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THE
Diagnosis  and  Treatment
     OF  OBSTETRIC CASES
BY
External [Abdominal] Examination
         and Manipnlation.
       PAUL F. MUNDE,  M.D.,

OBSTETRIC SURGEON TO MATERNITY HOSPITAL,, NEW YORK; ATTENDING PHYSICIAN FOR
 DISEASES OF WOMEN TO THE OUT-DEPARTMENT OF MOUNT SINAI HOSPITAL; EDITOR OF
   THE AMERICAN JOURNAL OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN;
    FELLOW OF THE NEW YORK OBSTETRICAL AND AMERICAN GYNECOLOGICAL
     SOCIETIES J CORRESPONDING FELLOW OF THE OBSTETRICAL SOCIETIES
      OF EDINBURGH AND PHILADELPHIA; AND OF THE GYNECOLOGI-
              CAL SOCIETY OF BOSTON.
Reprinted from the American Journal of Obstetrics for July and
           October, 1879, and April, 1880.     _____

NEW YOEK
WILLIAM WOOD & CO., 27 GREAT JONES STREET.
               1880. 
wa



]2$0 
PREFACE.
  The object designed in the preparation of this essay has
been fully stated in the introductory pages, viz.: to furnish the
English-speaking  portion  of the  medical profession  with a
complete epitome  of the subject of Palpation in Obstetrics—a
subject almost entirely neglected  in  English  obstetrical  text-
books.  The essay,  while  thus  intended to some extent as an
article for reference, particularly aims  at  the practical object
of popularizing the methods which it describes.   It is, there-
fore, designed chiefly for the  use  of  the student  and embryo
obstetrician, not for the obstetrical expert, who is, or should be,
familiar with all it contains.
  The drawings for the cuts were made for me, under my
directions, by my  friend, Dr. A.  H. Fridenberg,  to whom I
again desire to express my thanks.  The complex nature of the
various parts has prevented the three last cuts from  being as
clear as was desired.   They express the position of the hands,
however, and thus fulfil their object.
                                         Paul F. Munde.
     20 West 45th Street,
New York, March 30th, 1880. 
 
THE DIAGNOSIS  AND  TREATMENT  OF  OBSTETRIC  CASES
    BY EXTERNAL  (ABDOMINAL)  EXAMINATION  AND
                     MANIPULATION.
                             BY
                   PAUL F. MUNDE, M.D.,
            Obstetric Surgeon to Maternity Hospital, New York.

                                "Malgre ce laps de temps ecoule, le
                              Kujet peut Otre considere'commeneuf."
                              —Bulletin de I'Acad. Imper., Tome
                              XXV., p. 157.
   Seven years ago, towards the close of a  prolonged stay in
Vienna,  I conceived the project  of preparing an  exhaustive
paper  on  the  various  modes  and  procedures  by  which
abdominal examinations  and manipulations are conducted dur-
ing pregnancy and labor, and the numerous and  different con-
ditions in which their employment is beneficial or necessary.
Perhaps I should scarcely have thought of writing  on a prac-
tice so well known to all German obstetricians and  physicians,
and so universally taught and exercised in Germany, had I not
frequently seen in the lying-in wards in Yienna, as well as dur-
ing my previous three years' term of service as clinical assistant
to Scanzoni in the Maternity Hospital at "Wurzburg, how little
the young American medical  graduates,  even from  our best
schools, know of practical obstetrics, and particularly of external
diagnostic and therapeutical manipulations of pregnant and par-
turient women.   That this inexperience is not confined entirely
to our young practitioners was proved to me by a remark made
by an American physician, an intimate friend of mine, and one
who had seen a large number of obstetrical cases in this country,
who, while witnessing the ease and rapidity with  which the
period  of gestation and the fetal position were ascertained  by
external  examination in  a number of cases in  the reception
wards of Prof. Spaeth's clinic at Vienna, expressed his delight
at the procedure, and surprise that it is so little known  and
practised in the United States.  I was reminded by this remark
of the entire absence of any mention of this practice during my
own studies at the Yale and Harvard Medical Colleges, and of 
 4         Munde:  Diagnosis and Treatment of

 my sad ignorance in  this respect on  arriving in Europe after
 my graduation, which facts fully corroborated my friend's  ob-
 servation.  As for ever having seen the manipulation, that pos-
 sibility was out  of the question, for it is still one of the great
 and universally  acknowledged  defects of  American medical
 instruction (and one,  as we all know, difficult to remedy in our
 land of universal equality) that  but an extremely small propor-
 tion of our medical students have occasion to examine, perhaps
 not even to witness,  an  obstetrical case, and consequently the
 majority  learn this most important  branch solely from their
 text-books.  This has been my own experience, as it undoubt-
 edly has  also been that of all those students who were not so
 fortunate as to enjoy  the exceptional  advantages offered  them
 as internes in the lying-in wards of some of our large hospitals.
 So far as f have been able to learn, however great the advances
 in the other branches of medical instruction have  been, in the
 department of practical  obstetrics  there has been but little
 improvement  since I left my Alma  Mater thirteen  years
 ago.   A  simple  labor  or a  forceps or  other operative case
 seen at  a  distance from the benches of  an amphitheatre, or a
 chance  confinement case in dispensary practice, are something,
 it is true, and better than nothing, but  can scarcely be  called
practical  instruction in obstetrics.
  While in Vienna, I received from my friend, Dr. William L.
 Richardson, of Boston, a pamphlet on " External Manipulation
 in Obstetric Practice" which he had read before the Mass. Med.
 Society in June,  1871, and in which lie briefly describes the
 practice, and deplores the " little attention which has  as yet
 been paid to the subject in this  country," and warmly recom-
 mends it to the profession.
  On looking over the numerous German and other  European
 obstetrical authors then at my disposal,  I found that  few make
 more than cursory mention of the  details of abdominal man-
 ipulation,  Scanzoni1 and  Schroeder*  giving the   longest and
 clearest accounts  I was able to find.   The journal literature on
 the subject I also discovered to be by no means extensive and
 generally but little known.  This fact may, at first sight, appear
 curious  and unfavorable to the method, but  it can readily be
 explained, when  we consider  that it  is taught at all medical
  1 Geburtshulfe, Vol. I., 1867.         2 Geburtshiilfe, 3. Auflage, 1872. 
       Obstetric Cases by External Manipulation.      5

schools in (xermany as a matter of course, and that familiarity
in exercising  it must be acquired by practice, and  cannot be
learned theoretically.
  Of American authors I was able to ascertain only four who
had written special essays on this subject.  Prof. M. B. Wright,
of Cincinnati,1 Whittaker,*  John Drury,3 and Wm. L. Richard-
son ;4  all of whom, with the exception of the last named, refer-
red principally to the manipulation for the purpose of version,
hardly mentioning its diagnostic value.
  Bedford, in the last edition of his work on  the " Principles
and  Practice  of Obstetrics," published  in  1870, declares the
whole subject of external manipulation in obstetric practice to
be still " sub judiceT   Byford alone, in his " Theory and Prac-
tice  of Obstetrics,"'recommends version  by  external manipula-
tion in those cases when the patient  is seen  early in  labor, and
in his second edition (1873), pp. 358 seq., clearly describes the
operation and gives an illustrative woodcut.  Of diagnostic ex-
ternal examination neither  says a word, and it is  to  this, there-
fore, that I desire to call special attention in this paper.
  On this point Richardson (loc. cit.) says:  "While  the use of
external manipulation in the treatment of obstetric cases has
received but  little attention, its application as an  aid in the
diagnosis of the fetal position is a subject which has not  been
thought deserving of even a passing  allusion."
  While recently revising this paper, Dr. E.  Noeggerath, whom
I questioned about the literature, referred me to a most valua-
ble paper of his on " The  Operation of  Turning by External
Manipulations, considered from a historical  and practical point
of view.   With Cases," published in  the New  York Journal of
Medicine,  November,  1859, which gives almost  precisely the
same literature as quoted by me and goes over the therapeutic
procedures  very  thoroughly,  so far as  they were practised
twenty years ago.  1 have  made frequent use of  this paper in
the preparation of Chapter II. of this article.
  Influenced by these considerations, and fully acquainted as I
had  become with the examination and  manipulation in all its
  1 On Difficult Labors and their Treatment, 1854.
  2 On the Rectification of the Fetal Position by External Manipulation.
Phila. Med. and Surg. Rep., Dec. 18th, 1869.
  3 Turning the Fetus in Utero by External Manipulation. Phila., Feb. 27th,
1869.                         4 Loc. cit. 
6         Munde :  Diagnosis and Treatment of

features from my oft-repeated experience in over 1,200 cases of
gestation, as clinical assistant and tutor at the School for Mid-
wives  in  Wurzburg, and  in  fully 1,000  more during a  ten
months'  stay  in  Vienna, a detailed paper, not only on  the
therapeutical, but chiefly also on  the  diagnostic value of  the
procedure, seemed to me not  out  of place, and  I immediately
set to work in Vienna, during the winter of 1S71-72, to collect
the necessary data, intending to finish  the  article at  once, and
send it to this country  for  publication.   An eight months'
tour through Europe, however, prevented its completion at that
time ;  since my return from abroad I have repeatedly thought
of revising and finishing it, and had indeed completed it almost
to the  condition  in which  I  now present  it, three years  ago,
when it was again laid aside for more pressing work, until now,
when I hope the  subject has become neither uninteresting  nor
hackneyed—less important it  certainly is not than it  was seven
years ago.
   In  consequence of my dilatoriness,  several short papers  on
single  branches of my subject have gained precedence, the most
important  of  which  is  undoubtedly that by my friend, Dr.
James R. Chadwick, of  Boston, on " Palpation  in Obstetrics,
as practised in Germany," 1 to which paper, as well as  to  that
of Dr. Richardson, I am indebted for numerous valuable hints.
   Of the other  papers published within the  last eight years,
only two, both written by Dr. Frank C. Wilson, of Louisville,
Ky., discuss the main question of my paper, obstetric diagnosis
by palpation.   They are entitled "Fetal Physical Diagnosis"
and appeared in the American Practitioner for Dec, IS73, and
Dec, 1875, the  first paper  containing an " analysis of  the
physical examination" of 126, the second  of 106 cases.  Ad-
ditional articles, chiefly referring to  the nature, frequency, vari-
ations and importance of the fetal pulse as recognizable  by
auscultation have been contributed by Parvin, Underbill, Cum-
mings, Naylor, and several others, to ail of which I shall refer
in the course of this communication.   The publication of these
articles, in my opinion, in nowise interferes with the object of
  1 Boston Med. and Surg. Jour., Aug., 1872.
  That the subsequent papers have by no means exhausted the subject, and that
an article on "Palpatioa in Obstetrics" is still called for in this country, is
shown by the almost verbatim republication by himself of Dr. Chadwick's
piper of 1872, in the Amer. Practitioner for Nov. and Dec, 1876. 
       Obstetric Cases by External Manipulation.      7

this paper, for, as will be seen, I purpose to cover a much wider
field than  any or all of the recent productions  above men-
tioned.
  The last and most potent inducement not to delay longer the
publication of this paper, on which I have spent so much time
and labor, has come during the past autumn in the shape of a
book  by the well-known French  obstetrician, A.  Pinard, of
Paris,  on this very subject.  His work, entitled  " Traite du
palper abdominal au point de vue  obstetrical et de la version
par maneuvres externes," as the title  shows, treats of  the sub-
ject as fully as may well be done,  and has  met with great at-
tention in France.   Pinard confirms my own previous state-
ments, when he says  that " at present abdominal  palpation is
practised by a small number of obstetricans; but how small is
the number of practitioners who employ it and recognize its
importance!"
   Dr. Pinard has, in  my opinion, done a great service  by  col-
lecting and systematizing all the data of obstetric palpation; and
what he  has done for  France, I am endeavoring to do in a more
humble way for those  of our brethren who are not familiar with
the French language.   Surely, if  further  justification were
needed for the raison d'etre of this article, this is  justification
enough.
  Before proceeding  to a historical sketch of my subject, I wish
distinctly to state that it is not the ordinary superficial manual
examination of the abdomen of a woman supposed  to be preg-
nant, rapidly practised under the  clothes, to ascertain the  ap-
proximate size of the uterus and  the probable presence of a
fetus, which is briefly described in  all the text-books and doubt-
less  familiar to every  one,  to which I here  refer;  but  the
systematic, scientific,  and  accurate manipulation, by which in
most instances we  ascertain the existence of  pregnancy,  the
position  in utero, approximate size and general condition of the
fetus, and the relations of the uterus; by which a  mal-position
may frequently readily be rectified, the  expulsion of the pla-
centa facilitated, post-partum hemorrhage prevented or arrested,
and any  abnormities in form or texture of the upper portion of
the uterus and its appendages and of the abdomen detected.
  If much of what this paper contains is familiar  to many of
my readers, I  nevertheless trust that there may still be some 
8        Munde: Diagnosis and  Treatment of

to whom the information here imparted is  new, interesting,
and valuable, and for them this article is written.

                    HISTORICAL SKETCH.
  As will be seen, the literature of this subject, up to within the
past few years, is confined entirely to  the therapeutic employ-
ment of external  manipulations,  their diagnostic  utility  not
being recognized until quite recently.
  Although,  for completeness' sake, I might begin with Hip-
pocrates, and recount the rude and imperfect methods by which
the ancient Greeks and  Romans, and  later the Arabian physi-
cians, endeavored to rectify the abnormal position of the fetus,
for  practical  purposes  it suffices to commence  our historical
sketch with the revival of  medical science  after the Middle
Ages, when the  practice of midwifery was by popular consent
taken from the hands of women who, according to all accounts,
exercised their vocation in  the most  barbarous manner, and
intrusted to scientifically educated male physicians.
  In the sixteenth century,  Eucharius Rosslin (1513) and A.
Rueff1 (Zurich, 1554) in their Manuals of Midwifery, first give
accounts of a method of version by  means of external and in-
ternal manipulation, of which Rueff  especially gives a toler-
ably clear description, a free  translation of which is as follows :
" The parturient woman shall be ordered to her bed by the mid-
wife, and shall be placed on her back, with her  head low  and
her pelvis high.   Then  a dexterous woman is to stand at the
head of the  patient, and shall seize  the abdomen with both
hands and lift,  pull, and direct it gently towards herself; the
midwife sits before the  patient and waits, and crouching down
shall give aid by pushing and  directing the child so as to bring
it with both  thighs and the  breech  backwards  or upwards
towards the hack of the mother, also to turn the child so that
it can be  born  naturally, with the head  below, etc"  More
than a hundred  years later we find  the very same advice given
by Dr.  John Pechey.2
  Up to this period the rules for both  internal and external ex-
amination and manipulation were of the most simple and gen-
  'Ein schou lustig Trostbiichle von den Empfangknussen  und Geburten der
Menschen, etc.  Zurich, 1554.
  2Oompleat Midwife's Practice.  Enlarged by Dr.  John Pechey, 1698. 
       Obstetric Cases by External Manipulation.      9

eral kind, and could lay no claim to scientific value or perfection.
Mauriceau (1668) was the first to teach obstetrical exploration
in a scientific manner, and Puzos,1 while  materially improving
the art of obstetrical diagnosis, called attention to the  fact that
pregnancy may be  recognized by means of the combined  ex-
ploration  per  vaginam  and  per  abdominem as early as the
third month.  Although later Levret,2  Baudelocque,3  Jorg,4
Kiwisch,5 Hoist,6 Veit,7 and others laid stress on the importance
of this method, and although  it is the only means of diagnosti-
cating pregnancy in the earlier months, still it has not become
as universal  as it should be, and as the present state of perfec-
tion in physical examination in all  the  branches of  medical
science would lead us to expect.8
   The diagnosis of the pregnant state in the  later months is,
of  course, generally attended with  no great difficulties, but,
notwithstanding attention was called by Roederer9 to the value
of external exploration for this purpose, it is only within the
last half century that it has gradually become a well-known and
comparatively common practice.   Schroeder even says on page
76 of  the third edition of his " Midwifery," published  in 1872,
" that the importance  of external examination for  the  dia-
gnosis of pregnancy in the later months has not been  properly
appreciated until quite recently."
   The first methodic and scientific account of external manipu-
lation in its application to  cephalic version was published in
1807 by  Dr. Wigand  of Hamburg in the medical journal of
that city,10 and sent five years later as a dissertation to the uni-
versities of B.erlin and Paris, without, however, attracting pub-
lic attention.  Wigand placed the woman on her back on an
ordinary  bed, and with one  hand  gradually pressed  the  breast

   •Traite' des A.ccouchements, publie' par Morisot Deslandes, 1759.
   2 L'art des ace.  Paris, 1761, § 448.
   3 L'art des ace.  8th ed., Paris, 1844, § 371 seq.
   4Taschenbuch ftir pr. Aerzte u. Geburtshelfer.  Leipzig, 1814.
   5 Klin. Vortr. iiber Kraiikh. d. weibl. Geschl. Prag, 1854.
   GBeitr. z. Gyn. u. Geb.  Tubingen, 1867.
   1 Krankh. d. weibl. Geschl.  Erlangen, 1867.
   8 See Thomas, Dis. of Women, 1874, p. 63, line 15.
   9 J. G. Roederer, Elem. art. Obstet. Gottingae, 1753.
  10 Von einer  neuen mid leichten Methode die Kinder  zu wenden und ohne
grosse Kunst und Gewalt zur Welt zu fordern. Hamburger Mag., 1807, 1. B.,
p. 52 and three essays, etc., Hamburg, 1812., p. 35. 
10       Munde:  Diagnosis and Treatment of

of the  child upwards towards the fundus uteri, and with the
other the head downwards towards the brim of ti'.e pelvis ; the
fetus was  then  kept in its rectified position by means of pil-
lows applied to  the abdomen and chiefly to  the spot where the
feet were to be felt,  and the woman  was instructed  to  lie
principally on the side to which  the  head  appeared most  in-
clined  to move.  If the version  was attended with any diffi-
culty, Wigand gradually brought the head nearer the pelvis by
placing the woman for some  time on the side where the head
was situated, relying on the  inclined plane of the ilium and
the leverage  of the fetal  breech falling to  the other  side to
bring the head  down.   This  procedure  was put into practice
during the latter part of gestation, and repeated if necessary.
   Wigand's method,  although practised and appreciated  in
Germany, did not become generally known  to  the remainder
of  the professional  world until  the  Corsican  physician, A.
Mattei, published a book entitled " Essai sur  l'accouchement
physiologique, Paris chez Masson, 1855," in which he strongly
advocated palpation,  " le palper" "la palpation" as a dia-
gnostic and therapeutic agent in  obstetrics,  and advised  exter-
nal cephalic version, which he, however, wished called "reduc-
tion cephalique" in all breech and shoulder  presentations dur-
ing the last fortnight  of pregnancy.   He  considered  breech
presentations as not physiological, and consequently wished
them changed to head presentations during gestation, the oper-
ation, if necessary, to  be  repeated at the commencement  of
labor, when, in  case of need, the membranes may be ruptured
to fix the head.1
   Herrgott, of Strassburg,2 translated the above-mentioned pa-
per of Wigand and indorsed his and  Mattel's views.  Esterle
of Trent,3 however, published a paper proving that the latter
author had overestimated the  value of early version by exter-
nal manipulation, for among 500  women who were  examined
by external manipulation during the seventh and eighth months
of pregnancy, there were found  22 transverse positions of the
fetus in utero;  of those, 9 rectified themselves spontaneously
10 were changed  by external,  and 2 by combined internal and
               1 Gaz. m6d. de Paris, 23, 1855.
               2 Gaz. me'd. de Paris,  27 Juillet, 1856.
               3 Annali universali di med.  Milano, 1859. 
       Obstetric  Cases by External Manipulation.    11

external  manipulations,  and in 1 internal version alone was
necessary.
  In France, where the operation had already met with strong
advocates in  Velpeau (1835), Lecorche-Colombe (1836), Ca-
zeaux, Stoltz,  Gros, Labouverie, and  Real, an article was pub-
lished in 1863 by  Nivert,1 who likewise earnestly supported it.
  In  Germany, the  operation  was recommended by Cams,"
Grenser,  Martin,3 Spengler, Arneth, C. Braun,4 Hildebrandt,
Hegar 5 (who in conjunction  with Mattei"  advised the conver-
sion of every breech presentation into a head presentation, dur-
ing the latter months of pregnancy, by external manipulation),
Hecker,' and others.
  Two methods of bimanual cephalic version were  described
and recommended in  Germany by Busch and d'Outrepont, and
are known there by their names.   Busch  advised introducing
the hand corresponding  to the side on which the head  is situ-
uated, seizing the latter  with the palm and drawing it down
toward the pelvic inlet, while the  external hand elevates the
breech.  D'Outrepont introduced the opposite  hand into the
uterus, seized  the thorax of the child between fingers  and
thumb, rifted it up and  turned it  head downwards, while the
external hand pushed down the head.  The former method is
the least severe, the latter the most efficient; both are still oc-
casionally used in suitable cases. The later methods of Wright
and Hicks  are  merely improvements  on these two  in the
direction of greater safety and range of applicability.
   In England,  Sir James Simpson  had  already taught the
utility of placing  one hand on the  abdomen during  version to
steady the uterus for the hand within the organ, but Braxton
Hicks 8 first published a systematic account  of  a new plan of
performing  " bimanual version,"  which  has  since  become
known by his name, and which has been  until recently very
generally believed and stated by some authors9 to be  identi-
cal with that practised and described  by Dr. M. B. Wright, of
  'De la version cephalique  par man. externes.   Gaz. des Hopit., 1863,
Nos. 47, 50, 51, 56. Mon.  f. Gebrtsk., Bd. XXII., p. 152.
  2 Gynakologie, 1831.
  3 Beit. z. Gyn., H. 2, Jena, 1849.  Mon. f. Geb.,  Bd. XVI., p. 1.
  4 Allg. Wiener med.  Ztg., 1862, No. 65.  7 Klinik d. Geb., II., p. 141.
  6 Deutsche Klinik, 1866, No. 33.      8 Lancet, July 14th and 21st, 1860.
  0 Loc. cit.                       9 See, for instance, Richardson, 1. c. 
 12      Munde:  Diagnosis and Treatment of

