima, cap. xiii. The Induction of Premature Labour. 
3 
been proposed, and the reasons for the advisability of bringing 
on premature labour have been so multiplied, that the consi- 
deration of the subject is one that merits the attention of us all. 
I propose, therefore, to enter upon it at once, first considering 
the reasons which have been deemed necessary for its perform- 
ance ; and secondly, the different methods which have been 
adopted. 
The reasons- 
1. When the bony pelvis is too narrow to allow a child at full 
time to pass without its life being sacrificed. 
2. When dangerous affections exist in the mother, such as 
disease of the heart, ascites, &c., seriously aggravated by 
pregnancy. 
3. Severe symptoms arising from the pregnant state, such as 
intractable vomiting, jaundice, albuminuria, chorea, mania, &c. 
4. When a mother habitually gives birth to children so abnor- 
mally large that their lives are sacrificed during delivery, or when 
several hydrocephalic infants successively occur. 
5. When repeatedly the infant has been found to die in the 
latter months, from disease of the placenta, or other recognised 
cause. 
G. In cases of tumours impeding the passage, such as fibrous 
tumours of the uterus, exostosis, &c. 
7. When sudden haemorrhage has occurred, and there is reason 
to believe that the placenta wholly or partially presents. 
8. In cases of dropsy of the amnion, and ovarian tumours, 
productive of great distress to the mother. 
1. The first requires no reasoning ; it is so well known that a 
foetal head, from the seventh to the eighth month of development, 
is not only of considerably less dimensions than at the full term, 
but that it is so much more flexible, and capable of being moulded 
to the passage. And yet, even a seven-months' child may grow 
into a fine, strong, intellectual man. Of this we have numerous 
examples. The generally-accepted degree of deformity, necessi- 
tating the employment of premature induction, is when the con- 
jugate diameter measures from 2| to 3| inches. If only 2| 
inches, the operation should be undertaken at the seventh month; 
if 2$ inches, at seven and a half months; if 3 inches, at the 
eighth month. It will be well to reckon as the seventh month 
220 days from the last day of menstruation, 235 days as seven 
and a half months, and 250 days as the eighth month. 
2. Whenever a disease known to exist in the mother is so 
aggravated by the pregnant state as to place her life in jeopardy, 
there can be no hesitation in relieving her of that which is the 
immediate cause of danger. 4 
Abdominal Palpation in Pregnancy. 
"The object of auscultation is to recognize the fetal heart- 
sounds, and the maternal vascular murmurs, and to distin- 
guish them from the transmitted heart-sounds of the mother, 
from the spontaneous movements of the fetus, from the umbil- 
ical murmur, from the gurgling of gases and the splashing of 
fluids in the intestines, and from the aortal pulse." (C. Braun.) 
For the purposes of diagnosis, palpation is the determina- 
tion of the volume, consistence, form and position of the 
uterus; the size, position, presenting part and spontaneous 
movements of the fetus; the presence of more than one fetus, 
or of complicating abdominal or pelvic tumors; the life of the 
fetus, the transmitted thrill of the aortal pulse, the fullness 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 abdominal walls. 
Preliminaries.-The woman, to be examined, should be flat 
upon her back on a bed; her legs should be drawn up, and 
her head supported, in order to relax the abdominal 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 ab- 
domen alone exposed. Should modesty require, 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 wo- 
man, 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 in- 
equalities, 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 abdomen, the pressure being not 
constant in any one spot, for a rocking motion is imparted to Abdominal Palpation in Pregnancy. 
5 
the hands by alternate flexion 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; in the latter case, the one steadies the uterus 
and fetus, while the other studies their angles and form. This 
is most useful when the abdominal contents are very movable. 