 Cincinnati, six years previously.  According to a recent open
 correspondence on the subject,1 however, between Drs. Hicks
 and Wright, the  question of priority does  not come into play
 at all in the matter, for the two methods appear to be totally
 different in principle and practice, although  both striving to
 attain the same  end, the conversion  of a transverse  into a
 cephalic presentation. Dr. Wright's method, as stated by him-
 self, consists in passing the  hand corresponding to the  side
 where the head is located into the vagina, and the fingers and
 thumb through the cervix ; while the external hand grasps the
 breech and pushes it towards the centre of  the uterine cavity,
 the internal  fingers press up the presenting  shoulder,  the
 thumb being in the axilla, and propel it laterally in an oppo-
 site direction to  that taken by the breech.  The head then,
 without being directly  acted upon, glides into the superior
 strait, where, of course, it must be retained by proper means.
   Dr. Hicks' method differs herefrom  essentially, in that only
 one or  two fingers are  passed into the os, by which the pre-
 senting part is lifted and gently moved away from the superior
 strait, while  the  external hand presses  and guides  the head
 into the brim.
   In  both methods, combined external and internal version is
 employed, with the difference, as  Dr.  Wright very correctly
 says (1. c), that " the force used to change  the  position  of  the
 fetus  is in opposite directions.  The  outside hand is used by
 Dr. Hicks to push  down the head—by Dr. Wright to push up
 the breechr
   Wright's plan combines the good features of the methods of
 Busch and d'Outrepont, and while more effective, is doubtless
 also more severe than that of Hicks.
   In the latest (but one) English work on midwifery, by  Leish-
 man (October, 1875), not one word is said of the possibility of
 recognizing the fetal positions or presentations by external ex-
amination or abdominal palpation, which is only mentioned as
a means of detecting or causing active movements of the child
if the palpation be carefully performed.  The eye, we are told
will often  observe distinct projections or distortions of the  ab-
 domen, corresponding to  the  subjacent portions of the fetal
 body, but  that we may ascertain the exact presentation by a
      1 Hicks, Am. J. Obst., V., 4, 1873; Wright, ibid., VI., 1, 1873. 
        Obstetric  Cases by External Manipulation.     15

few touches of  the fingers to the abdomen does not appear to
be known to Dr. Leishman. Wigand''s method of external ver-
sion is referred to by Dr. L.  (1. c, p. 195) as an operation "the
directions for which include elaborate but, we fear, impractica-
ble instructions as to the manner in which we should proceed,"
and which was never intended by Wigand to produce more
than partial version.  In conjunction with  Braxton Hicks' (or
rather Robert Lee's ]) plan of introducing two fingers into the
partly dilated cervix and gradually pushing along the present-
ing part until the feet or head are within each, Wigand's exter-
nal version is spoken  of as very efficient, and a long and very
good description of the operation, now known as Braxton Hicks'
bimanual or bipolar version, is given in Hicks' own  words.
   In Playfair's recent work, the last  and probably the best
English text-book  on obstetrics  (March,  1878), we finally find
three-quarters of  a page devoted to the " detection of fetal
position by abdominal palpation," the  facility of which, Play-
fair says, has not been generally  appreciated in obstetric works,
although by a little practice easy to make out.  Playfair also
gives  the only diagram illustrating the procedure, which I
have reproduced (slightly modified) in Fig.  1."
   Version by external  manipulation is briefly but clearly de-
scribed by Playfair, and is very  properly restricted to the
cases in which  the membranes are still unruptured, the fetus
is in the transverse position, and there  is no immediate neces-
sity for  delivery.   Dr.  Hicks'  bimanual  operation is referred
to at some length and illustrated by cuts, and the various other
methods  of, ascertaining the presence and  position of a fetus,
and the errors to be avoided (fetal pulsations and movements,
intermittent uterine  contractions,  uterine souffle,  etc), are
described in sufficient detail.
  It thus appears that up to the past year the main  subject of
my paper was not even  alluded to in English works on obstet-
  1 See W. Tyler Smith's Lectures on Obstetrics, Am. Ed. 1858, p. 675, also
Leishman, 1. c.
  2 The fact that both Scanzoni and Schroeder have each given only a page
and a half to diagnostic palpation alone, this being the longest account I have
been able to find in any text-book, only shows that they considered this suffi-
cient for the students  of a couutry where the practice is daily taught on the
living subject in all the medical schools.  The reason why Playfair did not go
more into detail and define and warn against the various difficulties attending
the examination is probably to be sought in the limited scope of his epitome. 
14       Munde: Diagnosis ana Treatment of
 rics, and was even less known and appreciated in England than
 in this country.
   In America, besides the eight papers already mentioned, by
 Wright, Noeggerath, Whittaker, Drury, Richardson,  Chad-
 wick, and Wilson, nothing has, to my knowledge, been written
 on  the subject.  So far as I have been able to learn, external
 version is  briefly referred to in obstetrical lectures  as being
 within the range of possibility, but is scarcely ever advised or
 discussed in a scientific manner.
  Dr. Fordyce  Barker informed me that he has for years de-
 voted one lecture of each course at Bellevue to the description
 of obstetric diagnosis by external examination, illustrating the
 modus operandi on a patient in the amphitheatre ; so also does
 he  casually refer to the  feasibility of  external version, and
 employs both procedures whenever applicable in private prac-
 tice.  Dr. T. Gaillard Thomas and Dr. Wm. T. Lusk both ex-
 pressed themselves in a  precisely similar manner as regards
 their obstetric lectures at the College of Physicians  and Sur-
 geons and Bellevue Hospital respectively, and all three gentle-
 men agreed in saying that they thought the details of obstetric
 diagnosis, by palpation especially,  would be new to the major-
 ity of physicians in the land, not only of general practitioners,
 but  even of busy obstetricians, as they certainly must be to
 those men who had learned the practice only from the theoreti-
 cal lectures attended by them in this country ;  a paper,  there-
 fore, containing these details  could not fail to excite  interest
 and  prove valuable.  As  1 had supposed, the opportunity to
 become practically acquainted with the method was at no time
 offered the student.
  As I  have thus far shown how little my subject is dis-
 cussed in the text-books, I may say in the words  of Hoist,1
 when justifying  an  article on bimanual examination, which
 subject  is neglected in the books, that " a detailed discussion
 of this method of examination is necessary to the completeness
 of a text-book,  and information and counsel are subsequently
 sought in this particular branch by those who did not learn  to
 examine in the clinic" Therefore,  a paper like this, supplying,
 as it is designed to do, the deficiencies in the text-books, ful-
fils  an indication doubtless apparent  to  many, and offers  an
               1 Beitr'age zur Gyn. u. Geb., 1867, p. 2. 
       Obstetric  Cases by External J\[anipulation.    15

of course always  imperfect, substitute for formerly neglected
clinical instruction.
  External manipulations for other purposes than for that of
version were  not known or advised until within the last fifty
years,  with  the exception of  the expression of the placenta,
which  was  recommended and taught by Harvey and Hunter,
and mentioned by  Johnson in his " New System of Midwifery,"
1769, " if performed  on the outside of the abdomen, as equal
to pressure on the uterus."  Within a few years, Crede, of
Leipzig,1 devised  and described  an improvement  on the old
method of expression, which  is now known by his name, and
was  seconded by Spiegelberg/ Winckel,3  Schlile,4  Kiinecke,6
Chantreuil,6  and  is now  generally adopted  by  all German
physicians,  and  all foreigners   who  have profited  by the
teachings of the obstetricians of that country.
   The expression  of the fetus by  means of manual pressure on
the uterus through  the  abdominal  parietes in cases of  tedious
labor owing to deficient uterine contractions was advocated at
different  periods  during  the last  twenty  years by Ritgen,
Barnes, Kristeller,1 Playfair,8 and others, but has not been able
to find its way into the esteem of the profession.9
   The expression of the head of the fetus during the  extrac-
tion in footling  pr'esentations, by  means of pressure through
the abdominal walls,  was already recommended by Celsus (in
the time of Augustus), again by A. Pare (1560), Pugh  (1753),
Wigand (1800), has in our  time found  warm  supporters in
Spiegelberg, C. Braun, Martin, and Fluck, and quite recently
in Goodell (Am.  Jouk. Obst., Aug., 1S75, and Trans. Phila.
Obst.  Soc, Am. Joue. Obst., Feb. and June, 1876), particularly
after version in contracted pelvis, and is a manipulation of the
most decided  utility which often enables us to save  the life of
the child.
  1 Klin. Vortr. iiber  Geb., 1853, p. 599, and M. f. G., B.  16, p. 337, p. 345,
B. 17, p. 274, and B. 22, p. 310.
  2 Wiirzb. Med. Z., II., 1861, p. 39.
  3 M. f. Geb., B. 21, p. 365.              4 M. f. Geb., B. 22, p. 15.
  5 Schuckardt's Zeitschr. f. prakt. Heilk., 1866, p. 417.
  6 Arch. gen. de Med. and Am. J. of Obst., IV., p. 334.
  'Berl. kl. W.,  1867, No. 6, and M. f. Geb., B. 29, p. 337.
  8 Lancet, 1870, Vol. II., p. 465.
  9 This operation is mentioned already by  Albucasis, Kodericus  a  Castro
(1594), Jacob Buff (1554), Ambroise Pare, and Johann von Hoorn. 
16      Muxde: Diagnosis and Treatment of

  Auscultation for the purpose of diagnosticating the exist-
ence of pregnancy and the position of  the child was first em-
ployed by Mayer,1 who in 181S  discovered the pulsations of
the fetal  heart, but the real practical utility of this sign was
not understood until  Lejumeau de Kergaradec,2 in 1822, fully
demonstrated its value, and also  discovered the placental  or
uterine murmur, the origin of which he attributed to the rush-
ing of the blood in the  placenta.   Ritgen 3 denied the  placen-
tal origin of the murmur  and believed it to be caused by the
blood coursing through the tortuous uterine vessels, both veins
and arteries, a theory now generally adopted, notwithstanding
the supposition of Kiwisch (1851) that it originated  in the
external  epigastric arteries on account of their course being
more  tortuous and angular during gestation, or in the iliac
arteries, which are more  or less  compressed by the pregnant
uterus.
  Bouillaud, in 1836  (and again  in 1876), advanced  a view
supporting  in  a measure that of Kiwisch, namely, that the
placental  souffle  is produced by the compression of the intra-
pelvic arteries by the pregnant uterus.  On the other hand,
the majority  of  contemporaneous  French authors  locate the
bruit  entirely in the uterus ;  Laennec in  the  chief nutrient
artery of the  placenta ; Dubois (1831) believed that it arises
from  the  direct passage of the arterial blood into the  dilated
spaces of the venous system within the uterine walls ; Depaul4
claimed (and still claims in 1876)  that  the  souffle is produced
in the large arteries which supply the pregnant  uterus and are
most developed in the neighborhood of the  placenta.   An en-
tirely novel origin for  the uterine souffle has lately been dis-
covered by Glenard  (August, 1876),  to which 1  shall refer
in detail hereafter.  Among German  authors,  d'Outrepont,5
with  his pupils Ulsamer 6 and  Hans,1 Carus  and Busch (who
first mentioned the new discovery in their text-books), and  in

    1 Bibl. univ. des sciences, Tome IX., Geneva, 1818.
    2 Me'moire sur l'auscult. de la grossesse, Paris, 1822.
    3Mende's Beob. u. Bemerk. aus der Geb., Gottingen,  1825.
    4 Traite' theor. et prat, de l'auscult. obst., Paris,  1847.
    5Gemeins. Deutsche Zeitschr. f. Geb., 1832, VII.. p.  21.
    6Bhein. Jahrb. f. Med.  u. Chir., VII., p. 50
    7 Die Auscultation in Bezug auf Schwangerschaft, Wiirzburg, 1823. 
       Obstetric  Cases by External Manipulation.     17

later  years  Hohl,  JSTaegele,1  Hiiter,2  and Frankenhauser3 in-
vestigated  and followed up the  subject of obstetric ausculta-
tion, to which Dubois, Depaul,4 Stoltz, in  France, and Nagle,
Fergusson, and Kennedy,5 in  England, also paid special atten-
tion.
   At present it is familiar to and practised by every educated
accoucheur, although there are still  some points, such as the
detection of the sex of the child from the relative frequency of
the cardiac pulsations, and the influence of some forms of dys-
tocia on the rhythm of the fetal heart, which are yet open to
discussion.   The observations of  Steele, Strong,  Cummins,
Underhill, Naylor, Parvin, and others on these subjects will
be discussed under their respective headings.
   The quantity of literature given  above, although  slight in
comparison with what may be found  on many other not more
important  questions, is still large enough to show the amount
of attention and  thought which has  been devoted to the sub-
ject of external examination and manipulation by  many pro-
minent men  in  the  profession, and  consequently to demon-
strate practically its  value  and  importance, which  is  fully
appreciated  by all German  obstetricians.  The practice is,
therefore, taught in all the  German medical schools before,
and  on account of the greater readiness with which the women
submit to it, almost in preference to  internal examination.  It
is for this  reason that German  students are generally very
familiar with the external examination of a pregnant woman,
even though they be  somewhat deficient in the frequently
more difficult process of  indagation.   In Germany, no physi-
cian in private or hospital practice would think of giving a
definite opinion on an obstetrical case, either with reference to
diagnosis, prognosis,  or treatment, without having  controlled
the results of his exploration  per vaginam by the external pal-
pation, inspection,  and  auscultation of the abdomen; in lying-
in hospitals, indeed, every woman who applies for admission, no
matter at  what time  of  pregnancy, is by rule subjected to a
thorough external and internal examination.
         1 Die geburtsh. Auscultation, Mainz, 1838.
         2M. f. Geb., B. 18, Suppl., p. 23.
         3 M. f. Geb., B. 14, p. 161.
         4 Traite' the'or. et prat, de l'auscult. obst., Paris, 1847.
         5 Obs. on Obst. Ausc, Dublin,  1833. 
 18      Munde:  Diagnosis and Treatment of

   That the position of the child can be ascertained with much
 greater certainty and often  only in this manner, that errors in
 diagnosis and treatment  are much  more easily avoided, and
 particular  abnormal conditions  detected with greater facility
 by external manipulation than by internal examination alone,
 are facts which  no one who has had sufficient opportunity  to
 practise the procedure will attempt to deny, and which ought
 in  themselves to  be reason enough for the general adoption
 and employment  of this method.   Schroderl says:  For a
 less practised observer, unless the conditions be exceedingly un-
favorable, the determination of the fetal presentation by exter-
 nal examination allows of much less room for error than if
 undertaken by  internal  exploration cdone,  and  the former
 should never be .omitted, because it gives us an excellent con-
 trol of the results obtained by indagation."   By using all
 available  means of making a correct diagnosis  and  detect-
 ing whatever may be  injurious, we are  not only doing our
 duty  as physicians to  our patients,  whom it  is  our  first
 and chief  object  to  assist  and benefit, even, if necessary, at
 the cost of slight  personal inconvenience on either side, but
 we are also conforming  to the present requirements of our
 profession  in examining every  case  before us in the most
 thorough and scientific manner possible.
   An  objection which I have heard made in this country  to
 the universal introduction of external examination in obstetric
 cases is that private  patients, particularly those in the higher
 walks of life, will  not  submit to it on the  ground of its being
 an improper and unnecessary exposure of the person, and that
 it is therefore likely to be restricted to hospital and poor prac-
 tice.   I do not think that any woman who has  sufficient con-
 fidence in a physician to intrust to him  her life during con-
 finement will object to his palpating and auscultating her ab-
 domen after submitting to a vaginal examination,  when  she is
 told that the one method  of examin.tion is as necessary to the
 safety of herself and child  during  the coming or  already pre-
 sent ordeal as the other.  I quite agree with Dr. Wilson when
 he says (1. c.)  that he has never had a patient  refuse when
 the necessity for  the  examination  and the  information to be
 gained by it had  been explained to her, and that, instead of
                         1 Loc. cit., p. 112. 
       Obstetric Cases by External Manipulation.    19

lowering the physician in her estimation, it will tend to in-
spire her with confidence and convince her that he thoroughly
understands his business.
  I think further that, if our private patients were once initi-
ated into the benefits of this practice and the very slight in-
convenience occasioned them by it, and if our older physicians
would make it a rule to insist upon it in every case (and they
often are but little less able to dispense with  it  than  their
younger confreres), it would  soon  become a universal custom,
as much desired by patient as by physician.  Then we will see
our patients calling upon us of their own accord during the last
few weeks of pregnancy to demand, for their own satisfaction,
an examination which now we frequently can obtain only after
long persuasion;  and it will become customary  among the
women of the poorer classes to insure themselves against acci-
dent during childbirth by seeking the same information at the
clinics  and  dispensaries.  How many malpresentations could
thus be detected  and corrected, how  many dangers  averted,
how many women forewarned!   Scarcely one of us but has
met with  obstetric cases in which a previous examination,
before labor, would have enabled  him  to remedy a difficulty
or prepare for an unforeseen accident.
   External obstetric examination and manipulation admits of
division into two great chapters, accordingly as  the procedure
is adopted for the purpose of diagnosis or of treatment.

                             I.
                         DIAGNOSIS.
   For the purpose of  diagnosis we distinguish several practi-
cal subdivisions  of the procedure, each of which in a  measure
controls and supplements the others, and which  all together
tend to give certainty to the examination.
   These are:  Inspection, Palpation, Percussion, and  Aus-
cultation of the abdomen, and  shall each be treated of sepa-
rately.
   Tlie proper period for making  the examination is at any
time during the last  month of gestation, in order that  mal-
presentations  and any  abnormal conditions may  be  detected
and corrected previous to the  actual inception of labor, or at 
20      Munde:  Diagnosis and  Treatment of

least suitable preparations made to meet the probable difficulty.
It is also the first duty of the physician, as soon as he  is called
to an obstetric case, even before he makes the controlling vagi-
nal exploration, to practise external examination.
   Position of the woman.
   The woman to be examined invariably occupies a recumbent
position on her back, with slightly elevated head and with her
thighs drawn up,  in order  to relax the abdominal muscles.  If
she voluntarily contracts her muscles, as is often  the case from
apprehension or reflex irritation by the examining fingers, she
should be told to open her  mouth and take deep in- and expira-
tions, when during the latter her muscles will be found per-
fectly  relaxed.   Corsets and drawers  should be  removed, all
constricting bands about the waist loosened, and  the abdomen
entirely  exposed.   The lower extremities  are covered  by a
sheet, which ma}'  also extend  over  the  abdomen, or the che-
mise may be drawn down (not during inspection of  course),
but it should be borne in  mind  that any  covering, however
light, interferes with the facility,  delicacy, and accuracy of the
examination.
   The bladder and rectum should be in an empty condition,
and if necessary must be  evacuated immediately prior to the
exploration.

                       a.—inspection.

   The ocular examination of the abdomen of a pregnant wo-
man gives us a variety of diagnostic signs, such as the  size and
shape of the abdomen, the appearance of the skin, particularly
of the linea alba,  the presence or absence and the appearance
of cutaneous striae, the form of the umbilicus, and frequently
also the visible motions of the fetus.
   As regards the size and  shape of the abdomen, a somewhat
practised eye can form an  approximate estimate of the proba-
ble stage of pregnancy and perhaps also the position (not pre-
sentation) of the fetus  in utero ; for, as a rule, we find the ab-
domen in longitudiual positions to be long, narrow, and oval,
whereas in transverse positions it is broad and more distended
at its base and less so  above  the  umbilicus, which latter pecu-
liarity might also lead to  the diagnosis of twins, especially if
there be a longitudinal furrow in the median line, and each 
        Obstetric Cases by External Manipulation.    21

half of the abdomen be equally distended.  This longitudinal
furrow, or an apparent division of the abdomen into two halves,
may be simulated by a distended bladder or arise from a pecu-
liar formation of the fundus uteri (uterus arcuatus) and is there-
fore of but little value in the diagnosis of the fetal position
or plurality.   The  size and shape of the abdomen can be just
as well ascertained  by palpation, and is, moreover, subject to
so  many variations that  no conclusive  deduction  whatever
should be made therefrom.
   The skin of the abdomen may be perfectly white and smooth,
but generally it  shows numerous red or white shiny lines or
striae, which  arise from its distention during pregnancy, and
are owing to the  rupture of the deeper layer of the epidermis,
the rete mucosum or Malpighi, the red striae being of  recent
origin and occurring principally with primigravidse, and the
white marks  being  the evidence of former pregnancy and  hav-
ing already undergone the process of cicatrization, an explana-
tion first given by Crede.1  These lacerations of the rete Malpi-
ghi could, of course, only indicate a first  pregnancy, as the
old cicatrices do not disappear in the course  of time, but the
fact of their being frequently seen in cases of distention of the
skin by tumors, ascites, and even simply from obesity, and their
being not unfrequently wanting, even in multigravidae, makes
them of but  secondary importance  in the diagnosis of preg-
nancy.
   According to Hecker and Buhl,2 these striae are wanting in
6 per cent of  all cases; in 11 per cent of primigravidae,  in 5
per cent of multigravidae.  They are found also on the nates
and thighs, as well  as mammae, and Schultze3 saw them on the
thighs of women who had borne no  children in 36 per cent,
and  in  men  in 6  per  cent.   He explains this fact by  the
greater increase in the breadth of the hips in the  female sex
at puberty.
  The linea alba ordinarily assumes a dark color  during the
first pregnancy, especially in brunette women, and retains  this
pigmentation  generally in after-life,  so  that it can only be
considered a diagnostic sign with the first child.
     'Mon. f. Geb., 1858.
     2Klinik d. Geb., Leipzig, 1861.
     3 Jenaische Z. f. Med. u. Nat., 4. Band, 3. u. 4. Heft, 1868, p. 577. 
22        Munde:  Diagnosis and Treatment of

  The umbilicus becomes gradually flatter and less depressed
during the last five months of pregnancy, and occasionally even
protrudes above the surrounding skin, without, however, being
at all characteristic of pregnancy, inasmuch as any considera-
ble  distention of  the abdomen  may produce the  same  result.
Should the abdominal walls  not be too thick or rigid, we can
often see sudden protrusions of certain parts, and rapid twiteh-
ings over the abdominal surface, arising  from the motions of
the  child and its close contiguity to the intrauterine surface.  I
have repeatedly  observed the fetal head  in breech or  trans-
verse presentations  distinctly  recognizable by sight through
the  thin  abdominal  and uterine walls, and  the smaller parts,
arms and legs, can be recognized at  times in almost every case.
It must be borne in mind, however, for the avoidance of error,
that such twitchings may be simulated, even at will, by con-
tractions of the abdominal muscles  and  the peristaltic motions
of the intestines.
  Dr.  Ludwig Bandl, of Vienna, has recently' pointed  out a
phenomenon recognizable by inspection of  the abdomen  during
labor only, which is of considerable practical importance.  He
found that, in those cases wdiere there exists an abnormal obsta-
cle  to the expulsion of the child, such as  contracted  pelvis,
malposition  of the child, etc., a distinct transverse furrow ap-
pears on the abdomen, about midway between the umbilicus and
pubes, just at the junction of the cervix and body of the uterus.
This furrow is produced by the wedging in  of  the cervix into
the brim  of the pelvis  by the presenting  part, and the conco-
mitant fruitless concentric contractions of  the uterine body.  It
occurs only in abnormal labors, and affords a valuable indication
as to the time and necessity for operative interference, for obvi-
ously the undue continuation  of this  condition would  very
readily result in the production of a rupture of the uterus.  In-
deed, Bandl first  witnessed this sign after  such an accident. In
normal labors, the presenting part passes into the pelvic cavity
and fills out the cervical canal equally, thus  preventing  the oc-
currence of a transverse furrow.  I have seen this furrow in
several cases where  there  was  excessive  pelvic obliquity and
consequent anteversion of the  uterus, a  condition simulating

       1 Trans. Germ. Med. Assoc, 1875.   Arch. f. Gyn., VIII., 3. 
       Obstetric Cases by External Manipulation.    23

in its influence on the progress of labor the minor degrees of
contracted pelvis.
                      B.--PALPATION.
  By gently and firmly pressing the palmar surfaces  (n;>t the
tips only) of all the fingers of both hands into the abdominal
parietes and gradually moving them  over the surface of the
abdomen with  the least possible irritation, we are able, in the
majority of instances,  to  detect  wdth absolute  certainty the
shape  and consistence of  the uterus, period of  pregnancy as
shown by the size, the  amount of the liquor amnii, the position,
approximate size, life, and greater or  lesser degree of mobility
of the child, its different members, the presence of more than one
                          Fig. 1.

fetus, the  fulness of the urinary bladder, and finally sa\y ab-
normal  condition which may be present, such as tumors and
malpositions of the uterus,  diastasis of the recti muscles, asci-
tes, etc.
  Method of Palpation.—1st. The physician, having warmed
his hands, stands on the right of the patient and gently places
them on her bare  abdomen, moving  them  slowly about with 
 24      Muxde:  Diagnosis and  Treatment of

 a slight pressing, " pawing" motion,  keeping them sometimes
 close together, at others separated, now examining only one spot,
 then endeavoring to bring the uterus and its contents between
 the two hands.  With the hands kept nearly flat on the abdo-
 men, the shape, consistence, inequalities, and general configura-
 tion of the uterus are ascertained step by step ;  the facility of
 this exploration being modified by the greater or lesser amount
 of abdominal adipose tissue, the thickness of which can be de-
 termined by pinching up a fold of the integument between the
 forefinger  and thumb.   2d. The second step is  to ascertain
 the period of gestation, which is done  by slowly  passing  the
 tips of  the fingers towards the upper part of the abdomen,
 gently pressing them in  until resistance ceases, and the fingers
 can be pressed in more or less deeply towards the spinal col-
 umn, when the fundus can usually be grasped and felt as a
 rounded, firm, convex surface.  By pressing  the ulnar or radial
 edge of the hand, as the case may be, deep into the abdominal
 wall at the point where the fundus ceases, and laying the hand
 flat on  the integument, the number of finger-breadths which
 the fundus is situated above the symphysis or umbilicus,  or be-
 low the ensiform  process or umbilicus, is  easily determined,
 and consequently also the approximate period of the pregnancy
 (as will be shown hereafter). 3d. This having been ascertained,
 the hands, moving along side by side,  seek the palpable parts of
 the fetus—the head or breech, the knees and feet (the arms, be-
 ing folded on the thorax, are  scarcely ever accessible to the
 external  touch), and the  back, and  by gently  pressing, per-
 haps slightly displacing them, determine their character.   4th.
 The presenting part is detected by grasping the hypogastric
 or suprapubic region with the whole  hand,  four fingers  being
 on one side and the thumb on the other (Fig. 2), or by placing
 one's self by the side of the woman  with one's back towards
 her head, putting one hand with the fingers downwards on each
 of the inguinal  regions, and attempting to make the finger
points meet in the median line  (Fig.  3);  the presenting part
 will thus be firmly grasped between the fingers and thumb, or
between both hands, and its character, whether head or breech,
generally easily determined.
  5th. To detect the mobility of the fetalp>arts, the tips of the
fingers are gently placed on the  abdominal integument, and 
        Obstetric  Cases by External Manipulation.    25

then quickly and suddenly thrust inwards against the subjacent
parts, which, if extremities, will be withdrawn ; if head or breech,
will recede and rebound against the exploring fingers {ballotte-
ment).   The motion of external ballottement is rather a shove
                          Fig." 3.

than a blow and is best executed by an action from the elbow,
the wrist and hand being stiff and but slightly flexed. 
26     Munde:  Diagnosis and Treatment of

   It is hardly possible to explain  every minute  technicality of
the manual of external examination, for it  is best learned  by
practice; the above description is sufficiently explicit to enable
any one, with the assistance of  time  and careful  attention to
the special points to be referred to hereafter, to examine a preg-
na: t woman by this method with a fair prospect of making an
accurate diagnosis.  One point must be remembered, and that
is, that no force whatever need be employed in any part of the
examination, and that the woman should be subjected to no real
discomfort or pain; indeed, forcible or promiscuous manipula-
tion will in  itself frustrate the object of the procedure, by ex-
citing reflex contractions of the abdominal and uterine muscles,
and thus withdrawing the fetus from the touch of the examiner.
   Period of Pregnancy.—The size  and shape of the uterus,
particularly  the former,  are liable to vary greatly  at  the same
stage of gestation in different persons, according to the size of
the child and the quantity of amniotic fluid.
   If wTe divide the normal  period of gestation, 280 days, reck-
oning from the  commencement of the last menstruation, into
ten lunar months of 28 days each, we find the following condi-
tions during each of the ten months:
   1st and 2d months.—The uterus is still in the cavity of the
pelvis and not palpable.
   Sd and kth months.—During the third  month the fundus
uteri gradually rises above  the brim of the pelvis, especially if
there be contraction of the latter, and in very emaciated per-
sons becomes accessible to palpation.   Ordinarily the uterus is
not palpable until towards the end of the fourth month, when
it may be felt about midway between the symphysis pubis and
the umbilicus (four fingers' breadth above the symphysis) as a
rounded, elastic body with  a tolerably even surface.   Ballotte-
ment may occasionally be felt.
   5th month.—The fundus gradually rises, and at the end of
this month is to  be felt  about  one finger's  breadth below the
umbilicus, generally slightly to the right  of the median line;
in lean persons the voluntary motions  and the several parts of
the fetus can frequently  be  detected by the hand, and ballotte-
ment is  not unfrequently felt.
   Gth month.—The fundus  uteri is palpable about one finger's
breadth above the umbilicus, the fetal parts become more  dis- 
       Obstetric Cases by External Manipulation.     27

tinct, especially in multiparae, ballottement is usual, and the
presentation can  ordinarily be made out without much diffi-
culty.  The surface of the uterus becomes more irregular, in
accordance with the increased  size  and strength of the child,
and the consequent protrusion of the uterine walls by its mem-
bers.   The fetal  heart-sounds, which are occasionally faintly
heard at the end of the fifth month, have  now become perfectly
distinct to a practised ear.
  1th month.—Fundus uteri three fingers' breadth  above the
umbilicus, distinctly inclining towards the right side.   The cir-
cumference of the abdomen at the umbilicus is 91 cm.; midway
between umbilicus and symphysis, 91 cm.;  from  the ensiform
process to the symphysis, about 12 cm.   The umbilicus is flat;
the fetal parts become more and more distinct.
  8th  month.—Fundus midway between umbilicus  and ensi-
form process, 4-5" above the  former, and slightly towards the
right side (Scanzoni); circumference of abdomen at  height of
umbilicus averages 95 cm.; between navel and  symphysis, 97
cm.; distance between ensiform process and symphysis, 43.5 cm.
(Schroeder).   The umbilical fossa  is entirely obliterated.  In
primigravidae the head is situated more  in the median line, in
multigravidae it is frequently found slightly to one side or the
other.  The fetal parts during the  last two months have grad-
ually become more easily palpable;  the fetus has lost its ex-
treme  mobility, although the breech and head still readily re-
spond  to the motion of ballottement.
  9th  month.—Fundus immediately below the  ensiform pro-
cess, having reached its highest point.  Distance between ensi-
form process  and symphysis, fully 41 cm.;  circumference at
umbilicus,  97.5  cm.; below,  99  cm.   Umbilicus  protrudes
(Schroeder).   The fetus closely touches the uterine  walls, the
surface of  the  uterus is  consequently less  impressible.  That
part of the uterus and abdomen in  which the breech lies gener-
ally protrudes, thus  destroying the spherical  shape  of the
fundus.
  10th month.—During the first half of this month,  the uterus
still increases in size,  and not  being able  to extend any higher
in a vertical direction, expands laterally under the false ribs,
particularly on the right  side ; the integument of the  precor-
dial region is then often so tight as to prevent the palpation of 
 28      Munde :  Diagnosis and Treatment of

 the fundus.  The  circumference at the umbilicus is 99 cm.;
 below it, 100 cm. ; the distance from  ensiform process to sym-
 physis, 15.5 cm. (Schroeder).  During the last two weeks  of
 gestation  the  lower segment  of the  uterus,  and  with it the
 presenting part of  the fetus, descend  often quite suddenly
 into the grasp  of the superior strait of  the  pelvis and  become
 more or less firmly fixed there ; consequently the fundus leaves
 the precordial  region and becomes palpable again about mid-
 way between the umbilicus and the ensiform process,  nearly
 where it was at the end of the  8th month, generally  slightly
 higher than at that period ;  it  has fallen forward in its descent,
 and the change in the appearance of the abdomen is percepti-
 ble even to the casual observer.
   Scanzoni,  Schroeder, Playfair, and  indeed most  writers on
 obstetrics agree in their description of the descent of the uterus
 during the two closing weeks of gestation.
   It is evident that this old  method of measuring the height
 of the fundus uteri as so many finger breadths above or below
 the umbilicus  must be  an  exceedingly uncertain one, because
 the length between the umbilicus and  symphysis pubis varies
 greatly in different individuals.  As  the most ready, conve-
 nient, and ordinarily sufficiently definite plan, I have, however,
 described it above ; but I still must agree with Sutugin' when
 he  expresses his surprise that careful teachers like Hildebrandt
 and Schroeder  should still advise this method  of examination.
 Ahlfeld,2 and four years after him  Yassily Sutugin, have both
 measured the height of the fundus  uteri from the upper border
 of  the  symphysis  pubis with  tape-measure  and  pelvimeter
 (which latter instrument is much the more reliable), and have
 constructed tables of  the average height which differ but very
 slightly and are positively trustworthy.
  They both arrive at the conclusion  that  the height  of the
 fundus uteri above the pubes is a reliable objective symptom
 of various periods of pregnancy in normal and reducible oblique
 presentations, when the womb contains  only one fetus.  In
  1 Vassily Sutugin :  On the Means of Ascertaining the Length of Gestation
 by Measurements of the Fetus and gravid Uterus during the Second Period of
 Pregnancy.  Trans. Lond. Obst. Soc.  Obst. J. Gr. Br., Sept.,  '75.
  2 Arch. f. Gynakologie, Band II., Heft 3,  1871.  Bestimmungen der Grdsse
und des Alters der  Frucht. 
       Obstetric Cases by External Manipulation.     29

plural pregnancy, non-reducible, oblique, and transverse presen-
tations, the height of the uterus cannot be used to indicate the
period of.pregnancy.
   Contrary to the universally accepted opinion, Ahlfeld, Sutu-
gin, and Richelot' decide that the fundus uteri keeps ascending
to the very end of pregnancy, and that there is no  descent of
the fundus during the tenth month ; this rule is applicable to
every case  individually, whether primipara or  multipara, pro-
vided the patient be placed during examination in  a horizontal
position.  As a rule, on the patient assuming the erect posture,
the measurements show, however, that  during  the  last  month
of  pregnancy the  fundus uteri stands two  finger breadths
lower than during the preceding month.   The difference in
height of the fundus in primiparae and multiparae is  almost in-
appreciable ;  as regards breadth, however, in  the  multiparas
the womb is  somewhat  broader, commencing with  the  thirty-
fourth week of pregnancy.   This is  also the case  in breech
presentations, in  which  the  height, however, is 3  centimetres
greater than in head presentations.
  The average  height of the  fundus  uteri and the average
breadth of the uterus were found by Sutugin to be, in the
                       Aver. Height.              Aver. Breadth.
    21st  week ..........19.0 cm.................14.0 cm.
                                ...............15.0  •'
22d	u	......19.0
23d	a	......19.0
24th	a	......19.0
25th	a	......21.0
26th	a	......21.0
27th 28th		......19.0 ......20.1
29th 30th	u	......21.5 ......22.4
31st	a	......21.9
32d	a	......22.0
33d	't	......22.1
34th	a	......23.2
35th 36th		, 23.8 ......24.0
37th	u	......24.15
.15.5
.15.5
.16.5
.15.5
.16.0
.16.8
.17.1
.17.4
.17.9
.18.3
.19.1
,18.9
.19.6
,19.8
,19.8
  'Richelot: ZurDiagnostik der Schwangerschaft. Inaug. Diss., Konigsberg,
1868. 
30       Munde: Diagnosis and Treatment of
                      Aver. Height.             Aver. Breadth.
    38th  week..........24.5 cm...............20.4 cm.
    39th   "  ..........24.9  "  ...............20.4  "
    40th   "  ..........25.4  "  ................20.4  "
  In the  erect posture the average  height of the fundus was
22.5 cm.  in the 40th week, 23.3 cm. in the 39th, 23.1 cm.  in
the 38th, 23.3 cm.  in  the 37th,  22.5 cm. in the 36th, 22 cm.
in the 35th week.
  It is scarcely necessary to say,  after the above remarks, that
instrumental  measurement of the dimensions of  the abdomen
is greatly to be preferred to a mere  manual estimate.
  Although these measurements will  generally be found ac-
curate in determining the period of gestation, they do  not, as
already stated by Sutugin, hold good when the fetus occupies
a transverse position, by which, of course, the vertical diameter
of the uterus is  shortened; nor  always in case of twins, with
which the transverse diameter also becomes disproportionately
large, nor in case of contraction of  the  pelvic brim, by which
the presenting part is prevented from  descending during the
last fortnight of gestation, and consequently the usual descent
of the fundus also does not take  place ;  nor in case of fulness
of the bladder or rectum,  by which  the  uterus is likewise pre-
vented from sinking to its proper level in the pelvis.  Deformi-
ties  of the vertebral column  or  thorax, tumors of the  uterus,
ovaries, or  pelvis, and  hydramnios, may further influence the
correctness of the above data.
  Of course, the result of the  external examination  should
always be  controlled, and may  frequently be modified, by a
vaginal exploration.
  According to  measurements made by Hecker,1 which agree
generally with those already quoted from Schroeder, the size of
the abdomen in pregnancy, as mentioned before, is  extremely
variable ; in  112 cases  he found that the abdomen  increases
in  circumference steadily until confinement,  in the  tenth
month 3 to  1 cm., in the ninth and tenth months 7 to 8 cm.
The circumference  measured  in the ninth month 89  to  112
cm.; in the tenth month,  88 to 116 cm.; and during labor, 90
to 116 cm.  The average in  the tenth month was: for primi-
gravidae, 97 cm.; for multigravidae, 100 cm.
                   1 Hecker and Buhl, loc. cit. 
       Obstetric Cases by External Manipidation.     31

  The tension and firmness of the abdominal walls does not
necessarily diminish with the increasing  number of pregnan-
cies, although it  is undoubtedly more  common to find the  ab-
dominal and  uterine parietes more flabby, pendulous, and im-
pressible in multiparae (the more, the greater the number of chil-
dren) than in primiparae.  The increased circumference of the
abdomen  in  the  former, mentioned   by Hecker, probably
depends partly on  this cause  and partly on  the increase of
abdominal adipose tissue so commonly found in women as they
advance in age.  During the first four months, the uterine walls
are firm and  tense, with the increase of liquor amnii, however,
they become  thinner, more  impressible and  pliant, until the
filling out of the uterine cavity by the growth of the child and
its  consequently diminished  mobility again renders them less
yielding to the touch.
  The uterus is easily recognized by the touch as an elastic, regu-
lar body, rounded above and extending down into the  pelvis.  In
the earlier months, so long  as  the fetus  does not occupy any
permanent position, its shape is more spherical, later, when the
child assumes a fixed, generally longitudinal position, it conforms
to the shape of its contents and becomes ovoid.   The fundus
uteri generally inclines slightly towards  the right  side of  the
abdomen, a phenomenon  which has been variously explained,
Madame Lachapelle supposing it to result from the right round
ligament being shorter than the left, and E. Martin attributing
it to  the presence of organic muscular fibres in the round liga-
ment.  Scanzoni1 gives the following explanation :
  The uterus, increasing in size, pushes the intestines out of
their normal position;  these latter retire where they have the
most room, that is, to the left  upper portion of the abdominal
cavity, the right being occupied by the liver; the uterus is thus
obliged to take  the  only open space and incline towards  the
right side, pushing the abdominal wall before it.
   Any abnormities in the shape of the uterus or the  presenee
of  subperitoneal  fibroid  tumors are easily detected by palpa-
tation.  I have several times observed a distinct depression of
the fundus in the  median  line with a bulging out on both sides,
which could  be and doubtless was nothing else than the slight-
eat degree of uterus  bicornis (or uterus arcuatus according to
                         1 Loc. cit. 
32       Munde:  Diagnosis and Treatment oj