When it is wished to test the consistence or mobility (includ- 
ing ballottement) of the underlying parts, the very tips of the 
fingers of one hand should first be placed gently upon the 
abdominal integument, almost 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 fetus, two other procedures are 
commonly followed. In the first, the right hand of the inves- 
tigator, with thumb abducted, 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 ap- 
proximated, until they grasp between them the presenting 
part of the fetus. The distinguishing characteristics of a pre- 
senting head or breech may best be brought out by giving the 
part a sort of shake in this way, by which it is tossed to and 
fro between the thumb and fingers. 
The second method of palpating the' presenting part is by 
laying the two hands flat upon the opposite sides of the abdo- 
men, the points of the fingers being directed toward and lying 
just above the middle of Poupart's ligaments on each side; 
they are then thrust downward and inward towards the cav- 
ity of the pelvis, until they come upon and hold between 
them the presenting part. This method is rarely resorted to, 
unless the previous one yields an ambiguous or negative re- 
sult. It is slightly painful, but the examiner is by it enabled 6 
Abdominal Palpation in Pregnancy. 
to explore deeper in the pelvis, and thus often reach a deep- 
seated head, which would not be accessible to the former pro- 
cedure. No force sufficient to cause the woman any real pain 
need ever be employed during these manipulations. 
Attention to the minutiae enumerated above is of import- 
ance, 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 object in view. 
At the Bedside.-While facing the woman, 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 fetus corresponds to the longitudinal axis 
of the uterus; in other words, that he has a longitudinal posi- 
tion 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 may be required to support the body of the 
uterus, should it incline to fall away from the median line of 
the body. 
The Period of the Pregnancy is determined chiefly from the 
height of the fundus, which depends in the later months almost 
entirely upon the size of the fetus. The measurement of the 
abdominal circumference gives no data, as proved by Hecker, 
Spiegelberg and Richelot, who, for example, found for the 
tenth month of pregnancy variations of inches (H.), 
33-42% inches (S.), and inches (R.) 
In transverse and twin pregnancies, this manner of diagnos- 
ticating the period gives untrustworthy results, for then the 
long axis of the uterus will be the transverse, and in conse- 
quence 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 vagi- Abdominal Palpation in Pregnancy. 
7 
nal examination, and from the statements of the mother, must 
then be relied upon. 
The following are the rules to be observed 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 um- 
bilicus to the tip of the ensiform cartilage, and one passing 
through each of the last two points. 
Lunar months. 
3d Trimester 
6 
5 
4 
3 
2 
I 
9th. 
8th. 
7th. 
6th. 
5th. 
4th. 
3d- 
Capable of 
Life. 
loth. 
2cl Trimester 
1st Trimester. 
The normal term of gestation - two hundred and eighty 
•days, reckoned from the commencement of the last menstru- 
ation-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 of 
the second trimester it has reached the height of the umbili- 
cus, 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 trimester corresponds to the other lines of 
the scale. 
The distance between each of these lines is about equal to 
the breadth of two fingers, whence the common saying that 8 
Abdominal Palpation in Pregnancy. 
the fundus stands "two fingers above the symphysis pubis, or 
two fingers below the navel," etc., indicating the end of the 
fourth and fifth lunar months respectively, and so on. 
During the tenth lunar month, the uterus is generally sup- 
posed 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 allowed for, 
until further abdominal and vaginal examination has confirmed 
the supposition. A complete descent of the uterus woqld, 
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 cor- 
rect 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 other less reliable, but not unim- 
portant, data to be obtained from palpation. These will be 
more fully described in other connections later, and will here 
be only mentioned as they successively appear in the several 
months. 
Fourth lunar month.-The uterus is felt as a rounded, elas- 
tic tumor, above the symphysis pubis, and continued into the 
pelvis; its consistency is soft, and in multiparae often uneven. 
It may be a little harder in several places adjoining the fetal 
parts, but the latter are not distinctly felt. Ballottement 
through the abdominal walls is very rare. 
Fifth lunar month.-Uterus a little to one side of the median 
line, generally to the right. Spontaneous movement of the 
fetus, and abdominal ballottement rarely felt. (Fetal heart- 
sounds, in rare cases, heard on auscultation.) 