Kussmaul1)  and is  a remnant of the formation of the uterus
from the two ducts of Miiller.
  An exceedingly slight concavity with a corresponding pro-
minence of the "two cornua is generally noticed during the con-
traction of the uterus in labor in these cases.   Knowing, as we
do, the various forms of dystocia which are liable to happen
in exaggerated  cases of this deformity, the  detection  of  its
presence is  not without practical value as regards prognosis
and treatment.
  A valuable  diagnostic sign of pregnancy has been pointed
out by Braxton Hicks,'2 namely, the occurrence of regular in-
termittent contraction and relaxation of the uterus when that
organ is firmly  grasped by the hand  through  the abdominal
walls, without friction  or  activ pressure  being  used.   This
intermittent contraction occurs  every five  or ten minutes, or
oftener, and Playfair says 3 that he  has never known it  to fail
or be absent  when pregnancy existed.  This sign has the ad-
vantage over the fetal movement that it is  constant, not easily
simulated by  anything else, and that  it occurs  whether the
uterus contains  a living or a dead child.  The history of the
case will  prevent  its giving rise to errors  in the case of the
enlargement of  the uterus by tumors or retained fluid,  where
this sign may also occur.
  The chief object of palpation, the diagnosis of the presence of
a fetus and its position, is seldom possible before the end of the
fifth month, the quantity of liquor amnii, the  diminutive size,
and  the pliability  and  mobility of  the  child, the tension and
thickness  of the uterine  walls,  rendering  it very difficult to
obtain a definite result which could perhaps only be arrived at
by bimanual examination.
  Before  the  seventh lunar  month the quantity of  amniotic
fluid is so much out of proportion to the size of the fetus that
the latter floats free in the  uterine cavity, neither  marring the
symmetry of the uterine  outline nor remaining long enough
in contact with the uterine walls to allow  of the distinct pal-
pation of  its individual members.   From that time, however
(exceptionally even during the sixth month), the several por-
  'Von detn Mangel, Verkiimmerung und Verdoppelung der Gebarmutter.
Wiirzburg, 18o9.
  2 Obst.  Trans., Vol. XIII.              3 L. c, p. 152. 
        Obstetric Cases by External Manipulation.    33

 tious of the fetal body become more and more distinct to the
 touch, and are recognized by the following characteristics:
   The head is felt as a round, hard, exceedingly movable  body
 (usually giving  the  bounding  sensation called ballottement),
 apparently floating about entirely free, on account of  its  flexi-
 ble connection  with  the neck.
   The  breech is a larger, softer, more  irregular, less  movable
 tumor, the rebound  of which  is  much slower and less  vivid
 than that of the head.
   The back, being the continuation of the breech, is  detected
 by the uninterrupted, regular resistance offered to the palpating
 fingers (Scanzoni says that with very thin and flaccid abdominal
 walls he  has several times  been  able to recognize the  back  by
 the spinous processes of the vertebrae ; I have never met with
 such a case).
   The feet  and  legs are recognized as very  movable, often
 sharply projecting,  small,  irregular bodies, which  are easily
 pushed  about, and frequently retaliate by striking sharp blows
 to the examining hand.
   The arms are not  usually palpable, because they are  kept in
 a crossed  and flexed  position on the thorax.
   From the place  which  each  of  these  different members
 occupies in  the uterus, it is easy to diagnosticate the  momen-
 tary situation  of the child,  which, however, frequently volun-
 tarily changes its position.   According  to B. S. Schultze, Fas-
 bender, and Hoening, the change of the fetal position in the
 seventh and eighth months takes place in 12.1 per cent of primi-
 gravidse, and 23 per cent of multigravidae, two-thirds of all the
 changes being from  one head presentation to another.
   Sutugin1 finds that changes of position  are quite common
 in plurigravidae  even  at  the end  of  pregnancy;  in primi-
gravidse they are much more rare near term, but do still occur
 during the last wreek, and even during actual labor itself.  The
 frequency of change of  fetal  position  both in primigravidse
and  plurigravidae is nearly three times  as frequent  in  con-
 tracted pelves as in normal  pelves.
   Contractions of the uterus and  abdominal muscles exert con-
siderable influence on the frequency of  the change of position,
 and especially  of the  presentation,  which, however,  do not
              1 St. Petersburg  Med. Ztg., 1875, V., 2. 
31       Munde: Diagnosis and Treatment of

appear to be affected by the sex and size of the fetus, and the
size  and age of the mother.   The  spontaneous movements of
the fetus are easily detected by the examining hand, and serve
to indicate, 1st, the undoubted presence  and life of the child ;
2d, the probable quantity of amniotic fluid, and 3d, the approxi-
mate size and  strength of tlie  child.   If  the child is strong
and  healthy, its motions will generally be quick and active, pro
vided the amount of liquor amnii  permits sufficient freedom ;
if the amniotic fluid is excessive in quantity, the fetal move-
ment will be rapid, but weak and flighty, because, as a rule,
the  size of the fetus and  the amount of liquor amnii are in
inverse proportion.
   The voluntary motions of the child  are not always felt, be-
cause in some cases the uterus incloses its  contents too firmly
and there is too little fluid  present, in others the fetus is weak,
sickly, and incapable of active exertion; however, some moth-
ers never feel quickening during their whole pregnancy, and
still the children are born strong and healthy.
   These voluntary fetal motions are of  two kinds: 1, a slow,
gliding, rolling motion, proceeding  from the  whole child, and
2, quick sharp knocks or blows which result from  the action
of its upper or lower extremities.  These  so-called  active mo-
tions of the fetus are rarely felt or observed before the twentieth
week of gestation.  Only one  instance do  I find mentioned of
their having been felt as early as  the beginning of the fourth
month, an extraordinary and  precocious development of the
child being the probable cause. >  In addition to this spontane-
ous  mobility, the examining physician  can, in most cases, espe-
cially if the uterine and abdominal walls be thin and flaccid, the
child small and the amniotic; fluid  abundant,  press and push
the  child about in the uterus with greater or lesser facility,  and
thus cause the passive fetal motions, which sensation, together
with the  palpation of the different portions of the child, espe-
cially the head, and the general appearance of the abdomen,
ought with some practice  to give him at  least an approxi-
mate idea of the probable size of the fetus.   A more than ap-
proximate idea is very difficult to obtain, even with the assist-
ance of a vaginal examination;  although Prof.  Carl Braun, of
Yienna, with his immense  experience, professes to be able to
                 1 Cramoisy, L'abeille med., 29, 1857. 
       Obstetric Cases by External Manipulation.    35

diagnosticate the weight  and length of the fetus  in utero by
means of external and internal examination, there are not very
many practitioners who have sufficient experience to do the
same, and I have seen Prof. Braun  himself occasionally shoot
pretty wide of the mark.
  As an aid in this calculation  and the diagnosis of  the stage
of pregnancy, as also for  the benefit of prognosis and treat-
ment, Ahlfeld, of Leipzig, has lately1 published an account of a
number of measurements which he made of the length of the
uterus  (to which I have  already referred  in another connec-
tion), and therefrom he computed the length and consequently
the weight of the child.   Footing on several  observations of
his and others, that the length of the uterine axis of the fe-
tus is about half the length of its whole  body, he drew the
natural inference that the length of the fetus  would also be
about double that  of the uterus in which it lies, and therefore
measured the length of the uterus, placing  one branch of Bau-
delocque's   pelvimeter against  the  fetal   head  or breech in
the  vagina (or  rather in that  part  of the uterus which pro-
jects into the vagina) and the other at the spot on the abdomen
where the  fundus uteri could be distinctly felt, and doubling
the number obtained, the actual length of the child was ascer-
tained.  On an average he found, in 250 cases, that in the 36th
week  the  child measured  18.3 centimetres in  length, and
weighed, the weight being computed by analogy,  2,806 gram-
mes f in the 37th week, 48.3 cm., and 2,878 grms.; in the 38th
week, 49.9 cm., and 3,016 grms.; in the 39th week, 50.6 cm., and
3,321 grms.; and in  the 40th week, 50.5 cm., and 3,168 grms.
Transverse positions were  measured in the same manner, the
branches of the pelvimeter being placed transversely against
breech and head of the fetus  in utero.   Sutugin (1. c.) sub-
stantially agrees with  Ahlfeld's measurements, and finds  that
the height of  the base of the  uterus  is equal to  one-half the
length  of  the  fetus.   Although the practical value of this
new procedure still needs the confirmation  of  time and experi-
ence, the facility and painlessness of its application recommend
it for frequent trial  in all cases where the prognosis or treat-
   1 L. c.
  * 2.75. centimetres = about  1"; 30 grammes = \  i.; about  500 grammes =
lb. i. 
 36       Munde: Diagnosis and Treatment of

 ment in a measure depend  on the size  of the child (premature
 delivery  for  habitual excessive development  of the child  at
 term, contracted pelvis, cancer of the cervix, etc.).
    The  spontaneous movements of the  fetus are frequently ex-
 cited or increased by the  temporary application of cold to the
 abdomen, not in consequence of the  direct transmission of the
 cold itself to the fetus, but through  reflex action from the ab-
 dominal integument to the  abdominal muscles, which contract
 and press on the uterus, which in its turn contracts and thereby
 incommodes the fetus, causing it to protest with hands and  feet
 against the disturbance and to rapidly change its position.  I have
 witnessed this phenomenon  hundreds of times, when  students,
 forgetting the rule  to warm their hands before examining,  pro-
 ceeded  to palpate the abdomen, and produced not only a slight
 shock to the mother (the avoidance of which heedlessness is not
 unimportant, especially in fashionable private practice), but  also
 contractions  of the uterus, thereby interfering with the exami-
 nation.  I am thus explicit in explaining this to me always simple
 phenomenon, because  Dr.  Chadwick (loc. cit., p. 7) says that
 it is inconceivable that the cold itself should  penetrate to the
 fetus and excite the unwonted activity;" that it is " within the
 bounds  of reason, though  improbable," that the reflex nervous
 current thus  excited could influence the uterus and indirectly
 the fetus, and that he has had " no opportunity of verifying
 the truth of this assertion as to the application of  cold."
   We all know how easy it is to excite  uterine contractions by
 merely  pressing the uterus through the abdominal walls, which
 is substantially the same action as that offered by me  in expla-
 nation of the  increased fetal movements after the momentary
 external application of cold.   The observation of the contrac-
 tion of the muscles  of a part in consequence  of an irritation of
 the skin of that same part is of too common, not only every-
 day, but every-minute, occurrence to need further comment.
   A unique case in literature, in which  the umbilical  cord was
 detected, by inspection and palpation near term, on a level with
 the umbilicus, has   recently been  reported by  E.  Bidder.1
 The cord crossed the back  of the fetus transversely  and was
easily movable, but could  not  be slipped  over the  breech.
1 St. Petersburg Med. Wochensch., 1876. 
       Obstetric  Cases by External Manipidation.    37

It pulsated  152 times to the minute.  At birth the cord was
found to measure only 30 centimetres.
  Dr. Paul Budin, of Paris, has recently'  described a peculiar
" ovarian pain " which he frequently observed during the pal-
pation of pregnant and parturient women, chiefly on the left
side, where he distinctly felt  an oval transverse body  corre-
sponding in size and position  to the ovary.  Pressure  on this
body caused intense pain.  The round ligament could  also be
felt.  While I have frequently found one or the other ovarian
region sensitive to pressure in pregnant and parturient women,
I certainly do not recollect having ever detected the ovary  by
external palpation in that condition, and should scarcely expect
to do so, except in a high degree of emaciation  of the abdom-
inal wall.
                   Position of the Child.
  By position of the child, I mean  the relation of its longitudi-
nal axis to that of the uterus ; if both axes are parallel, the child
occupies a longitudinal, if  they cross each other, a transverse
position.
  By presentation I mean the relations which (the position,
longitudinal  or transverse, being  fixed) certain parts of the
child  hold to certain portions of the uterus; thus, when the
head is in the lower uterine segment, we  have a head ; when
the breech occupies that situation, a  breech;  and  when the
thorax crosses the pelvic brim, a  transverse (or thorax) presen-
tation.  Various subdivisions, according  as the back of the
child  is turned towards one or the other portion of the uterus,
are designated as first or second, being generally known by the
name of the group to which they belong, viz., I. or II. vertex,
face, breech, footling, or transverse presentation.
  In order to avoid mistakes and unnecessary repetition, it may
be well to introduce here a synop&is of the different positions
and presentations as  generally  adopted in  this country and
abroad.
  Positions :  Longitudinal and transverse.
  Longitudinal positions are  divided into  vertex and face, and
into breech or foot presentations, each of which are again sub-
divided into first and second subpresentations.
                    1 Progres Med., 9, 1879. 
38        Munde:  Diagnosis and Treatment of

   Vertex or occipital presentations :
 I.  Left occipitoanterior, L. O. A.  Occiput and  back turned
  towards the left side  of  the  mother, right parietal  bone
  presenting per vaginam.
II.  Right occipito-anterior, R. O. A.  Occiput and back to the
  right side, left parietal bone presenting.
  Face presentations :
 I.  Left frontal; forehead and back  to  the left  side, right
  cheek presenting.
II.  Right frontal;  forehead and back to the right side, left
  cheek presenting.
  Breech or footling presentations :
 I.  Back to the left side,  left hip presenting.
II.  Back to the right side, right hip presenting.
  Transverse presentations :
 I.  Dorso-anterior ;  back towards abdomen of  mother.   1st
  subdivision, head in left iliac fossa of mother, L. D. A.  2d
  subdivision, head in  right iliac fossa of mother, R. D. A.
 II. Dorso-posterior; back towards spinal  column  of  mother.
  1st and 2d subdivisions as above, L. D. P. and R. D. P.
  Various minor subdivisions, such as the III. and  IV. antero-
vertex, or occipito-posterior presentations  (considered to be
merely  abnormal rotations  or ar»*est  of  rotation of  the two
regular  vertex presentations),  frontal presentations  (rare in-
stances of arrested face-presentations, usually requiring forceus
or craniotomy), and complete and incomplete foot  and knee
presentations, only call for brief mention.   The  third and
fourth face and breech presentations (corresponding to vertex),
I omit entirely from this  classification, as they are mere steps
in the mechanism and have  no practical importance.
  Longitudinal Positions.—The  presence  of  a large round
body in the upper portion of the uterus, as  a rule, indicates that
the long axis of the latter and that of the child correspond.
Should the small parts be also found near the fundus, the pro-
bability  always is in favor of a head presentation, inasmuch as
the arms seldom leave their condition of flexion on the thorax
and thus rarely become palpable.  The usually easy detection
of the hard round head above the symphysis pubis confirms
the diagnosis, which would be changed to that of a breech pre-
sentation were this same hard body to be felt above the umbilicus. 
       Obstetric Cases by External Ma7iip)ulatwn.    39

Occasionally the presenting part is  found resting on the iliac
fossa, generally on the left side, because of  the usual dextral
inclination  of  the  fundus, and is then easily movable, as is
also the case when it  occupies the  pelvic inlet previous to the
last few weeks  before  term ; as soon as it has descended into
the pelvis  it becomes more  or  less fixed  and thus serves to
foreshadow the near approach of labor.
  According to Sutugin,1 the fetus lies during pregnancy with
its back turned posteriorly and either to the  right or left side.
The back is found  turned directly to the side of the mother
only in the erect posture, and in the recumbent  posture only
if contractions  have preceded the examination.  In the early
part of gestation, the position with the back to the right side
                           Fig. 4.

occurs more  frequently than  towards term; near the end of
pregnancy, however, the back is found more commonly on the
left side.
  Not until the head has sunk to the floor of the pelvis during
labor, does it withdraw from palpation, and the examining fin-
gers will  feel instead  the softer and more slender neck.   At
this  stage, however, diagnostic palpation of the presenting
part gives wTay to indagation.
  Until recently it was thought possible to detect a face pre-
               'St. Petersburg Med. Ztg., 1875, V., 2. 
 10       Muxde:  Diagnosis and Treatment <f

 sentation only by internal examination, after the os was suffi-
 ciently dilated to permit the touching of the presenting part;
 in 1868, however, Prof. Breisky, of Berne,'  described a method
 of  diagnosing this presentation by palpation,  which  I have
 since had repeated occasion of  testing and  verifying.  Instead
 of feeling on both sides of the symphysis pubis the hard, round,
 more or less movable body which represents the fetal head,
 we find on one side a firm, smooth, convex surface correspond-
 ing to the forehead and vertex  of the child, with a depression
 immediately above, caused by the back of the neck, and on the
 other side an  indistinct resistance produced by the soft chin,
 neck, and  thorax (Fig. 4).  Owing to the peculiar position of
 the child, its feet are felt,  and,  contrary to  the rule, the pulsa-
 tions of its heart heard, on the side corresponding to the chin.
   These signs thus enable us, not only to detect the actual pre-
 sence of a face  presentation before labor has commenced, but
 even to determine the side to which the forehead is turned, a
 not unvaluable piece of information, considering how difficult
 at an early stage of labor the differential diagnosis of face pre-
 sentations usually is, and  useful in case version should become
 necessary.
  Prof. Spiegelberg says  that similar conditions are found in
 high antero-vertex presentations.
  Ordinarily it  is not difficult  to distinguish the two large
 round  parts of  the fetus, the  head and  the breech; occasion-
 ally, however, when the abdominal walls are very thick or rigid,
 the uterus contracted, or the child small and very movable in
 a large amount of liquor amnii, it will be found  almost impos-
 sible to arrive at a definite diagnosis.   The hardness and round-
 ness and greater degree of ballottement of the head, the depres-
 sion of the neck between the head and shoulders, and the absence
 of the femoral prolongation peculiar to the breech, are the chief
 distinguishing marks.  Fassbender2 declares that the  parch-
 ment-like crackling of the cranial bones, occasionally discernible
 per vaginam, may under favorable circumstances (certainly
 only with very thin uterine and abdominal  parietes, I should
 think) also be felt by abdominal palpation, and  serve  to dis-
tinguish  the head from the breech  in breech and transverse
presentations.   Sometimes the small size of the child renders the
     1 M. f. G., B. 32.                  * M.  f. G., B. 33, p. 435. 
        Obstetric Cases by External Manipulation.    41

 ischial tuberosities unusually prominent and pointed, and may
 lead to the breech being taken for the extremities ; the ballotte-
 ment, which the latter never possess, will, however, prevent this
 mistake.
   The two extremities of the fetal ovoid having been found, it
 is generally easy to  discover their connecting link, the back,
 which in longitudinal positions is usually directed either to the
 left or right side.   It may be recognized occasionally by being
 distinctly  palpable, ordinarily only by the greater resistance
 which it imparts to that side of the  abdomen; this sign is so
 well marked, however, as to be unmistakable.   Frequently the
 back will not be found entirely in one lateral half of the abdo-
 med or turned  directly towards one  side, but  is situated near
 the median line, more or less in that half of the uterus in which
 the extremities also are  situated ; still, on  careful examination
 it will  appear  that the  back points often a  little anteriorly,
 but always towards the side in which the  extremities  are not,
 thus clearly designating  the subpresentation (I. or II.), and pre-
 venting  error.   It is more  common to find the back turned
 towards the left side in I. subpresentations than the reverse, be-
 cause of the usual inclination of the fundus  uteri, and with it the
 upper half of the child, towards the right side.  If in such cases
 no extremities  can be found, they must be considered to be in
 the posterior part  of the uterus, as is  easily explained by  the
 position of the  back near the median line.  Except in cases sim-
 ilar to those just mentioned, in which the whole fetus occupies
 one lateral half of the abdomen, usually the right, the body and
 legs of the child are generally found on opposite sides of the
 median line.
   The extremities, characterized by their small size, mobility,
 and by the  quick, short  blows they impart to  the examining
 hand, are unmistakable and need no further description.
   Footling presentations are distinguishable from breech pre-
 sentations only with great difficulty by external examination.
   Schroeder (1. c.)  says that the former may be diagnosed, if
 the breech has  deviated somewhat towards the side where the
back is  situated, thus in I.  subpresentations, towards the left
side.
   Transverse Positions.—In these the fundus  and lower seg-
ment of the uterus are empty, the long  axis of  the abdomen 
12       Munde: Diagnosis and  Treatment of

corresponding generally to its transverse diameter ; on either
side a large  body is  palpable, to  which the above-mentioned
distinguishing marks may be applied, and frequently, although
not always, a long hard surface stretching  between  these two
bodies representing the fetal back.  Should this hard surface
not be palpable, the probability is  that the  back of the child is
turned towards the spinal column,  or that the thickness of  the
intervening tissues prevents its being felt.
  In oblique positions, which are merely temporary  deviations
from longitudinal or transverse positions, the head or breech is
found  in one or other iliac  fossa, or resting on the right  or
left border of the pelvic brim, and the body of the  fetus occu-
pies a more  or  less   oblique position  in  the  uterine cavity.
Generally, these positions voluntarily change, when labor com-
mences, into regular longitudinal or transverse positions, and are
always particularly amenable to rectification by external man-
ipulation.
   Twins.—The diagnosis of  the presence of twins, before  the
birth of the first child, if at all possible, is so only by combined
external and internal examination, and can be made with abso-
lute certainty only when, in addition to the detection of a fetal
head or breech per vaginam, a second  head or breech is dis-
tinctly felt through the abdominal walls, or when two distinct
and separate heads or pedal extremities are  palpable externally,
in short,  when two  absolutely identical  parts are present.
Occasionally it  is possible to define the  bodies of the two
fetuses  more  or less   clearly by palpation, and at times  the
great  mobility of the parts  palpable through  the  abdominal
walls, whereas the presenting part is felt  per  vaginam to be
already fixed in the pelvic cavity, may lead us to  the  suppo-
sition  and detection  of  a twin  pregnancy.  I once detected
twins  in Vienna in a case where  they had  not  been  suspected
by the assistants who examined  before  me, by comparing  the
small size and mobility of the presenting head with the large
size of the abdomen, which evidently was not due to hydram-
nios.   I asked myself the question: Why should the presenting
head be so small, and  consequently so movable, and the abdo-
men so large unless there were hydramnios or twins ?   Palpa-
tion told me that there was no unusual amount  of liquor amnii
present, consequently  there must  be  two fetuses in utero.   I 
         Obstetric  Cases by External Manipulation.    43

 hazarded the diagnosis, and was gratified  at  hearing  the  next
 morning that the woman  had been  safely delivered of twins.
 In general, the size and shape of the abdomen, the longitudinal
 furrow  in the median  line (usually merely theoretical), the
 seeming multiplicity of  small members, the exceedingly active,
 ubiquitous motions of  the child, the sensations of the mother,
 even the hearing of the fetal heart-sounds  at different spots of
 the abdomen, are all uncertain and treacherous signs compared
 with the detection of  two identical parts.   Of the numerous
 cases of twins which I have seen either under my own care or
 in various hospitals, only  a  very small minority  have  been
 detected before the birth of the first child,  notwithstanding
 the customary  careful  external  and  internal  examination.
 That the recognition of the presence of  three or  more fetuses
 in utero is  possible only  under most exceptional  and favor-
 able circumstances is evident.
   The only instance, so far as I am aware, mentioned in litera-
 ture of the diagnosis by palpation of triplets is reported by Dr.
 Pinard.1  The careful  palpation of the very  much distended
 abdomen revealed the  presence of  three  heads, one  in  the
 superior strait, another in the right iliac  fossa, and  a third
 very movable and above the umbilicus.  This fact was so clear
 that the diagnosis of triplets was unhesitatingly made, and con-
 firmed at the confinement three months later.    Two distinctly
 separate fetal heart-sounds could only be  heard, one to  the
 left below the umbilicus, the other to  the right side above.
 In a case of triplets observed by me, the presence of a second
 or third  child was not suspected  until the  preceding one  had
 been expelled.   This was in a great measure owing to the im-
 mense accumulation of  adipose tissue in the abdominal walls.
                PALPATION  AFTER  DELIVERY.
   Immediately after the expulsion of the child, the palpating
 hand shows  us the uterus diminished to less than one-half its
 size during labor, reaching not quite up to the  umbilicus and
 frequently presenting an irregular outline.  This irregularity
 manifests itself by a greater prominence  of one or  the other
cornu,  and denotes the site and the  non-detachment  of  the
placenta.  During the  expression of  the placenta, the  uterus
               1 Annales de Gyne'cologie, Jan., 1877. 
41       Munde: Diagnosis and  Treatment of

contracts proportionately, and immediately after the expulsion
of the placenta is felt as a hard, smooth ball, reaching scarcely
midway between umbilicus and pubes.  Within  several hours
after delivery, however, the uterus again expands somewhat,
rises out of the pelvis, and the fundus is then felt at about the
same altitude as before the expulsion of the placenta, generally
slightly turned towards the right side.  Slowly and  gradually
the uterus decreases in size in the course of normal involution,
and at the end of the second week the fundus still projects
5.2 cm.; at the end  of the third week, 4.6 cm. above the sym-
physis pubis.   Not until  the end of  the  second  month  may
the uterus be  considered as restored to its normal position  and
weight, when, although it still projects about 3 cm.  above  the
symphysis, it is no longer palpable by the external  hand alone.1
   A distended bladder or rectum may  displace the uterus to
one side, generally the right, or cause the  fundus to reach
higher than normal.
   The flaccidity of  the abdominal parietes after delivery  will
frequently permit the palpating hand to detect  abnormities
and tumors of which no  previous  suspicion  was  entertained.
Thus  I  have recently had a case  in my service : t Maternity
 Hospital, in which a large subperitoneal fibroid was detected
in the left cornu after delivery, and another in private prac-
 tice at present, in which  my palpating hand  accidentally dis-
 covered a firm tumor in the left  hypochondriac region, which,
 from its peculiar  form and location, I am  constrained  to  con-
 sider  a  floating  kidney.   The existence of either tumor  had
 never been suspected before.
   The importance of carefully palpating the abdomen during
 the lying-in state is obvious after the above remarks, and when
 we consider the frequent distention  of the uterus with coagula
 during  the first  twenty-four  hours  succeeding  delivery.  I
 never omit to map out the fundus uteri with my hand at every
 visit to a puerpera during the first week post partum.   Almost
 without exception  the round and  ovarian ligaments and Fal-
 lopian tubes  can  readily  be  felt at their  points  of  departure
 from  the  uterine  cornua, and occasionally the ovaries them-
 selves may be palpated in very thin subjects.  The  pulsations
   1 Garrigues, " When shall Lying-in Women leave their beds ?" Proc. Med.
 So?. Co. Kings,  Oct., 1877. 
       Obstetric Cases by External Manipulation.    45

of the abdominal aorta can invariably be felt through  the
abdominal walls above the fundus  uteri, and the vessel be
compressed against  the vertebral column, a procedure  to be
remembered in case  of post-partum hemorrhage.