Sixth lunar month.-Fetal parts, and consequently the pre- Abdominal Palpation in Pregnancy. 
9 
sentation, can commonly be made out. Spontaneous move- 
ments felt. (Fetal heart-sounds heard.) 
Seventh and eighth lunar months.-All the parts of the fetus 
gradually become more manifest to palpation. Fetus gradu- 
ally loses its extreme mobility. Head increasing in hardness, 
as well as in size. 
Ninth lunar month.-The fetus, 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. 
Tenth lunar month.-Uterus generally descends into the 
pelvis, by which the presenting part of the fetus 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 multiparae than in primiparae, owing to the greater tension 
of the abdominal walls in the latter. The fetus 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 im- 
perfections. Three points are important in applying it, how- 
ever : that the fetus 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 dila- 
tation 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 prevent the uterus from sinking to 
its proper level in the pelvis. 
Fullness 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 determined by taking up a fold between 
the thumb and fingers. This gives another indication, for it 
has been proved that the amount of adipose tissue in the walls 
decreases with each successive pregnancy. 10 
Abdominal Palpation in Pregnancy. 
Deformity of the pelvis, of the vertical column, or of the 
thorax, an unusual amount of amniotic fluid, and the pres- 
ence of complicating tumors, may lead us astray, unless such 
conditions are discovered and due allowance made. 
Having thus settled, preliminarily, the duration of the preg- 
nancy, subject, however, to modification or correction after 
the vaginal examination, the physician proceeds to diagnosti- 
cate the position and presenting part of the fetus, and to detect 
any abnormal condition that may exist. If the urinary blad- 
der is full, it will be felt as a more or less prominent, elastic 
tumor, immediately above the symphysis pubis, and must be 
evacuated. 
The consistence of the abdomen varies with the nature of 
its walls, and more especially of its contents. The walls, 
when fat, will be soft to the feel, even when somewhat dis- 
tended ; yet in primiparae they are apt to be very tense toward 
the end of the pregnancy, owing to the unusual dilatation. 
The uterus is felt as an elastic, more or less firm bladder, 
rounded above and prolonged downwards into the pelvis. 
Toward the end of gestation it assumes more nearly the ovoid 
form of the fetus; it never, however, quite loses a slight an- 
tero-posterior groove in its fundus, the last trace of its forma- 
tion by the union of Muller's ducts; this is more marked dur- 
ing a contraction. Its shape when pregnant (and contracting) 
or dilated from other cause, is acknowledged to be chiefly 
dependent upon its contents. Up to the seventh or eighth 
lunar month the uterus is so distended by the proportionately 
great amount of liquor amnii, that the fetus floats free of its 
walls, and does not mar the symmetry of its rounded outline. 
After that time, however, the relation of the fetus to the fluid 
is gradually reversed, and the uterus assumes, in a measure, 
the form given it by the fetus. 
Peculiarities of the Fetal Parts.-The two great extremities 
of the fetus, as it lies doubled up in the uterus, are the head 
and the breech; they are recognized by their individual pecu- 
liarities, and by the rounded terminal character common to 
both. Abdominal Palpation in Pregnancy. 
11 
The head is felt as a round, hard body, entirely free from 
angles or even prominences, more movable than the breech, 
and more or less isolated (because of the hollow at the neck) 
from the neighboring resistant points. When the head is 
freely movable, one of its. chief distinctive features is its bal- 
lottement, 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 floating 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 propelled, 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 different 
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 marked, but as its bones 
gradually become more ossified, with the increase in size of 
the fetus, 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 
pointed (the tuberosities of the ischia), by not being hard, and 
by not rebounding suddenly upon the fingers after a blow 
(ballottement). 
The back is recognized by the long, uninterrupted resistant 
surface it presents to palpation. It is said that the spinous 
processes of the vertebrae can, in some instances, be felt; if 
so, the occurrence must be of extreme rarity. 
The small extremities-the legs and arms-are generally de- 
tected as small, irregularly-shaped bodies, easily pushed about 
by the hands, often spontaneously changing their positions, 
and frequently dealing blows to the hand of the observer. 12 
Abdominal Palpation in Pregnancy. 
The momentary application of cold to the abdomen is said' 
to increase these spontaneous movements of the fetus; it is 
inconceivable that the cold itself should penetrate to the fetus 
and excite the unwonted activity, especially if we are to be- 
lieve Hebra's statement, made in my hearing, that a thermom- 
eter placed between the teeth and cheek is not sensibly affected 
by the continued application of ice to the cheek externally. 
It is more probable that the reflex nervous current excited in 
the woman in such a case, has an effect upon her uterus, and 
thus indirectly produces an impression upon the fetus. 
At the Bedside.-Having first established the longitudinal 
or transverse position of the fetus, and the period of the 
pregnancy, the next step is to decide upon the presentation 
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 
symphysis pubis; not unfrequently, it lies somewhat to one 
side, especially in the earlier months of pregnancy, when it 
is less crowded down into the pelvis by the pressure of the 
fundus uteri upon the breech. If not discovered over the 
symphysis 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 sought. Ft must lie in the opposite verti- 
cal half to that in which the head lies. 
The presenting part, whether head or breech, may be above 
the brim of the pelvis, 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 relatively to that 
of the pelvis. In the latter ca,se, the presenting head 
still be reached 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 Abdominal Palpation in Pregnancy. 
13 
has descended 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. 
The remaining regions of the abdomen are then to be ex- 
plored to determine in which direction the back is turned, and 
in which quarter the small extremities lie. The back is com- 
monly directed either to the right or left side of the mother, 
and may be recognized rather by the greater resistance, im- 
parted 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 lat- 
eral half of the abdomen, the limbs are to be sought for, both 
by deep pressure and by gentle manipulation. 
Transverse Positions.-In these the head and breech are first 
to be distinguished from each other as they lie in the opposite 
lateral segments of the abdomen. 
The back and limbs are then felt for, with a view to deter- 
mining 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 fetus may 
not be elucidated in every case, but enough will almost inva- 
riably be made out to enable us to decide upon the presenta- 
tions and positions, recognized in the classification 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 substi- 
tuting the English term "presentation" for the exact transla- 
tion of the German word "lage," which would be "posi- 
tion." This is all the more to be deplored, for "position" 
(lage) seems to have been specially chosen, because of the 
importance accorded in Germany 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 Ameri- 14 
Abdominal Palpation in Pregnancy. 
can 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 third and fourth occipital presentations, of English and 
American authors, are designated as abnormal "rotations" of 
the other two occipital presentations. 
After the vaginal examination, in breech presentations, 
more exactitude is sometimes 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 occa- 
sionally refer to German text-books. 
Classification of Presentations and Positions of the Vienna 
School. 
I.-Longitudinal Presentations. 
(Langenlage.) 
Occipital. 
(Schadellage.) 
Head.- (Kopflage.) 
Face. 
(Gesichtslage.) 
Breech. 
(Steisslage.) 
2d. 
ist. 
2d. 
1st. 
2d. 
1st. 
( (Riicken nach rechts.) 
( Back toward right side. 
[ (Riicken nach links.) 
r Back toward left side. 
[ (Riicken nach rechts.) 
Back toward right side. 
[ (Riicken nach links.) 
[■ Back toward left side. 
I (Riicken nach rechts.) 
Back toward right side. 
[ (Riicken nach links.) 
j Back toward left side. 
Oblique presentations (schieflage) always change into longi- 
tudinal or transverse. Abdominal Palpation in Pregnancy. 
15 
II.-Transverse Presentations. 
(Querlage.) 
First. 
Head in left side. 
(Kopflinks.) 