COMPLICATIONS OF PREGNANCY AND  PARTURITION REVEALED BY
                         PALPATION.
   The death of'the fetus during pregnancy'is not recognizable
with certainty, but may be suspected, if the palpating hand dis-
covers an unusual flabbiness  and compressibility of the  abdo-
men in contrast to  its former firm  and elastic  feel, if  the
motions of the child are not distinguishable, if its body remain
passively in any spot to which it is pushed and thus gives the
impression of an inanimate  body, if  its head feels unusually
soft and flaccid (unreliable), and lastly, if with all  these signs
the fetal heart-sounds also are inaudible.  The mere absence
of the  heart-sounds at any one examination without any addi-
tional evidence is no proof whatever of the death of the child,
as will be more distinctly stated hereafter.
   Uterine contractions, even when  not  perceptible to  the
patient,  are easily  recognized by the palpating hand before,
during, and after labor, and the difference in nature and degree
of the pains (so-called  false or true,  partial, weak, spasmodic,
tetanic),  or their  entire absence (inertia, atony, exhaustion,
paralysis, either general or partial of the uterus),  determined
without difficulty—a knowledge of vital importance for treat-
ment and prognosis.
   The size of  the fetal head can  only be  approximatively
ascertained by palpation.   In cases where the parturient canal
is more or less contracted by deformity of the bony pelvis, dis-
ease of the cervix (carcinoma), or uterine tumors (fibroid), it is
of great  importance to have at least  a fair idea of  the  size
and compressibility  of  the fetal head, and this  can be gained
by careful and  practised  palpation, together with vaginal ex-
ploration and a comparison of the  general  dimensions of the
child.   External examination in such cases will teach us more
about the prognosis  and treatment, whether the latter is to be
manual on instrumental, or whether the delivery is likely to be
terminated by the unaided efforts of nature.
   Hydrocephalus may occasionally be diagnosticated by pal- 
46       Munde:  Diagnosis and Treatment of

pation, if the  head is found  to be unusually large, compara-
tively soft, and  even  faintly fluctuating, and if, in  a normal
pelvis, it remains above the  brim in spite of energetic uterine
contractions.
  In rupture of the uterus during natural  delivery, palpation
gives us probably the  most positive information.  If the lacera-
tion is sufficiently extensive, the fetus usually escapes into the
abdominal cavity, either partly or wholly, and is  then felt with
much greater distinctness  than when still in the uterus, which
organ contracts  and occupies the side of the abdominal  cavity
opposite  that  containing the fetus.   The  appearance of the
abdomen in well-marked cases is almost characteristic, one side
showing a distinct rounded tumor, the contracted uterus, which
is much  smaller than when it  contained the fetus, and the
other the body and limbs of the child, the latter in thin sub-
jects especially  appearing as  though they were  covered only
by  the skin.   A more or less defined  depression separates the
uterus and the fetus.   " When the fetus 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 para-
lysis of the latter "  (Chadwick, 1. c).  Later on  the uterus be-
comes more relaxed,  and blood serum and  liquor amnii may
collect in and  distend  the dependent portions of  the peritoneal
cavity.
  A new symptom of rupture  of  the uterus recognizable by
inspection and palpation was witnessed by Tully 1 in a case at
the Maternite  in Paris in 1867, viz., the appearance of " a volu-
minous tumor just  above  the pelvis, resembling the distended
bladder,  but more clearly defined, appearing to be filled with a
gelatinous mass.'' There was no other sign of rupture, but after
the version and delivery of a dead child, at the autopsy a small
circular perforation and a large rent were found in the anterior
wall of the neck, the latter communicating with a large subperi-
toneal cavity filled with coagula—the suprapubic tumor before
death.  Hecker corroborates this symptom,  and says that  it
may appear in the hypogastric or  inguinal  region  or  in the
vagina.   Its occurrence in the last-mentioned  locality was ob-
served recently by Dr. R.  J. Preston, of Abingdon, Va.2
  Dr. John S. Parry  3 mentions " the appearance of a fluctuat.
  •Am. Jotjb. Obst., May,  1869.        2 Virg. med. Mthly., Dec,  1874.
                sAm.  Joub. Obst., Aug., 1873. 
        Obstetric  Cases by External Manipulation.    47

ing tumor over the pubis before the death of the patient,"' in a
case of rupture of the  uterus witnessed by him.  The signifi-
cance of the suprapubic tumor was not appreciated until post-
mortem.  The importance of this symptom, as indicating  the
occurrence of a possibly as yet slight uterine perforation, which
may be prevented  from increasing by the timely extraction of
the fetus, is obvious, and its proper appreciation may enable us
to diminish the mortality of this  accident.
   Abdominal tumors,  such  as uterine fibroids, ovarian cysts,
etc., are usually accessible only to palpation,  and may be rec-
ognized  by the irregularity which they impart to the general
outline of the abdomen, increasing its breadth or size, or  dis-
placing the uterus if they be large, or destroying the smooth
contour of the womb if they be situated in its  substance.
   Extrauterine Fetation.—The  diagnosis  of  this condition is
so uncertain, even  with the aid of all the means  at our dispo-
sal, that it will be  possible  to detect it by external examination
only when a distinct lateral tumor is palpable,  evidently  un-
connected with the uterus, in which (provided,  of course,  the
gestation be sufficiently advanced) the fetal parts are plainly to
be felt and the fetal  heart-sounds clearly audible.  The uterus
can be felt in  such cases only in extreme emaciation,  as its en-
largement never corresponds in degree with the period of preg-
nancy.   Percussion may in the earlier months aid us in fixing
the boundaries of the ovisac and thus corroborating the previ-
ously suspected diagnosis.

                  OBSTACLES TO  PALPATION.
   There are various conditions, temporary or permanent, which
more or less interfere with the proper performance of palpa-
tion.
   Tension of the abdominal walls, more common and continu-
ous in primiparae, is  also found as the result of voluntary con-
traction of the abdominal muscles in multigravidae, and is then
usually overcome by the precautions mentioned  under " Posi-
tion of the womanP  Occasionally it will be found an insuper-
able obstacle,  and percussion may then be employed as a mea-
gre substitute.
   Muscular contractions of the uterus utterly preclude  satis-
factory palpation or  auscultation.  When  they are seen to be 
48       Muxde :  Diagnosis and Treatment of

easily excited, the examination should be made with unusual
care and delicacy, and, of course, only in the periods between
the contractions.  The latter are also aroused by voluntary con-
tractions of the abdominal muscles, which  must be prevented
by requiring  the  woman to keep her mouth open or count in
order to prevent her from str; ining.
   Unusual tenderness of the abdomen is generally only partial,
in spots where the constant kicking of the child has produced a
feeling  of soreness, or where  the fetal head presses  firmly
against  one or  the  other  inguinal region.   This sensitiveness
is rarely sufficient to preclude careful palpation, although there
are rare  cases in  which there appears to be such a  degree of
hyperesthesia of  the  peritoneal  envelope of  the uterus as to
render abdominal palpation entirely unbearable.  This  abnor-
mal sensitiveness  is thought to be due to  a chronic state of
subacute peritonitis caused by the hyperdistention of the ute-
rine peritoneum during pregnancy, and usually disappears to-
wards the end of gestation.
  Hydramnios, if at all sufficient to warrant the name, is al-
most always  an insurmountable obstacle to palpation.   The
hand can make but little  impression on the distended  elastic
abdominal walls, and  the only information of the presence of
a fetus will be imparted by the occasional thump of one of the
large parts of the child, head or breech, against the hand, par-
ticularly if the presenting part be pushed up per vaginam. In
lesser degrees  of  distention, the fetus is extremely movable,
ballottement  is unusually distinct, and fluctuation may some-
times be felt.
  An  excess of adipose  tissue in the  abdominal walls  is one
of  the greatest obstacles  to successful palpation, particularly
during the earlier months, and, although usually diminished
somewhat towards term by the distention of  the abdomen, is
not entirely overcome by any means at our disposal.
  Ascites and flatus will rarely interfere  seriously with pal-
pation, because in the former the fluid by its gravity seeks  the
deeper portion of the abdominal cavity, and the intestines, dis-
tended by the latter, will  only serve  to displace the uterus,
generally to the right side.  It is principally by increasing  the
tension  of the  abdominal walls that they prove an obstacle.
Their presence is easily recognized by percussion.  Simulated
pregnancy, graviditas  nervosa, owes its origin to the enlarge- 
       Obstetric  Cases by External Manipulation.    49

ment of the abdomen by the intestines distended by flatus, the
movements of which, together with the spasmodic contractions
of the abdominal muscles, may closely resemble the fetal mo-
tions and have deceived even practised observers.1

                      c.—PERCUSSION.
  This is the least  valuable of the four modes of procedure
mentioned, and will  generally serve only to strengthen the dia-
gnosis formed by the other three.  Through it we ascertain
the degree of distention of the bladder, which certainly is of
importance both during examination and labor as well as in the
puerperal state, and is a prominent symptom, indeed the only
external one in retroversion or flexion of the gravid uterus ; as
also the presence of feces in the colon.   Should the thickness
of  the abdominal walls or their rigidity  prevent successful
palpation, we  can detect the boundary  of  the uterus and the
height of the fundus through percussion, a knowledge  which
can occasionally be acquired as early as the  fourth month of
pregnancy, especially with an empty  bladder and an  ante-
verted uterus. In this latter  respect percussion is not to be
undervalued, otherwise it is of but little practical value.   The
relations of the  bladder and  uterus  in the earliest months
of pregnancy, and the similarity in percussion-sound of uter-
ine substance, the fetus, and  the liquor  amnii render such
results as those claimed by Piorry, who professed to be able to
diagnosticate pregnancy as early as the  second month, and
even  the position of the fetus in utero during the later months
by  means of the plessimeter, doubtful and incredible.

                     D.--AUSCULTATION.

  Next to palpation, auscultation gives us the most important
and reliable information on the  existence  of pregnancy and
the position of the fetus, for  it enables us to hear: 1st, the
pulsations of the fetal heart; 2d, the murmur in the umbilical
cord, the umbilical or funic murmur; and  3d, the uterine or
  1 In this chapter on " Palpation," I have of necessity repeatedly quoted the
substance, if not the words, of Chadwick's excellent paper mentioned above,
because 1 found it at times impossible to improve either on his classification
or description. 
 50       Munde :  Diagnosis and Treatment of

placental murmur, besides the regular pulsations of the abdom-
inal aorta, and  the gurgling noises  caused  by the  fluids and
air in the  intestines.  Of these  three  chief sounds, the first
and third  are audible  in  nearly  every regular pregnancy,
the second  only rarely, and then  under pathological condi-
tions.  Occasionally a  splashing noise may be heard, due
to the succussion of the liquor  amnii  by the rapid and vig-
orous  movements of the  fetus.   Several  other sounds  are
audible during  pregnancy  and labor,  such as the indistinct
shock imparted  to  the abdominal walls by the fetal motions
during the months immediately following quickening, the fetal
shock; the muscular subsurrus of the exhausted uterus during
a  tedious labor, which often closely simulates the fetal heart;
a  rustling sound  supposed to be produced by gaseous decom-
position of the  liquor amnii when the fetus is  dead; and a
series of rapid scratching sounds, attributed by Caillant to the
separation  and crushing of the placenta by the uterine contrac-
tions.  By far the most important are the

              Pulsations of the Fetal Heart,

which, when distinctly and clearly heard, besides determining
the existence  of pregnancy, leave no  doubt of the presence of
a living and generally healthy fetus.
   Although various observers, such as Depaul, Cazeaux, Hen-
nig,1 and recently Underbill,2 claim  to  have heard the fetal
heart before the eighteenth week of intrauterine life, the two
last-named unquestionably even as early as the fourteenth week,
such cases are exceedingly rare, for all authorities  agree that
they are first audible in the period from  the eighteenth  to
the twentieth week (Scanzoni even says rarely before the twenty-
fourth week), before which  time the diminutive size of the
fetal heart, the comparative preponderance of amniotic fluid,
and consequent  only exceptional approximation of the  child
to the uterine walls, would naturally prevent their penetrating
through the surrounding media.   The case related by Depaul,3
and quoted by most text-books, of a woman in whom he heard
        1 Wiener Med. Halle, 1861.
        2 Obst. Jour. Great Britain and Ireland, Nov., 1875.
        3Traite'd'Auscult. Obstetr., Paris, 1847. 
       Obstetric  Cases by External Manipulation.     51

the fetal  pulsations (118 to  the minute) eleven weeks  after
possible impregnation, is not quite beyond question, because
his own figures  show that at least three months had elapsed
from the date of the first coitus.
   In  another case, Depaul  detected  the pulsations  in the
fifteenth week, and Dr. Ritchie1 mentions one where he heard
them  certainly  before  the  sixteenth  week, at some  period
between  the  twelfth and sixteenth week.   Of seventy-three
cases  which Depaul  examined for the purpose, before the
twentieth week,  eleven were in the third month, and in  none
were they audible; twenty-two were in  the fourth month, in
two of which only, both at three  months and a half, could
they be heard;  and in the remainder, who  were more  than
four months pregnant, the fetal heart could  be heard in the
majority of the cases.
   Nsegele2 gives the eighteenth week as the earliest period at
which he heard the fetal pulsations, and Evory Kennedy says
that as a rule they must not be expected before the time of
quickening, although in  rare  cases  they may be detected
before the end of the fourth month.   Leishman and Playfair
both mention the  eighteenth  to  the  twentieth week  as the
average period at which they can be heard.
   I myself have lately heard the  fetal  heart  distinctly (152
per minute) in a lady pregnant with her  third child, in whom
the last menstruation ceased exactly seventeen  weeks  to the
day before  I made my examination.   She  had plainly felt
quickening nineteen days before, that is, during the fourteenth
week.
   As Underbill  says (1. c), the question of the earliest period
at which these sounds can be heard is of great importance for
two reasons:  1st. To aid in fixing or confirming the diagno-
sis of early pregnancy;  2d. From a physiologically interesting
standpoint, to show at how early a period of  development the
fetal heart is capable of producing sounds audible though the
abdominal walls  of the mother.   According to Schroeder, dur-
ing the fourth lunar month, the fetus is from 10  to  17 cm.
(1 to 6£'v) in length, and weighs as mui h as 1,860 grains, or
about 3|  ounces.  The  somewhat remarkably fact, that  so
small an organ as the heart of a fetus of that size  is capable
  'Obstet. Jour. Gr. Br., N-,v., 187.">.        ? Treat, on Obstetr. Auscult. 
52        Mu:n:>e: Diagnosis and  Treatment of

of such energetic contraction as to be audible through several
media, may be  explained  by the anatomical truth that the
fetal heart during the early months is relatively much larger
in proportion to the remainder of the  bod}" than  later  in
intrauterine life, or in  the adult.  According to Meckel,  at
the second month the proportion is as 1 to 50; at birth, as 1
to 120; and in adult life, as 1 to  160.
   As in  auscultating for other sounds, so  also  are the fetal
heart-sounds  audible  either by  direct aural or by mediate
stethoscopal auscultation.   Doubtless there  are  many objec-
tions  to  direct  auscultation, such as uncleanliness  or conta-
gious disease of the woman, scabies, for instance; the imprac-
ticability of applying the ear to the abdomen during the earlier
months, when the uterus has risen but a few inches above the
symphysis pubis; the necessity of depressing the head so much
as to interfere  with  regular cerebral  circulation,  and thus
impede hearing, or of  pressing  the  ear  in so  deeply if the
woman is very fat, or there is an  excess of liquor amnii, or the
womb is  separated from the abdominal parietes by intestinal
convolutions, whereby also the acuteness of hearing is weakened ;
the distaste naturally felt  by a lady  to the proximity of the
examination;  and various  bruits from  the  observer's  hair,
whiskers, clothing, interfering with the clearness of hearing.
All of these objections are  certainly avoided by the use of the
stethoscope, indeed frequently one or other of them will imper-
atively demand the employment of that instrument.   But, for
my part, T have always practised and prefer  direct ausculta-
tion, the ear being separated  from the  abdomen only by the
chemise or a thin handkerchief, because I have found it easier
to find and localize the pulsations to one particular  region by
this method;  once  found,  the stethoscope no doubt aids  in
rendering them  more distinct for counting.   The majority  of
obstetricians  prefer  mediate  auscultation  (Playfair does not
even  mention the direct method).  Influenced by  the above
objections, and under the same circumstances, I certainly agree
with them.  Playfair says  that, after failing with the ordinary
instrument, he has occasionally  succeeded with the bin-aural
stethoscope, so generally used in this country, which  intensi-
fies the sound  in a remarkable manner.  An  objection to the 
       Obstetric Cases by External Manipulation.    53

stethoscope, which  might lose its triviality in some cases, is
that the abdomen requires to be laid bare.
  If we apply our ear directly or mediately to the abdomen of
a pregnant woman after the fifth month, we can under ordinary
circumstances easily hear the rapid dicrotic (double) beat of the
fetal heart, which is entirely similar in rhythm to that of an
adult heart, only twice as fast and much fainter, and can, there-
fore, with proper care never be mistaken for the pulsations of
the abdominal aorta of the mother, which are synchronous with
her radial pulse, however quick that  may be.   This peculiar,
rapid double  beat of the fetal heart, when once distinctly heard,
is always recognized;  it has very properly been compared with
the ticking of a watch heard through a pillow, and its pulsations
are ordinarily easily counted.  They number from 120 to 160 per
minute (according to Slater from 120 to 140, averaging 132), and
their rapidity remains the same, as a rule, with slight variations,
during the whole pregnancy; they gradually gain in strength,
however, with the increasing growth and vigor of the child, and
consequently become plainer the nearer the gestation approaches
to term.   Disturbing causes, such as pressure with the hands or
stethoscope, manipulations,  mental or physical  excitement of
the mother,  may accelerate  them or  render  them irregular,
and uterine  contractions during labor, or fetal  or placental
disease may diminish  their frequency or change their rhythm.
  Inasmuch  as this peculiar sound is neither produceable by
nor attributable to any other organ  than the fetal heart, its
presence  is the only absolutely certain sign of existing preg-
nancy.  Stress must  be  laid on  the fact that  its not being
audible at a given moment by no means in itself disproves the
existence of pregnancy or the presence of a living child,  for
there are certain conditions, such as excessive quantity of amni-
otic fluid, thickness of the abdominal walls, attachment of the
placenta to, or the  presence of fibroid tumors in the anterior
wall of  the uterus,  an  exceedingly loud uterine murmur, great
mobility, and particularly an unfavorable position of the fetus,
in which its  back is  removed from  the  anterior wall of the
uterus,  and  the  presence  of  uterine  contractions, which,
through their compression of  the placental circulation after
rupture of the membranes temporarily suspend the fetal car-
diac pulsations (a  circumstance to which attention has been 
54        Munde:  Diagnosis and Treatment of