Second. 
Head in right side. 
(Kopf rechts.) 
2d. 
f 
1st. 
2d. 
f 
1st. 
[(Stellung.) | (Riicken nach hinten.) 
f Position. I Back backwards. 
(Stellung.) | (Riicken nach vorne.) 
f Position. I Back forwards. 
( (Stellung.) | (Riicken nach hinten.) 
J" Position. I Back backwards. 
(Stellung.) (Riicken nach vorne.) 
( Position. I Back forwards. 
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 determined, exclusively, from the data 
thus furnished. 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 im- 
portance in practice. Before reviewing the signs yielded by 
palpation, in each of the presentations and positions, I must 
briefly refer to the assistance furnished in this respect by 
another mode of examination. 
Auscultation of the Fetal 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 instrument may be applied to any 
part of the abdomen, without necessitating a constrained pos- 
ture or a congested head, on the part of the auscultator; it is 
open to only one objection, that the woman's abdomen must 16 
Abdominal Palpation in Pregnancy. 
be laid bare. It has been proved that the fetal heart-sounds 
are, almost invariably, best heard through the back of the 
fetus, 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 
fetal 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 intervene between the breast and the 
uterine walls, a condition peculiarly unfavorable to the trans- 
mission of sound. This rule has but one recognized excep- 
tion, though, of course, unusual circumstances may render it 
unreliable. In face presentations, from the unnatural position 
of the head, the occiput being pushed back upon the verte- 
bral column, the dorsum of the fetus is separated from the 
uterine walls on that side, and the breast is thrust forward 
against them on the other, thus reversing the ordinary condi- 
tion of things. Here the heart-sounds will best be heard in 
that region of the abdomen nearest to the breast of the fetus. 
In all other presentations, the spot at which the fetal heart- 
sounds are heard with the greatest distinctness will always 
guide us to the position of the back. If the back of the fetus 
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 fetal heart-sounds are never heard. It will now 
be seen how auscultation of the fetal heart-sounds will confirm 
or refute the data, furnished by palpation, as to the lay of the 
back. 
* Signs obtained in each of the Presentations and Positions 
through Palpation and Auscultation. 
First Occipital.-Head over the pubes. Breech in fundus 
uteri. Back in left side of abdomen; small extremities in 
right. Fetal heart-sounds in left lower segment of abdomen. 
Second Occipital.-Head and breech as above. Back and 
fetal heart-sounds in right side; small extremities in left. 
First Face.-Head over pubes, somewhat to left. Breech Abdominal Palpation in Pregnancy. 
17 
in fundus somewhat to left. Small extremities in right side, 
also fetal heart-sounds. 
Second Face.-Head over pubes, and somewhat to right. 
Breech in fundus, somewhat to right. Small extremities and 
fetal 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 presentations. 
First Breech.-Breech over pubes. Head in fundus uteri. 
Back in left side of abdomen; small extremities in right. 
Second Breech.-Breech and head as above. Back in right 
gide; small extremities in left. 
First Transverse.-Head in left side; breech in right. 
First Position. - Back forwards. Small extremities back- 
wards. Heart-sounds heard. 
Second Position.-Back backwards. Small extremities for- 
wards. Heart-sounds not heard, or but very faintly. 
Second Transverse.-Head in right side; breech in left. 
First Position as in first transverse. 
Second 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 conclusive. Up to the tenth lunar month, 
the two fetuses 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 
experienced obstetricians as this: 
First. The recognition, by palpation, of several similar 
large fetal parts (head or breech). Perhaps, while one is deep 
in the pelvis, two others may be felt through the abdomen. 
Second. The recognition, by palpation, of numerous, 
small, movable, fetal parts (legs and arms), or their sponta- 
neous motions in several regions of the abdomen. 
2 18 
Abdominal Palpation in Pregnancy. 
Third. The exact diagnosis, by palpation, of position of 
each fetus. 