called by Hiiter, in Marburg, and Schwartz, in Gottingen), and
winch  1 have very frequently observed  myself—all  of which
conditions may for a time  prevent  the pulsations from being
heard by the auscultating ear.
  Generally we hear them with sufficient distinctness to enable
us to count them, but frequently, owing to the above-mentioned
reasons or to natural weakness of the child, they are very indis-
tinctly audible, as if coming from a distance, and occasionally I
have remarked  nothing but  an indefinite murmur  or  thrill
imparted to my ear, giving me, however, a sign which, by dint
of long practice, and aided by the  peculiar sense of elasticity
perceptible to the ear when applied  directly to the abdomen in
a normal, healthy pregnancy, I considered perfectly conclusive
of the life of the fetus.  I have too often experienced  this
almost indefinable  sensation to regard it as mere imagination;
it can be explained in no better manner, perhaps, than by saying
that intuitively, as it were, the practised touch acquires a vague,
indescribable impression of the presence of a living body within
the abdominal cavity.  It must be this  peculiar sign which
Pajot1  calls by the name of " choc foetal," and declares exceed-
ingly valuable, particularly during the fourth and fifth months.
He describes it as I do—a sensation of shock and abrupt bruit
—very delicate, very faint, and still  certain, and always recog-
nized by a practised ear.   Of course, I  should hardly rely on
this evidence alone in determining the life or death of the fetus
in a doubtful case.
  Occasionally  we  can only  hear  the  beating  after  some
search,  and then  only  in  one small  spot, beyond  a certain
radius of  which it becomes weaker  or entirely inaudible, and
frequently it  changes  places  in accordance with the altered
position of the fetus; wre should, therefore, never be satisfied
with one auscultation, and thereon base our diagnosis, for I have
frequently seen cases where the pulsations were first extremely
distinct at one spot and then disappeared entirely, the fetus
having probably altered its position and removed its thorax
or back  from the anterior  uterine wall,  and  on examination
some  time after, were  again found  at or near the  old place.
Out of 906 cases examined by Depaul d.iring the last  three
months of pregnancy,  only in 8 was he unable to detect the
           1 Traite d'Auscultation Obstfitricale, Paris, 1817. 
       Obstetric Cases by External Manipulation.     55

fetal heart; and  only in 12 out of 180 cases did Dr.  Ander-
son, of Glasgow, meet with the same result, and in each of
these 12  the  child was still-born  (Playfair, 1.  c).   To  pro-
nounce the child dead, on the strength of the absence of the
fetal cardiac pulsations  at one examination, would thus mani-
festly be a rash proceeding.  It is  only when several auscul-
tations at different periods, and made, if possible, by several
competent persons, give  the same negative result, that we
should feel justified in pronouncing  the child to  be dead,
especially if other pathognomonic symptoms, such as peculiar
sensations of the mother, a  feeling  of weight  and want of life
in,  and  flabbiness  of  the  abdomen, etc., come  to our aid.
Should the pulsations  be audible  at different  spots of the
abdomen, the place where they are loudest would indicate the
closest proximity of the child, generally its back  or side, some-
times its  thorax, and  thus serve  to  determine the position.
As a rule,  the thinner the uterine and  abdominal  walls, the
more developed the fetus, and  the nearer its thorax or back
to the anterior wall of the uterus, the more clearly and dis-
tinctly audible are  the pulsations  of the fetal heart, and the
left occipito-vertex presentation being the most  common, it
is chiefly at the lower  part of the left side  of the  abdomen
that we can hear  them most loudly.
   Owing to the  peculiar position  of  the fetus  in utero, it is
evident that that portion of its body where the sound of the
fetal heart is  produced cannot  be contiguous to the anterior
wall of the uterus (with only one exception, i.  e., during the
mechanism of a face presentation); it is, therefore, generally
the dorsal surface of the thorax which approaches the anterior
part of the uterus, and from which  the  fetal pulsations are
transmitted.  Should  the  back perchance  be  turned  away
from the maternal abdomen, and point either to her back or
sides, the pulsations will  usually be  inaudible  or very indis-
tinct.
   We thus find the sounds in vertex presentations best audible
at either side  of  the abdomen  below  the  umbilicus, generally
on the side opposite to  that where the feet  of  the  child are
palpable.  Occasionally, especially in obliquity  of the  uterus,
the whole body of the fetus inclines to one side  of the median
line, and we then find back, feet,  and pulsations all  on one, 
56        Munde: Diagnosis and Treatment of

usually the right, side ; the direction of the back will, however,
indicate the position  to  us, and prevent  an error.  Scanzoni
holds the opinion that it is safer  to  determine the  position
from  the pulsations of the fetal heart than from  the often
indistinct palpation of the members of the child, especially in
doubtful cases, where these two signs seem to be in  opposition
to each other;  should the feet of  the  child  apparently be  on
the right side and the fetal heart be also best audible there,
he would still consider the back of the child to be directed  to-
ward the right side of the mother, and attribute the apparent
irregularity to  a peculiar torsion of the body of the fetus, its
back  being turned anteriorly, but still  in  the right   half of
the uterus.
   It is only in face presentations, where in the later  stage of
labor the peculiar posture of the  child  (chin  anteriorly and
removed from thorax,   occiput on nucha) approaches  the
anterior wall of  the thorax to the anterior wall of  the uterus,
that the pulsations are heard  on the same side with the feet,
close to  the median line; at an earlier period, however, while
the forehead and vertex with the  back are  still turned more
towards the  lateral and  anterior portion of the uterus, that is,
be tore the face has entered the superior  strait and the rotation
of the chin forwards has  commenced, the pulsations are audible,
as in vertex presentations, on the  side to which the dorsum
is directed.
   In breech presentations, the thorax  of  the child  is situated
hio-her in the uterus  than when the head points downwards,
and consequently the fetal heart is heard on either side also,
but usually on a level with or above the umbilicus.  In trans-
verse positions,  we hear it  below the umbilicus near the
median line, but generally a little towards the side  where  the
head is situated.
   Owing to the  frequent  variations  and the  uncertainty  of
always hearing the fetal  heart in  similar positions  in exactly
the same particular place, it is evident that  the distinction of
vertex from  face, and breech from footling presentations can-
not be  made  alone from this  sign, which,  in  such cases, can
only be  considered as a confirmation and valuable adjuvant.
   The different subpresentations  of each  of the   above  can,
however, generally be easily distinguished by auscultation alone, 
       Obstetric Cases by External Manipulation.    57

in those designated as first, the fetal heart being almost invari-
ably audible on the left, and in second, on the right side of the
median line.   In face presentations, as  before  mentioned, the
conditions  are reversed : first siibpres. (forehead  left,  chin
right), fetal heart on  the right;  second (forehead left, chin
right), on the left side.
  Since  the discovery  of the  audibility of  the  fetal cardiac
pulsations, the most remarkable theory regarding them is that
first proclaimed  by  Frankenhauser, of  Jena, in  1859,1 to the
effect that  the sex of the fetus in utero can be determined as
soon as the fetal  heart  is distinctly countable, by the relative
frequency  of the pulsations, those of the male children being
less rapid than those of the females.  Finding that the cardiac
pulsations  of  one hundred  children,  whose mothers he  had
examined during pregnancy and labor with the object of com-
paring the  frequency of the fetal pulsations at these two periods,
differed materially, and that the less frequent pulsations always
occurred in women who were subsequently delivered  of boys,
and the more rapid in women who  gave birth to  girls, he
proceeded  carefully  to count the fetal pulsations in fifty gravidse
and regularly  noted down the probable sex  of  the  fetus as
indicated  by the pulsations.  In all of the fifty cases he  pre-
dicted the sex correctly, twenty-two of the children being boys
and twenty-eight girls; the average rapidity for  the boys was
121, for the girls 111  pulsations per minute.  This difference
continued  for some time after birth.
   A statement so astonishing and interesting, both to the  pro-
fession  and  the lay  public, could not  fail  to  excite wide-
spread  comment and frequent investigation.  The first to
report his disappointment was Prof. Breslau, of  Zurich, who,
in  March, I860,2 published the results of his  examination of
fifty pregnant women, in twenty-five of which he made a wrong,
and in nineteen  a correct diagnosis (six cases being omitted as
uncertain).  He consequently expresses his belief that  Franken-
hauser's luck in  not missing once in his fifty cases was like the
luck of a  player at " rouge et noir"  and that the celebrated
discovery  " is based on error and  self-deception."  As regards
 the continuance of the difference in pulsation after birth,
 asserted by Frankenhauser, Breslau gives a table  of thirty
    ' Monatsschr. f. Geb., XIV., 3.            2  Mon. f. Geb., I860. 
 58       Munde : Diagnosis and  Treatment of

 children examined by him within twenty-four  hours of their
 birth, according to which it appears that the average of cardiac
 pulsations of boys was 119, of girls 113, thus showing a diminu-
 tion in rapidity for both  sexes, but particularly for  the girls.
   Hennig,  of  Leipzig, in the same number of the Monats-
 schrift fur  Geburtshidfe, reports  twelve cases,  five  boys with
 an average cardiac double pulse of 113, and seven girls with
 155 per minute.  The fact that several of the observations made
 on girls were  made  very early in pregnancy, as  soon indeed
 as the fetal heart became audible, in a measure invalidates their
 testimony, for, as he himself says, the frequency of the cardiac
 pulsations of the fetus are in an  inverse ratio to  the number
 of months of gestation.
   Haake, of Leipzig {ibid.), also reports fifty cases, and  finds
 that the frequent variations  in the rapidity of the fetal pulsa-
 tions during pregnancy,  influenced, no doubt,  by the move
 ments of the fetus and probably other, to us unknown, exciting
 causes (a fact already pointed out by Hohl, in  18331), render
 the possibility of determining the sex  of  the fetus  therefrom
 exceedingly doubtful.  Although employing all the precautions
 recommended by Frankenhauser, Haake was unable to diagnose
 the sex of  the  fetus correctly in  a single instance.   He also
 differs from Hennig in not having been able to  find a propor-
 tionate  decrease in the rapidity of the fetal heart  with the
 advance  of pregnancy.
   Steinbach,2 on the other hand, corroborates the statements of
 Frankenhauser, making the average 131 for males and 138 for
 females,  and predicting   the  sex  correctly,  and Zepuder3  in
 forty-five out of fifty-seven cases, after examining sixty cases,
 arrives at the same conclusion (average for females  138-111,
 for males 120-132).   Notwithstanding  this corroborative evi-
 dence, Scanzoni, in 1867,4 declares that his observations have
 led him to doubt the correctness of Frankenhauser's statements,
 but advises further investigation of the matter, an advice which
 has been followed by Cumming,  Wilson,  Steele,  Engelhorn,
 Hutton, Parvin, Devilliers, Peters, Mattei, Naylor, Budin, and
 doubtless numerous others, whose results have never been made
public.
  1 Hohl, die geburtshulfl.  Exploration, Bd. I., 1833.
  2 Mon. f. Geb., Dec, 1861.
  3 Wiener Med. Halle, 14, 18G2.          4 Lehrb. d. Geb., I., p. 162. 
       Obstetric Cases by External Manipulation.    59

  One  of  the most  original and  searching article-  on this
s ibject has been written by James Cumming,1 of Edinburgh,
who examined first forty-one and later one hundred and twelve
pregnant  women, with  the view  of ascertaining:   1st,  the
relation between the sex of the fetus and the rapidity of its
cardiac  pulsations ; 2d, the relations between the weight of the
fetus and  its cardiac  pulsations;  and 3d,  the relation of the
maternal to the fetal pulse.  He arrived at the following con-
clusions :
  1. That the indications resulting from  auscultation of the
fetal heart are of  a certain value in aiding us to  diagnose the
sex  of  the fetus in utero, but  cannot solely be  relied upon.
Of   sixty-one  cases specially selected  for  this  examination,
forty, or nearly two-thirds were correct, and  twenty-one incor-
rect.
  2. That there seems to be a relation (or ratio)  between the
weight  and the pulsations  of the fetus in utero.   Some of the
children had a rapid  pulse and were predicted to be  females,
but at birth they were found to be males, of  below the average
weight  (7.28 lb. for  males);  others had  a pulse below the
 average (138) and were pronounced males, but at birth proved
 to be females of large size, exceeding the average 6.8 lb. for
 new-born female  children.  But of seventy-seven cases thus
 examined, in forty-seven this ratio was  apparent; it would,
 therefore, seem that when the fetal pulse is below the  average,
 the fetus is above average weight  (of its sex), and vice-versa,
 when the pulsations are above the  average, the fetus is below
 the average weight (of its sex).
   3. That for the weight per pound, the pulsations are slower
 in the male than in the female.
   1. That there is no relation between the fetal  and  maternal
 pulse.
   Devilliers found the average in the sexes  to be the  same as
 Steinbach, but preceded Cumming in attributing  the difference
 to the size and weight rather than the sex of the child, believ-
 ing large  and well-developed children to have  slower pulsa-
 tions, whereby the relatively less frequent pulsations  of male
 children are accounted for.
   Dr. J.  T.  Hutton, of Brooklyn,  succeeded in  correctly pre-
        1 Edinb. Med. Jour., June, 1870, and Oct. and Nov., 1875. 
60       Munde:  Diagnosis and Treatment of
dieting  the sex in  seven  cses, and put the  average number
of pulsations, like Frankenhauser, at 111 for the  females, and
124 for the males, allowing a variation of six  beats upwards
from  124, or downwards  from 111, without  endangering the
diagnosis, if the auscultation took place in the ninth month.
   Induced by Cumming's  first publication in 1870, Dr. Frank
C. Wilson,  of  Louisville, Ky.,  turned his attention to  this
subject and reported his experience in two interesting and able
papers,  printed in the American Practitioner for Dec, 1873,
and Dec, 1875, the first  containing  an  analysis of 126, the
second of 106 cases, in which the sex  of the fetus in utero was
predicted. Of the first 1.26 cases, in  109  only were positively
accurate notes kept, and only in 9 of  these did the prediction
of the sex prove incorrect; of the second series of 106 it is not
stated in what proportion the diagnosis  of the sex  failed.
Taking all these 215 cases, the average pulse was found to be
for the males 125, for the  females 143, for both sexes together
131, this figure being the dividing line between  the sexes, a
range 4  beats above or below which would constitute a doubt-
ful zone, where it would be impossible to predict the sex  with
any degree of certainty.  The ratio of pulsations for the  two
sexes in his 215 cases is given by Dr.  Wilson as follows:
     From 110  to 125.........62 males and  2 females.
       "  125  to 130.........29   "    "   7   "
       "  130 to 131.........11   "    "   4   "
       "  131 to 138.........  2   "    "12   "
       "  138 to 143.........  2   "    "23   "
       "  143 to 170.........  2   "    "50   "
   The following very useful table for the determination of the
fetal sex has been  formulated  by Dr.  Wilson from the above
figures:
From 110 to  125 almost certainly male.
   "   125 to 130 probably male.
   "   130 to  134 doubtful, with chances in favor of male.
   "   134 to  138 doubtful, with chances in favor of female.
   "   138 to  143 probably female.
   "   143 to  170 almost certainly female.
   The results arrived at  by Dr. Wilson  will be seen to be
unusually favorable to Frankenhauser's theory, and no other
author has so conveniently arranged his figures for  practical 
        Obstetric  Cases by External Manipulation.    61

use.  But they by no  means settle the question,  for a  later
publication by Engelhorn, of Leipzig,1 finds,  after a careful
examination of thirty-seven  cases, that no  constant relation
exists between the sex and the rapidity of the  cardiac pulsa-
tions of the fetus.  The average frequency for boys  was indeed
somewhat less, 137.7 to 110.8 for girls, but  this difference is
too slight, and too easily affected by external influences or the
various times of examination, to be of any practical value,
especially as some very low rates (128) occurred in girls, and
very high ones (150 to 160) in boys.
   As regards the relation between the maternal and the  fetal
pulse,  Engelhorn  found that to a maternal pulse of 60  to
80 beats, corresponds on an average a fetal  pulse of 134.9
beats, and to the maternal pulse of 80  to 100  corresponds on
an average a fetal pulse of 143.9, and he believes that this
proportion is based on  a more secure foundation than the
dependence of the rapidity of the fetal pulse on its sex.   As
an explanation of this evident relation between the pulse-rates
of mother and  child, he says that, in the absence of direct
vascular and nervous connection between the  two, it  may be
supposed to depend on differences in the amount of carbonic
acid in the blood, regulating the vaso-motor nervous  centres
of the fetus.  Other observers,  such as Fiedler,2  Hohl, and
Steinbach, have noticed  a  rise  and fall in  the fetal pulse,
corresponding with similar variations in the  temperature and
pulse of the  mother during typhoid fever  and variola, but
Engelhorn suggests whether it  was not the  high maternal
temperature, more than the  pulse, which  affected fetal nutri
tion and cardiac contractions.
   In accordance with the table by Yolkmann, which shows
that an average decrease of the pulse by 4.4 beats per minute,
takes place in proportion to an increase in  length of 10 centi-
metres of the whole body, Engelhorn found that  to a body-
length  of 40  to  45 centimetres corresponded 147.9  fetal
pulsations per minute;  to 45 to  50 centimetres, 137.9 pulsa-
tions;  over 50  centimetres,  126.6 pulsations.   Whether this
latter result is practically available to assist in determining the
age of the fetus in utero is, however, pronounced doubtful.
   Dr. D. A. K. Steele,3 from a careful record of fifty cases of
  1 Arch. f. Gyn., IX., 3, 1876.
  2 Mon. f. Geb., XIX.              3 Chicago Med. Jour., Sept., 1874. 
62        Munde:  Diagnosis and Treatment of

pregnancy, arrives at  the following conclusions:  1st, in  the
majority of cases male fetal hearts are slower than female;  2d,
the average dividing line is  132  fetal pulsations per minute;
below this 68-4- per cent are male, 20 per cent female, 11-*-  per
cent doubtful; above this 53^ per cent are female, 26f per cent
male, 20 per cent doubtful;  3d, the most accurate observations
are made during the last four  weeks of gestation;  4th,  the
rapidity of the heart's action is increased in proportion to the
feebleness of  the fetus; 5th, calcareous or  fatty degeneration
of the placenta renders the pulsations  feeble and irregular;
6th, in some  cases it would  be  possible to diagnose diseased
conditions of the placenta from careful observation of the fetal
heart; 7th, the weight of the child does not increase the force
of the fetal heart.
  In  the  same number of  the  same journal, Dr. Albert H.
Strong, of Chicago, likewise reports his experience in fifty cases
of pregnancy, in twenty-six cases of which a correct, in twenty-
four an incorrect diagnosis was  made.   He found the average
pulse of the males to be 136.3, of the females 137, which figures
in themselves show the worthlessness of  this test for determin-
ing sex in utero.
   A like  result is arrived at by Edward D.  Peters1 in thirty
cases observed in the Boston Lying-in Asylum.   He found the
average pulse of males to be 136^, of girls 146^, a difference
in itself  sufficient to  be of value, were not the  fetal pulse
subject to so many variations from external influences (exercise
of mother, active motions of child,  unappreciable causes) as
scarcely ever to  present precisely  the same  rate at any  two
examinations.  Peters' observations show that, contrary to the
law of extrauterine life, the largest children, male and female,
had a  considerably higher  pulse-rate than  the smaller ones
(150 and 143 for largest girls and  boys  respectively;  143  and
131 for smallest girls and boys respectively).
   Recently2  Dr. Mattei examined several hundred pregnant
women and  drew the  conclusion that a fetal  pulse below  135
indicates a male, above 150 female; only in three cases did his
prediction turn out to be wrong, and these three  were small
 and feeble females, whose pulse-rate was so slow as to be taken
             1 Bost. Med. and Surg.  Jour., Aug. 23d, 1877.
             2 Arch, de Tocologie, March, 1876. 
Obstetric Cases by External Manipulation.     63
for males.   This conclusion certainly does not agree with the
majority of those drawn from the careful and  conscientious
observations of the numerous writers above quoted, and I can-
not help thinking, must be accepted with some hesitation as an
example of unusually lucky guesswork.
   The fallacy of estimating the sex of the fetus by the rapidity
of its cardiac pulsations has recently been shown most conclu-
sively by Mr. Chas. G. R. Nayior, of Edinburgh,1 in a paper
on "The Influence of  Digestion in the  Mother  upon  the
Frequency of the Fetal Pulse."  He examined five women in
the Maternity  Hospital of Edinburgh, at repeated intervals,
half an hour before and two hours after each meal (dinner, tea,
and supper), being careful to keep the woman absolutely quiet
in bed, in the recumbent position for at least half  an hour prior
to each auscultation.   He found the fetal pulse-rate invariably
increased after meals, the increase ranging from 4 to 32 beats,
a rise of 14 to 20 beats being the  most frequent.  The degree
of increase  did  not seem to be affected by the article  of  diet,
the highest  rise of  32 beats following a  tea of  bread, butter
and tea, and one of the lowest, 8 beats, a dinner of Irish  stew
and bread.
   Dr.  Willis E. Ford reports2 the results obtained in sixty-two
cases.   The average pulse rate of twenty-four female children
was 143, the highest 160, the  lowest 120 ; of thirty-eight male
children, the average was 142.5, the highest 170, the lowest 110.
   The latest and also most positively adverse  conclusion on
this subject has been arrived at by Paul Budin and Chaignot,3
who,  at the instigation  of Prof. Depaul,  examined  seventy
cases with reference to the relation between the cardiac  pul-
sations and  the weight and  sex of the fetus.  They decide that
there is no  absolutely practical relation between sex and  pul-
sations, for  the  latter may and do vary from fifteen to thirty
beats at different auscultations, and even during  the same ex-
amination, and both high and low pulsations are found indis-
criminately in children of either sex.   As regards the relation
of weight, pulsations, and sex, they found quite as much aver-
age  variation,  although  in a certain number  of cases  they
  1 Edinb. Med. Jour., May. 1876.
  2 On the Diagnosis of the Sex of the Fetus in Utero, N. Y. Med. Rec, Dec,
ISjg                  3 Gazette medicale de Paris, April 12th, 1879. 
64        Munde:  Diagnosis and  Treatment of
detected a higher rate in the larger children than in the smaller
(smallest boy, 2,175  grammes, 132 beats ;  smallest girl, 2,008
grms.,  Ill;  largest boy, 4,210 grms., 114; largest girl, 3,650
grins.,  141-150), thus differing from Cumming's results in his
second series above referred to.  But they  distinctly state, that
there is no relation whatever  between the weight, cardiac pul-
sations, and sex of the fetus.1
   All this mass of conflicting  testimony,  as is  but too often
the  case  in  our scientific controversies,  does not seem to have
positively settled the  question :  Can the sex of the fetus in utero
be positively and  uniformly determined by the  relative rapid-
ity of its cardiac pulsations ?   In all probability, like the allied
mystery of the influences directing the original sex of the child,
it will  ever remain a doubtful point, frequently open to correct,
but  usually  chance, interpretation, and  a fertile  source for in-
vestigation and conjecture.
  1 Since this article went to press, two additional papers have appeared on
this subject, one by Dr. P. V. Schenck, of St. Louis, in the St. Louis Courier
of Medicine for August, 1879, and the other by Dr. Georges Dausats, of Bor-
deaux, in the Archives de Tocologie for July and August, 1879, which latter
paper is still to be continued.
  Dr. Schenck  examined  160 cases, and found the following figures: Totfcl
average, 138.5 ; total male average, 132.6 ; total female average, 145.7 ; lowest
male, 120 ; highest male,  160 ; lowest female, 125 ; highest female, 172.  The
most he can say is, that  " in a large majority of cases the male  heart beats.
slower than the female."  Dausats' article, even in its present unfinished con-
dition, is a very complete treatise on the subject, and is entitled, "Researches
on the Frequency of the Fetal Heart-Sounds."  It discusses the differences in
frequency during pregnancy and labor as influenced by age, sex, weight, size,
motion, sickness, multiple pregnancy, uterine contractions, dystocia, etc., and
gives in a fall historical review almost precisely the same authorities as quoted
\>y me.  Basing on very careful  observations  of  107 cases, to which he adds
428 collated from recent authors, being a total  of  535 cases, he concludes
that, 1st. There is a certain connection between sex and habitual frequency of
the fetal pulse which, however,  becomes appreciable only when the  number
of pulsations exceeds 145, or falls below 135.   2d. Above 145 it is generally a
girl, below 135  a boy. 3d. Omitting the cases of a pulse-rate between 135 and
145, the prediction of the sex will prove correct on an average 7 times out of
10.  When we  consider that about as many girls are born as boys, it is evi-
dent that this proportion of correct prediction is only better by 2 out of 10,
or one-fifth, than one might expect to obtain by a pure guess.
   The number of the St. Louis Courier of Medicine above mentioned con-
tains, by the way, a letter from Paris, by Dr. F. Hartman, describing  "Ab-
dominal Palpation as a Mode of  Diagnobing Fetal Positions and Conditions,"
a practice which the writer of the letter witnessed at the bedside and heard
described in the  college there, evidently as  a result of the appearance of
Pinard's book. 
       Obstetric Cases by External Manipulation.     65

  All authors hitherto have agreed in employing the necessary
precautions  during their examinations to avoid  errors  and
attain  as nearly  as  possible  a  uniform result.  They have
been careful to keep the women quiet in a recumbent position
and free from mental or physical excitement, for some time
before proceeding  to auscultation; they have  examined  at
different times, and compared the figures of  each  exploration,
using only the average for their calculations ; they have care-
fully  excluded all doubtful  cases in -which the pulsations
were not distinctly countable  or  in which some special cause
for fallacy existed—they have done all this, and more still, to
obtain a fair  and  truthful statement, and what has been the
fruit of all  their  labors?   Steinbach, Zepuder, Hennig, Hut-
ton, Mattei, Cumming, and Wilson have (the last two only to a
certain qualified extent) corroborated Frankenhauser's observa-
tions, while the undoubtedly equally weighty evidence of Bres-
lau, Haake, Scanzoni, Nayior, Engelhorn, and Budin, based on
equally careful researches, utterly denies the existence of  any
law for the  prediction of the  sex of the  fetus in  utero, as its
originator would have us accept.   The latest and one  of  the
ablest advocates  of the law,  Dr.  Wilson,  in his last paper
(Dec, 1S75) does not feel justified in  saying more than that,
" although  the sex  may not  be  determined  with absolute
certainty, yet  we can  certainly make a very shrewd guess;"
and the last author but one on the subject, Engelhorn (June,
1876), concludes his paper with the remark, that his  own  and
the observations of others justify him  in believing that the in-
fluences governing the frequency of the fetal cardiac pulsations
will probably  never be determined with sufficient  accuracy to
enable us to draw from them, before birth,  any positive  con-
clusions regarding the sex of the  fetus.
   I  regret  exceedingly  that  I did not  avail myself  of  the
abundant and convenient opportunity offered me abroad to
institute a systematic inquiry into the question, but I was in a
measure deterred from thinking of it by  the evident disbelief
with which  Frankenhauser's discovery was  regarded by Scan-
zoni, who apparently thought the matter settled in the negative.
Whatever individual cases I may since have examined with the
view of satisfying either the mothers or myself  as to the  sex 
66       Munde: Diagnosis and  Treatment of

of the expected child, some with a  correct, others, apparently
equally certain^ with a mistaken diagnosis, have led me to con-
cur with Engelhorn's and Budin's opinion.  You may be suc-
cessful or yon may not, in either case it is a matter of chance,
and if correct, you get the credit of having made, as Dr. Wilson
says, " a shrewd guess."  Therefore it is best always to qualify
your diagnosis  as to the sex by saying that the prima facie evi-
dence (the frequency of the  pulsations) would denote a male or
female child, as the case may  be, but that the result will show
whether your  supposition is correct.   The disappointment of
finding a girl, when a boy  is  ardently desired, and has been
promised by the obliging medical attendant, or vice versa, may
cause serious trouble  to the patient  and much annoyance to
the doctor.
  The  therapeutical indications to be derived during  labor
from  irregularities in the fetal  cardiac pulsations are exceed-
ingly simple.   As has already been stated above, during the
normal uterine contractions or labor-pains the placenta is com-
pressed and its circulation more or less interfered with, as long
as the pain lasts ;  naturally the fetal heart is affected thereby,
and its pulsations become for  the  time faint or diminished in
frequency, to regain their normal strength and  rhythm as soon
as the disturbing compression  ceases.   From this normal inter-
mittent irregularity the fetus in no  wise suffers;  should the
uterine contractions, however, become so severe, constant, or
rapidly recurrent as to  continue this  depression of  the  fetal
circulation for  some length of  time, the fetal  heart-sounds do
not regain  their normal  power and rapidity, but grow fainter
and fainter and more and more irregular and infrequent, until
they finally cease entirely.   This is apt to be  the case in the
spasmodic condition known  as tetanus uteri,  and after the use
of large doses of  ergot during the second stage of labor.   The
indication to check the  excessive contractility  of the uterine
muscular fibres by narcotics and antispasmodics, and  if unsuc-
cessful therewith, to effect the delivery of the child as rapidly
as possible if its life would be  saved, is  urgently imperative.
Further, any constant and  increasing  irregularity of the fetal
pulsations, during a severe or  tedious labor, where the head
is subjected to severe  and  lasting  pressure, will demand the 
Obstetric Cases by External Manipulation.     67
speedy  extraction of the  child, as  does also  a non-reducible
prolapse of the umbilical cord when the child is still alive and
its heart shows signs of failing.   As the fetal heart is the evi-
dence of the life and health of the fetus in utero, it is evident
that it should be carefully watched by repeated examinations
during  every labor in order to detect and remedy any danger
to the child as soon  as it occurs.

                  The  Umbilical Murmur.
   Not to be compared in interest or  importance to the fetal
cardiac pulsations, but still possessed  of considerable scientific
and some practical  value, is the funic or umbilical souffle, a
single  blowing systolic  murmur heard synchronous with the
fetal heart (generally most distinctly at the spot where the lat-
ter is audible), in certain pathological conditions of the cord or
fetus.   This fact of its being synchronous with the fetal heart
sufficiently  distinguishes it from the uterine  murmur, which
coincides in  rhythm with the  pulse  of the mother, and also
greatly exceeds the funic  souffle  in  strength and intensity.
The first author whom I find credited with having pointed out
this sign is Evory Kennedy in 1833/ who attributed the mur-
mur to  compression of the cord by its being wound or twisted
around  portions  of the child's body, as he was able to produce
it at will by pressure  on the cord before detaching the child
after birth.  This  opinion was shared by Naegele, Spondli,3
Devilliers3 and  others, while  Kiwisch, Mossinan,  Martin, and
Breit endeavored to explain the sign in other ways.   Breit
took the untenable  ground that stenosis  of the cord was the
main cause.   Kiwisch  utterly denied its causation  through
duplicaturesof the cord, without offering any adequate explana-
tion ; Mossmann4 believed it  to depend  entirely on organic
valvular disease  of the fetal heart, basing his  opinion on a
case of his, where this pathological condition was found post
mortem ; Martin 5 in twenty-three instances, of funic murmur
found only fourteen in which the cord was wound  around the
fetal body, and in twenty-eight cases of such duplicature there
  1 Treatise on Obstetric Auscultation, 1833.
  2 Mon.  f. Geb., III., 1854.           3 Union Med., II., 1854.
  4Mon.  f. Gel-., IV.                »Ibid , VII., 1856. 
68        Muxde: Diagnosis and Treatment of

was no murmur, wherefore he  doubts the causative agency of
the above anomaly.  Gregor Schmitt,1 of Wiirzburg,  reported
five cases in which the funic murmur was audible, in two of
which the cord was found slightly wound  around the neck of
the fetus, in  one it was prolapsed, in one no  anomaly of
the cord was detected, and  in  the  fifth  and most interesting
case the autopsy, performed by Yirchow, revealed marked hy-
pertrophy of the right ventricle, insufficiency of the  tricuspid
and mitral valves, and numerous small,  bright-red, gelatinous
nodules  on  both these valves.  This last case  corroborates
Mossmann's view, as  also does a case reported  by Andrese.2
Frankenhauser 3 and Hecker4 both  locate  the murmur in the
umbilical arteries, the latter chiefly at the point of exit from
the fetal body; whereas Scanzoni5 expresses decided doubts as
to the possibility of a souffle occurring in  such  small arteries
as the  umbilical,  and believes that, although  the  cause of
the murmur in all probability generally consists in compression
of the cord, the murmur  itself does not  originate in  the funic
vessels, but in the fetal heart, being caused by the rapid influx
of the  reduced volume of blood into the disproportionately
large cardiac cavities, and thence transmission of the murmur
throughout the cord.  As evidence he quotes the above-men-
tioned case of Schmitt.
   Schroeder 6 states that the precise conditions  under which
the funic murmur occurs  are not known, but that it  undoubt-
edly occurs in the cord, probably close to the umbilicus, per-
haps caused by flexion of the cord  at the junction of the  cord
and skin; that he, as well as Hecker, found it less frequently
when the cord was wound around the fetus, and that  he there-
fore  thinks  this accident can scarcely be considered  a cause.
As a proof of  its  origin  near  the  umbilicus he  mentions the
fact  that it  is generally  best  heard where the fetal heart  is
most distinct, but disappears at more distant spots, leaving only
the clear, if faint, fetal pulsations.
   The most complete recent paper (but  one) on the  subject is
1 Scanzoni's Beitr'age, 3, 1S58.
3L. c.
6Lehrb. d. Geb., I., 1867.
2 Diss, inaug., Konigsberg, 1870.
4 Hecker u. Buhl, Klinik der Geb., I.
6 Geburtshiilfe, 1872. 
       Obstetric Cases by External Manipulation.     69

by Winckel,1 who met with twenty-seven cases among three-
hundred confinements, from which he drew the following con-
clusions, which I think may be considered as  expressing most
clearly the present state of the question : The souffle occurred
in nine per cent of his  cases (Frankenhauser says  eight per
cent, Schroeder and Hecker give as high as fourteen  to fifteen
percent; as far as my experience goes, I should incline more
to the proportion stated by Winckel, making  it even less fre-
quent).  It occurred with equal frequency in primipara?  and
multiparae.  It was  most frequent in  vertex  presentations,
occurring only twice in breech and once in an oblique presen-
tation;  thus refuting (as  did also Hecker)  Frankenhauser's
assertion that it  is most frequently audible in breech presenta-
tions.  The souffle was almost uniformly audible in the  neigh-
borhood of the fetal heart, the latter  being clear and distinct
at one spot, a few centimetres distant  from which the  souffle
was loudest and the  fetal heart less distinct.   Winckel says
that the souffle may be audible at a distance  from the cardiac
pulsations  as well as close  to  them, thus in a L. O. A. presen-
tation it may be heard on the right side of the fundus if the
cord is  compressed at that spot by the thigh; but  its being
audible near the fetal heart is easily explained by considering
that the compressed portion of the cord, if compression  occurs
by its being twisted around the body  or one  of the limbs of
the fetus, is naturally, at  the best, but a short  distance from
the fetal  thorax and  heart.  The audibility of the murmur
between the symphysis and umbilicus by no means necessarily
indicates that the cord is wound around the neck of  the fetus,
as Frankenhauser believed, because the latter accident  occurs
very much more frequently than  the  murmur;  and  twisting
of the cord in general is only occasionally accompanied by the
souffle.  (The four cases reported by Dr. Wilson,2 in which he
heard the  funic souffle over the pubis,  diagnosticated  there-
from  the twisting of the cord around  the neck, and found his
diagnosis confirmed at the delivery shortly after, are certainly
too positive instances to permit of their being considered as
mere  chance coincidences.  Perhaps we may put the facts thus :
1 Pathologie der Geburt., 1869.
2 L. c, 1873. 
70       Muxde: Diagnosis and  Treatment of
The n on-audibility of the souffle over the pubis—or indeed
anywhere—does not prove that the cord is not twisted around
the neck or some  other portion of the child ;  where it is audi-
ble, however, above the pubis, we may predict with tolerable
certainty that the cord is coiled around the neck, or if audible
elsewhere, around some other portion  of the child.)
  Winckel agrees  with  the majority  of authors in locating
the murmur in  the cord itself, but  believes that it occurs not
only in the arteries of the cord, but even  more frequently in
the more compressible umbilical vein, basing his assumption
on the fact that frequently a protracted funic murmur is not
productive of evil to  the child, which would scarcely be prob-
able if arteries and vein were both obstructed.  As  regards
the significance of the murmur, Winckel differs from Scanzoni,
Hecker, Martin, and others (who  deny that it has any practical
importance), and agrees with Schmitt and Wilson, that a long-
continued funic murmur cannot but be indicative of danger to
the child, and  may under appropriate  circumstances call for
active interference.  During pregnancy, as Schroeder says, it
possesses absolutely no practical  value, for even if the  exact
condition causing   the murmur could  be  ascertained (as, for
instance, if the cord could be felt crossing the fetal back  or
limbs through the thin utero-abdominal walls, as Winckel and
Spoendli claim  repeatedly to have done), nothing could be done
to remedy the malposition at the time.  On such occasions
the fetus must  be left to change  its position for a less precari-
ous one by its own individual mobility.
  To recapitulate :  The funic souffle is caused  by some obstruc-
tion to the flow of the blood  through the umbilical vein  or
arteries, either  both together or separately, if the latter, more
likely the vein ; or it  may originate in the fetal  heart itself,
when its valves are diseased.  The obstruction in the  cord
may be produced either by its compression between the  body
of the fetus and the organs  of the mother (as in prolapsus  of
the funis), or by its being more or less  tightly wound  around
the neck, body, or  limbs  of the  fetus, or finally by its being
tied in a true  knot (a very rare  occurrence).   Owing to the
frequent  changes  of  position of the  child, and the slipping
of the loop of cord in consequence, the compression is  often 
       Obstetric Cases by External Manipulation.     71

removed and the murmur  thus necessarily  becomes intermit-
tent, being audible at one examination  and inaudible at an-
other ; if it is  permanent  and always in the same place, the
inference  would  be that the  cord is  either tightly wound
around the neck, perhaps more than once, or that  it is tied in
a true knot.  The audibility of  the murmur over the spot
where the neck has been ascertained to be, although favoring
that view, does  not  necessarily or invariably denote that the
cord is wound around the neck (as Wilson asserts); neither is
it a natural inference (also Wilson),  if the murmur  is heard not
at the neck, but at some point in the course of the cord, that it
is caused by a knot at that place.   Case forty-seven reported
by Dr. Wilson,1 of a constant funic scuffle being heard at the
neck, which was thought to be due to the  cord  being around
the neck, but which  at delivery proved to " be caused by  an
excessively varicose condition of the funis " itself disproves the
uniformity of the rule laid dowm by him.
  The most recent contribution to this subject has been offered
by Pinard,2 of Paris, who made a series of exceedingly interest-
ing experiments on a large number of umbilical cords, taken
from women whom he had repeatedly examined during gesta-
tion and labor, from which he drew the following  conclusions,
of which the second will be  seen to  be  novel and especially
interesting.   When a pregnant female is carefully examined
by auscultation during the latter half  of pregnancy, three vari-
eties of fetal murmurs may be heard :
^  1. A murmur corresponding to  the first sound of the fetal
heart, which is  muffled instead of  being sharp and distinct.
This is a  cardiac murmur, is permanent, and disappears some
hours or days after birth.
   2. A murmur with its maximum  at a  greater or lesser dis-
tance from the fetal heart.   This is a funicular  souffle, which
may be single or double, and is due to  the presence of  well-
developed semi-lunar or  diaphragmatic  valves, either in the
vein or  the arteries, or in both varieties of vessels together.
   3. A single transient murmur, isochronous with the  pulsa-
tion of  the fetal heart, but stronger  than either of the above
varieties.   This funicular souffle  is due  to a passing compres-
  1 Am. Pract., Dec, 1873.       2 Gaz. Med. de Paris, March 18th, 1876. 
72        Munde:  Diagnosis and Treatment of

sion of the  elements of the cord,  either by the fetal parts
themselves or by the stethoscope.
  As will be inferred  from what has  already been said, the
scope for operative interference on the part of the obstetrician
in cases of funic murmur  during actual labor is exceedingly
limited, being  confined to the removal of pressure from the
cord by a suitable lateral or knee-elbow position, if  the seat of
compression can be ascertained by  indagation, as in presenta-
tion of the cord  before rupture of  the membranes, or if the
murmur continues after the prolapsed  cord has been replaced,
or by manual or instrumental reposition of the actually pro-
lapsed cord ; further, to the rapid  loosening of the coils of
cord  around the child's  neck,  as soon as the  head emerges
from the  vulva, if the seat and persistence of the murmur lead
to the supposition that this is the case ; finally,  to the speedy
delivery of the child by whatever means may seem feasible and
advisable, if the constancy and increasing force of the murmur,
especially  if coupled with an irregularity or growing indistinct-
ness of the fetal  heart,  indicates  serious danger to the child.
The necessity, therefore, of carefully watching both the mur-
mur and the fetal heart during every case of funic souffle inter
p>artum is obvious.