Fourth. The immobility of the presenting part (as revealed 
by palpation and vaginal examination), especially after evacu- 
ation of the liquor amnii, while the parts felt through the 
abdominal walls are very movable. 
Fifth. The perception, by auscultation, of the fetal heart 
sounds at two opposite sides of the abdomen, while they are 
inaudible in the intervening space. 
Sixth. A striking want of accord between the presenting 
part (as revealed by palpation and vaginal examination) and 
the place of the heart-sounds. 
In general, an unusual size of the abdomen, a lateral dis- 
tention of the uterus, the sensation by the mother of fetal 
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, revealed to palpa- 
tion, vary so greatly in different cases that scarcely any rule 
can be given for them. The chief peculiarity is the presence 
of two abdominal tumors; one being the fetus with its inclos- 
ing cyst, in which, early in the pregnancy, movable, resistant 
parts may be felt, and later even the' position, etc., of the 
fetus be determined; the second "tumor is the uterus, some- 
what enlarged, but not so much so as the supposed duration 
of the pregnancy would require. Until the fetal parts or 
their motions can be made out, or the fetal heart-sounds can 
be heard, extra-uterine pregnancy can not be diagnosticated, 
by external examination, from any other cystic tumor. 
Complications of Pregnancy revealed by Palpation. 
The Death of the Fetus 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 previously been firm and 
resistant, as well as difficulty in defining the outline of the 
uterus; the impossibility of feeling the spontaneous move- Abdominal Palpation in Pregnancy. 
19 
ments of the fetus (very unreliable); the softness and non- 
resistance of the fetal 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 fetal heart-sound, which had been audi- 
ble to a skilled auscultator, can no longer be detected in any 
region of the abdomen. 
The Size of the Fetal Head relatively to that of the pelves. 
This, in all cases of narrow or deformed pelvis, is of the ut- 
most importance, as determining whether the delivery should 
be left to the course of nature, or whether manual or instru- 
mental interference is called for. The size and hardness of 
the head may be presumed from the general size of the fetus, 
and estimated directly by palpation. The head can seldom 
be fairly grasped, and its dimensions arrived at, except when 
over the pubes, and even then it requires long and constant 
practice to enable its size to be calculate?! with any degree of 
accuracy. 
Hydrocephalus is diagnosticated from the large size, and the 
absence of the usual hardness of the head, as well as from its 
remaining above the pelvic brim, in spite of strong uterine 
contractions, when previous easy births, or an exact measure- 
ment, has established the normal dimensions of the pelvis. 
Contractions of the Uterus are plainly detected through the 
abdominal walls, and their character determined. The differ- 
ent conditions of inertia, atony, exhaustion, paralysis, either 
general or partial, and tetanus of the uterus, during delivery, 
are thus recognized and appropriately treated. Colicky pains, 
from contractions of the uterus before the full term, may be 
distinguished from other similar pains, and proper means be 
taken to avert a threatening abortion or miscarriage. 
Retroversion of the pregnant uterus is commonly first indi- 
cated by retention of urine and colicky abdominal pains; on 
palpation the bladder will be detected, extending often as 
high as the umbilicus. The uterus will be out of reach. 
Rupture of the Uterus, during natural delivery, occurs, ac- 
cording to C. Braun, from the violence of the contractions, 20 
Abdominal Palpation in Pregnancy. 
and is located transversely at the junction of neck and body. 
It can only be certainly diagnosticated from the vaginal ex- 
amination, but may be suspected from the sudden cessation 
of pains, previously severe; from the great change in the 
position of the fetus, and the retreat of the presenting part; 
from the recognition of the contracted uterus as a hard tumor 
upon one side; and from the greater distinctness with which 
the fetus, having escaped into the peritoneal cavity, is felt. 
When the fetus does not thus escape, the fundus uteri com- 
monly falls to the opposite side to that in which the rupture 
has taken place, owing to the lo'cal paralysis of the latter. 
The abdomen becomes large, and fluids collect in its deep 
parts. 
Tumors, such as fibroids, ovarian cysts, etc. The former 
will often mar the symmetry of the uterine contour, and may 
then be carelessly taken for the small extremities, or even a 
second fetus; their persistence in one spot, in spite of manip- 
ulation, and their possible want of accord with the position 
of the fetus, will dispel the illusion. Ovarian cysts can gener- 
ally be made out as distinct elastic tumors, separated from the 
uterus by a well-marked furrow. t 
Hindrances and Expedients. 
Tension of the abdominal walls, when due simply to the 
unusual dilatation as often happens with primiparae, may gen- 
erally be overcome by attention to the details of examination, 
given in the early pages of this paper. Yet this condition 
will occasionally prove so obstinate as to render palpation 
fruitless. Percussion may then be resorted to. 
Muscular contractions of the abdominal and uterine walls. 
The latter are involuntary and unavoidable, unless through 
the delicacy of the explorer's touch. The intervals 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 exami- 
nation. The woman's attention may often have to be dis- Abdominal Palpation in Pregnancy. 
21 
tracted 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 fetus is freely movable, and ballottement easy. 
The fetal heart-sounds are weak or unheard. Too small an 
amount of liquor amnii, on the other hand, will allow the 
utenus to cling to the fetus before the contractions, and enable 
a long and tedious first stage of labor to be foreseen. 
Tenderness of the abdomen is rarely so great as to interfere 
seriously with careful palpation, though a circumscribed spot 
may be rendered so sensitive from the continual 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 occa- 
sionally, in which, at any time during the early months of 
pregnancy, an hyperaesthesia of the peritoneum is excited by 
spasms of the uterus; many of the local symptoms of a sub- 
acute peritonitis, such as pain, extreme tenderness on pres- 
sure, etc., are present, with entire absence of the constitu- 
tional disturbance, effusion, and other diagnostic symptoms of 
such a condition. The true nature of the affection has never 
been satisfactorily shown, so far as I can learn. It is pleasant, 
however, to feel that this state will improve with time and 
treatment, and have no prejudicial effect upon the regular 
course of the pregnancy, provided abortion is at the time 
guarded against. Such a complication would evidently pre- 
vent all palpation, as might also a true circumscribed periton- 
itis, such as is caused by the bursting of the cyst in extra- 
uterine pregnancy. 
Adipose tissue, when deposited in great amount in the ab- 
dominal walls, adds greatly to their thickness, and may thus 
form a serious hindrance to abdominal examination. No 
change occurs in the uterine walls from successive pregnan- 
cies, except a little unevenness of surface in some instances. 22 
Abdominal Palpation in Pregnancy. 
Ascites and Flatus may occur during pregnancy and prevent 
all access to the uterus through the abdomen. They are dis- 
tinguished from each other by percussion 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. 
You have seen, gentlemen, that while describing the various 
steps to be taken, I have illustrated my words by a manual 
demonstration. I have in this way discovered that the fundus 
of my patient's uterus rises to a point two inches above the 
navel. I have recognized the head over the pubes a little to 
the right of the median line ; in the left side I am able to trace 
a continuous resistant surface which I assume to be the back, 
especially as I find some small, fleeting objects in the right 
side of the abdomen. If this assumption is correct, I shall 
hear the fetal heart-sounds most plainly-though but faintly 
at this early period of pregnancy-at about this spot, which 
corresponds with the back of the child's thorax. It is audible, 
but could scarcely be caught by an untrained ear. 
The abdominal wall is so thin and lax in this patient that I 
should not hesitate, with this examination alone, to assert that 
the woman has reached the seventh lunar month of her preg- 
nancy, and that the child is in the first occipital presentation. 
I shall continue this subject, on the next opportunity, by 
describing the combination of the internal and external exam- 
ination, and subsequently the application of palpation to the 
treatment of malpresentation.