                   The  Uterine Murmur.
   As early as the fourth month of pregnancy, soon after the
uterus rises out of the pelvic cavity,  the auscultating ear in the
majority of cases readily  detects a single blowing or wheezing
sound synchronous with the maternal pulse and generally audi-
ble in greater or lesser intensity all over the uterine  ovoid. As
pregnancy increases, it becomes louder, often overpowering the
fetal heart-sounds, and is most plainly heard in either inguinal
region, more rarely in the  median line and near the fundus.
The sound is usually so distinct that even superficial ausculta-
tion cannot fail to distinguish it, but its intensity and site fre-
quently vary, and at times it may  be  very faint or entirely
inaudible, or have disappeared from the spot where it was once
plainly audible, to be heard only on the opposite side of the
abdomen.   This irregularity is attributed by Braxton Hicks,
during gestation, to the normal intermittent uterine contractions 
       Obstetric Cases by External Manipulation.    73

occurring during the second half of that period (already refer-
red to under Palpation), and his  opinion derives unquestiona-
ble support from the well-known influence which the  uterine
contractions during labor produce on the uterine murmur.  At
the inception of a pain, the murmur increases in intensity, but
rapidly diminishes and entirely ceases at the acme, to reappear
again when the contraction has passed away.   Whether it is
possible  to  distinguish  the  true from the so-called spurious
labor-pains by the above test, as  Dr. Wilson asserts,1 seems to
me doubtful, if we accept Dr. Hicks' explanation of the inter-
mittence of the  murmur during  pregnancy.   Nor  is this  test
needed, for a vaginal examination  will usually tell us whether
the alarm is a true or false one.   Neither am 1 quite sure of the
correctness of Dr. Wilson's assertion, that the continuance of the
murmur  after the expulsion of the placenta indicates a " relax-
ation of  the uterine walls incident  to concealed hemorrhage "
and serves  as  a  warning  to  the  obstetrician.   At least,
Scanzoni2 says that  he has heard it  on the fourth and sixth
days post partum, without making mention of its being a diag-
nostic sign  of impending post-partum hemorrhage or  of  that
accident  having occurred in his two cases.
   The causation of the puerperal souffle, as it is also called, has
been the subject of even more discussion than that of the funic
murmur.   The various theories  held  by Kiwisch, Bonillaud,
Depaul,  Dubois, have  already been  briefly mentioned in the
Historical Sketch.  Scanzoni, in  the fourth edition  of his
Treatise on  Obstetrics, 1867, expresses the  conviction (held
also by Depaul) that the uterine murmur is caused, in the major-
ity of cases, by the rushing of the blood in the tortuous branches
of the uterine  arteries, particularly in either inguinal  region,
where this tortuosity is most marked  and where the murmur
is ordinarily most pronounced ; that  it  may also be produced
by the passage of the  blood  from  the  arteries into the large
veins of  the uterus, a view coincided in by Dubois and later by
Skoda3;  and finally, that in a few  cases, where a slight pres-
sure on the external epigastric arteries is  shown to modify or
arrest the murmur, the latter vessels may  certainly be con-
            'L. c, 1873.       2L. c,  Vol. I., p. 167.
            3 Percussion and Auscultation, sixth edition. 
74       Munde:  Diagnosis and Treatment of

sidered to be the seat of that murmur.  This latter theory,
originally held and ultimately  relinquished by Kiwisch, and
admitted  by  Scanzoni for certain rare cases, has recently
been revived by Francois Glenard,  of Paris.1    By direct
observation, he claimed  to have found  that, when the  abdo-
men is  distended, the stretching is not uniform, but is con-
fined to the fibrous  structure called the linea alba.  This is
spread out into a large lozenge-shaped  area, bordered by  the
recti muscles.  These muscles are separated, but not increased
in breadth.   The gravid uterus is  thus slung, as it were, in a
bandage between and by them.   Examining, he finds that the
maternal souffle is heard upon a curved line which corresponds
to the course of the epigastric artery, which, in consequence of
the mode of expansion already  described, remains  throughout
at the same distance of ten centimetres from the spine of  the
ilium.  Finding  that  the souffle is most distinct over the epi-
gastric arteries, Glenard applied the crucial test of compressing
the artery in the  lower part of its course and succeeded in com-
pletely arresting the souffle.   The proof seemed  convincing,
and Glenard confidently volunteered to  demonstrate the truth
of his assertions to the Academie  de Medecine of  Paris.   In
this, however, he  signally failed, for he was utterly unable to
affect the murmur by any compression he could exert on  the
epigastric arteries.  Smarting under this failure, he  fortunately
succeeded  in discovering another  explanation of  his former
observations.  Injecting the uterus  of a woman who died three
days after labor,  he distended the arteries and found an artery
as large as the brachial  arising from  the uterine  artery and
lying on the uterus almost exactly in the course of  the epigas-
tric.  This artery he calls the puerperal artery, and believes it
to be the location of the souffle.
   Glenard's  discovery still  awaits confirmation,  which can
hardly be long in coming if it really is founded on fact.   For
my part, I believe that so large  a vessel  as the supposed
" puerperal  artery," if it really  existed, would have been dis-
covered years, nay, centuries ago, and that the explanation now
generally accepted, that the uterine  souffle has its  seat in  the
large and tortuous uterine arteries, is sufficiently explicit.  That
                  1 Arch, de Tocologie, 1876. 
         Obstetric Cases by External Manipulation.    75

a murmur may also  originate in the venous sinuses of the ute-
rus, and under certain circumstances in  the large abdominal
vessels, both veins and arteries, during the physiological chlo-
rotic condition of the blood in pregnancy, seems by no means
improbable.   A relation of the murmur  with the location of
the placenta, applicable  to  the diagnosis of  the seat of that
organ (whence the old term " placental" souffle), is denied by
all the  advocates  of this accepted theory, except Depaul.  I
myself have never been  able to diagnose  the seat of  the pla-
centa by the focus of the uterine souffle, except in so far as the
audibility of the souffle also near  the right horn of the uterus
would lead me to suppose that the placenta was there inserted,
a supposition which occasionally  proved  correct.  But statis-
tics by Gusserow, Martin, Bidder, and Schroeder show that
the placental site is found almost  with equal frequency on the
anterior and on the posterior wall of the uterus, but that its
lateral insertion is  quite rare, only in about five per cent of
the cases, the dextral  insertion being twice as frequent as the
sinistral.  If  the  souffle depended upon and were loudest in
the neighborhood of  the placental site,  it would,  therefore,
naturally in one-half the cases be most distinct near the median
line, in the other half not at all  or faintly audible, which, as
we all know, is not  the case, for it is most pronounced bilat-
erally where the uterine arteries are most  tortuous.  I can,
therefore, agree neither with the old observations of Hohl, nor
with those recently reported  by Wilson, because they are at
variance with my own and  the experience of the majority of
observers.  Besides, as already stated by Scanzoni and  Play-
fair, the murmur continues after the  removal of  the placenta.
Practically, as a diagnostic  sign of pregnancy, the souffle has
lost in value since the  observations of Velpeau, Depaul, Beau,
Peaslee, Spencer Wells, and numerous others have shown that
a murmur to all  intents and  purposes identical with it fre-
quently occurs in large ovarian and fibroid tumors, the surface
of which is covered with tortuous  and dilated blood-vessels.  In
combination  with the  other  well-known diagnostic signs it
deserves consideration ; alone it has but a supposititious value,
and a too firm reliance  on its  puerperal character would be
likely to lead to serious  errors in the diagnosis of abdominal
tumors.   As a sign of the life  of  the fetus it  is equally value- 
76        Munde: Diagnosis and Treatment of

less, for it continues after the death of the fetus, and even after
the birth of the child.
  Recently,1 Hotter in  Erlangen accidentally discovered that
the uterine souffle is  palpable, by detecting  with the  finger  a
distinct thrill in a circumference of  4-5  cm. around  the
umbilicus; this thrill was synchronous with the maternal pulse.
                           Fig. 5.

With the stethoscope a loud uterine  souffle was heard at this
spot.   This observation  was verified in  eleven  cases out  of
twenty in women near term.   That the thrill proceeds from
the uterine vessels,  and not from  the  epigastric artery,  is
proved by the change of position of the thrill when the posi-
tion of the  uterus is altered, as  when a woman assumes another
posture;  also by the fact that the vibrating tract of the uterine
souffle crosses the course of the artery.  A distinct thrill could
be felt per vaginam corresponding to the  external murmur  in
each lateral ascending branch of the  uterine artery.  The pal-
                  1 Arch. f. Gynakol., V.,  1873. 
        Obstetric Cases by External Manipulation.     11


pability of the uterine murmur had already been discovered by

Rapin,1 but was not corroborated.


       CHART FOR EXTERNAL EXAMINATION OF OBSTETRIC CASKS.

* r
Palpation.
Left.
3, 6, 9.

Right,
1, 4, 7.
Left.
3, 6, 9.
Right.
1, 4, 7.
Left.
3, 0, 9.
Right,
1. 4, 7.
 Extremities.                     fore-
legs.     ARMS.   BREECH.   HEAD.   HEAD. CHIN.
R. upper.
   1.

L. upper.
   3.
R. upper.
   1.
L. upper.
   3.
Sometimes
 centre
Occasion'h
right centre
4, 5.
Lower
 and
middle.

4, 5, <>,
7, 8, 9.
 Not
palpa-
 ble.
If palpable near
    centre.
5 and 8.
More frequently pal
 pable near centre.
5 and 8.
L. upper.
   3.
R. upper.
   1.
Left and
 middle
 upper.
  2,3.


Right and
 middle
 upper.
  1,2.
R. lower.
L. lower.
   9.


R. lower.
L. lower.
   9.
L. upper.
  2, 3.
R. upper
  1.2.
L. lower.
R.  lower.
   7.
L. lower,
   9.
R.  lower.
   7.
Left. Right
 9.
Right
  7.
Left.
 9.
Auscultation.			2 M
			3S
fetal	UTERINE		
HEART.	MURMUR.		'
L. lower.			
9 to 6.		>	3-p 2
		P.	'D ^ E3
R. lower.		cr	3""2 i
7 to 4.		CD	?<«&
		S	
First mid-			
dle, 5, 8;			■3»C
later,			
left,9, 6.		p	5 P-o 3 o <
First mid-		"	5 s.-s _ CD ,.
dle, 5,8;		P	^ ai
later, 1.		CD	§«I
lower,4, 7.	p o CD 3 P	& C o >-i P. CD	C O CD £.CD S-■ | s
L. middle to up-			
per, 6,3.	75	O	CD CD
R. middle to upper 4, 1.	a	CD P cr	El-1 o =*■
L. lower.		o 3 ro	
8, 9.			c S
			2 <
R. lower,		zl	3 CD en ^
7 8			— O"
		o	3 O
t-i Left			si1
$ lower, 33 8, 9. g; __		1 CD en? P	
& Right		p.	3 CD
9 lower,		e-,.	5c
S- 7.8.		O	91 if.
                                 II.
                            TREATMENT.

   That the therapeutic application of external obstetric manip-

ulation has attracted much greater  attention  than  mere diag-
nostic  palpation  is  apparent  on  referring  to the  number of

authorities quoted in the  historical portion of this paper.*

  The majority of recent authors on obstetrics mention the sub-

  1 Schweiz. Corr. Bl.,  2, 1873.
  21 have not thought  it necessary, in the Historical Sketch, to refer to
and cite the opinions of all  the numerous obstetric authors who have
written on or devoted chapters in their works to this topic; the substance
of their experience is  embodied in the works of the recent writers from
which I quote.   Those who wish to collect all the literature of the subject
of External Version from Genesis up, I refer to the excellent monograph
of Dr. Noeggerath,  in the New York Journal of Medicine, Nov., 1859. 
78        Mundb: Diagnosis and Treatment of

ject at greater or lesser length, particularly Scanzoni,1 Byford,11
Barnes,3 Playfair,4 Spiegelberg/ and Fritsch,6 the last of whom
gives the best account of external  version with which  I have
become acquainted.
  Byford, speaking of external version, says :  ..." It is to
be hoped that a persevering effort will be made by the practi-
tioners of this country to educate themselves for this purpose,
as there are so many good reasons  why it is to be preferred to
introducing the hand into the uterus."
  Playfair,  referring  to the  same operation,  remarks:  " In
spite of  the manifest  advantages  of the  procedure and  the
extreme facility with which it can be accomplished in suitable
cases, it has by no means  become the  established custom to
trust to it, and probably most practitioners have never attempted
it, even under the most favorable circumstances."
   While nearly all authors recommend the manual expression
of the placenta in  all obstetric  cases  (Byford alone  advises
simple  kneading of the uterus and the objectionable traction
on the cord, without  mentioning  systematic expression), and
this procedure  is probably practised by the majority of  edu-
cated obstetricians, the  operation  of external  version  is  evi-
dently  still  very much  neglected.   Indeed, as recently as in
the  spring  of  1877, Dr. Leopold Ellinger, of Stuttgart (well
known through  his instrument for dilatation of  the  cervical
canal), thought it worth his while  again to advocate the more
frequent employment of the measure by the relation of two cases
of his own and  one of Dr. Wolfgang Schmidt, of the same city,
in which it was employed with marked success.7  The reasons
for  this neglect are  to be  sought,  not so much in the  want of
appreciation of the measure by the profession, as in the pecu-
liar difficulties  attending  its  employment, difficulties  emanat-
ing solely from the distaste of our ladies,  who  have not  been
educated or accustomed to being  examined before  labor, and
which have already been referred to at the close of  the histor-
ical part of this paper.
   1 Geburtshulfe, Bd. 3, 1867.
   '2 Theory and Practice of Obstetrics, 1873.
   3 Obstetric Operations, Am.  Ed., 1870.
   4Midwifery, Am. Ed., 1878.
   6 Geburtshulfe, 1878.               7 Am. Jour. Obst., April, 1877.
   6 Klinik der geburtshulflichen Operationen, Halle, 1876. 
       Obstetric  Cases by External Manipidation.    79

  The various  purposes for which external manipulations are
employed in the  treatment of obstetric  cases are:  A. The
rectification of an existing malposition, or the conversion of
one presentation into another more desirable one  (transverse
into  head or breech, breech into head—external version; or
face into vertex).   B.  The expression of the  fetus.   C. The
expression of the placenta.  These manipulations differ chiefly
from those employed for a diagnostic object, in being useful or
practicable only during the various stages of labor.   To convert
a transverse into a longitudinal position several months or weeks
before labor is  possible, to be sure, but a useless proceeding, in
the face of the  great mobility of  the child and the chances it
has of spontaneously assuming the usual vertex presentation.

A.  RECTIFICATION  OF AN EXISTING MALPOSITION OR  PRESENTA-
             TION  BY EXTERNAL MANIPULATION.
                         1. Version.
  It seems  scarcely necessary to point out the obvious advan-
tage of a method  by which the  desired end is attained with
equal facility over  the ordinary operation of internal version—
an operation which is usually not over-difficult nor dangerous,
but which occasionally proves one of the  most  arduous in the
whole obstetric list, and the mortality of which is estimated
by  Churchill,  for the  mother,  as 1 in  16;  for  the  infant,
1 in 3.  Pinard gives  even a higher rate—10  per cent of
mothers, 50 per cent of children.   If there are  any means by
which this frightful infantile mortality can be diminished, they
should certainly be universally promulgated and adopted.  Of
course, we cannot  expect to save every child, even though we
turn it head downward  by external version, for a large propor-
tion of these children die from causes foreign to the operation,
and acting  upon  them whatever position they may occupy;
neither will it  be  possible to prevent the  occasional death of
the mother  from some  puerperal accident;  but the operation
of external version is so incalculably more simple, easy of exe-
cution, and  less hazardous to the mother, that, in my opinion,
some plans should be devised to popularize its employment.
   The oreat objection to its frequent practice  is the fact that
only in very exceptional instances does the physician have the
opportunity to see  his patient before labor commences.  He 
80       Munde: Diagnosis and  Treatment of

is, therefore, generally unaware of  the position  occupied  by
the child, and when called to the  labor usually finds the mem
branes ruptured, and the child so  firmly grasped by the uterus
as to render all efforts at external version futile.   Further, as
Fritsch truly  says, the physician is frequently imbued  with
the prevalent opinion that external version is but a theoretical
operation, and rarely productive of permanent benefit, and he,
therefore, takes but little pains to accomplish his object, find-
ing it easier and more  time-saving for himself to wait until
the os is dilated, perform internal podalic version and extrac-
tion, and rapidly  pass on to the  next patient, or return to his
bed.  Still another reason for its  non-employment is the lack
of dexterity of the physician in  detecting the abnormal  pres-
entation by palpation—an of ten invaluable faculty at a time of
labor, when the  presenting shoulder,  for instance, is not yet
reachable by  the vagina.   The  importance, therefore,  of  a
thorough knowledge of abdominal palpation is at once appar-
ent.  The chief  obstacle, however, to  the  frequent  employ-
ment of the method lies in the neglect of physicians to assure
themselves and their patients against avoidable accidents and
the unpleasant occurrence  of being  taken unawares, by  an
examination, external  and  internal, made  during the  week
preceding the expected  day of  confinement.   In Germany,
even the best families  employ midwives, and the physician is
called  in only when  that functionary happens  to  discover a
malpresentation, or when operative interference is called for;
thus are explained the  statements of Ellinger1 that several of
his colleagues, in a large obstetric practice  of twenty-five to
fifty years, had each  had occasion to perform external version
but once, while he himself had never been afforded the oppor-
tunity until the cases  arrived on which he bases his article.
In this country and in England, however, wl^ere midwives are
the exception and reputable  physicians are generally engaged
long beforehand for the expected confinement, nothing would
be easier than to accustom the  child-bearing  portion of the
community gradually to  the inevitable external examination
(supplemented, if then appearing necessary, by  indagation)
within a week or two of the approaching  labor.  Surely no
woman  who has been made  acquainted with  the importance of
                             'L c. 
        Obstetric Cases by External Manipulation.    81

this measure, and the  benefit  probably  to  be derived  there
from, will object to the innovation, and it will soon become  a
custom no more to be objected to than the usual indispensable
vaginal examination during labor.
  Referring to Pinard's  recent work,1 Tarnier made the  fol-
lowing remarks at the Societe de Medecine Publique, of Paris:2
" Before long, both physicians and midwives will  be obliged,
under penalty  of  neglecting a duty, to inform themselves dur-
ing  the last months  of  gestation, whether  the pregnancy is
normal and nothing obtains prejudicial to a physiological con-
finement.   The women, on the  other  hand, will soon learn of
the existence of a simple and painless method of avoiding or
relieving several possibly very grave accidents during parturi-
tion ; and naturally they will seek  to profit by it.  These ideas
will rapidly spread, and  in  the lower classes the  women will
gradually acquire the habit of going to the maternity hospitals
during  the last months  of pregnancy,  to ascertain whether the
position of the child  is  normal, and they may look forward
without fear to their delivery.  A great progress will then be
made, for the majority of obstetric operations will be avoided."
The means for  popularizing  and  properly utilizing the  bene-
fits  of  this  operation  have  already  been  pointed  out, and
nowhere is the  field more favorable for that purpose than in
this country.

  1 Traite du palper abdominal au point de vue obstetrical et de la version
par maneuvres externes, par  A.  Pinard, Prof, agrege, etc.  Paris, 1878.
  2 Annales de Gynecol., Dec, 1878.
  Although ordered  fully six  months ago, through some misunderstand-
ing of the book agent, Pinard's work has not yet  reached me.  All  I have
seen of it, therefore, is the review in the Annales de Gynecologie referred
to.   So far as I can judge from this  review, the book contains nothing
new on the subject of obstetric palpation other than what has already
been stated, or will still be  mentioned in this  article, excepting perhaps
the employment of an obstetric bandage of  original design to retain the
replaced fetus in its  normal position.
  Note.—At the moment of going to press (March  20th, 1880), Pinard's book
reaches me, kindly sent by the author himself.  My above remarks are
confirmed by its perusal.  Of its 264 pages, the first 61 treat of the influ-
ences producing the various Positions and Presentations of the Fetus; the
next 97 discuss very ably and fully the subject of Diagnostic Palpation;
and the last 106 describe in detail the operation of External Version. Of
these 106 pages, 40 are devoted to the  relation  of cases.  The topics of
Expression of Fetus and Placenta are entirely omitted. 
82       Mtjnde:  Diagnosis and Treatment of

  It is well known that the mobility of the child in  utero up
to the hour  of  labor  is exceedingly great,  and that it will
change its position, perform the  culbute, as  the French say,
perhaps dozens of times during the last two months  of  gesta-
tion; even after  labor has commenced  has the presentation or
position been  known to change  voluntarily.  Although this
excessive  mobility is not  the  rule, and the head, when once
well fixed above the  pelvic  brim,  as it  generally  is by the
seventh month, usually does not move until labor sets in, still
the reverse  so often happens, particularly in multipara?- and
women with lax utero-abdominal walls, the  very cases  which
predispose to preternatural positions, that an attempt to per-
manently rectify  the position  before the  actual inception  of
uterine contractions almost invariably proves futile.  The pre-
senting part usually slips away from  the  superior strait the
moment  the hand  retaining  it  is  removed, or the woman
changes  her position.   Although some authors (Schroeder,
Playfair,  Scanzoni) speak  of holding  the head  down by
pads, bandages, and pillows until labor commences,  none  of
them positively  advise it, knowing  very well the  inefficiency
of such passive  mechanical  means.  And  indeed  it  is  quite
unnecessary to undertake the  operation at  all  before  labor,
because not only is  it impossible to keep the child  in the posi-
tion to which  it  has been turned, but also will  it frequently
voluntarily assume  the normal vertex presentation  as  term
approaches—an observation which Fritsch mentions, and which
I have myself made a number of  times while conducting the
" touch exercises " for  students at Wiirzburg.   Fritsch and
Playfair  nevertheless  both advise  the rectification of the
abnormal position before  the  actual inception of labor, if  it
can be done without in the least injuring the mother, saying
that it can do no harm, and should be recommended  as an aid
to Nature in her  efforts to bring about a natural labor.   Usually
the manipulation will need to be repeated a number  of  times.
   The operation of External Version is, therefore, essentially
an operation  advisable and beneficial only  during  labor, espe-
cially during the first stage  of that act, before  the discharge
of the liquor amnii.  To insure the easy performance of the
measure, the utero-abdominal  walls should be  lax,  the fetal
position readily  palpable, the  liquor  amnii  present, and the 
       Obstetric  Cases by External Manipulation.    83

fetus easily movable.   Still the operation has occasionally suc-
ceeded after the rupture of the membranes, and should always
be attempted when the uterine walls are lax.  Fritsch reports
successes  of this kind, and I myself remember one  instance in
which I succeeded in turning the child on the feet by external
manipulation  twelve  hours after the discharge of  the waters.
In this case, I held down  the  breech with  one hand, passed
two fingers of the other  into the vagina, seized the feet and
extracted  the child,   The size of the  child  will materially
influence the practicability of this maneuvre, which, of course,
will more easily succeed with a small than a large child.  But
the child  must be  living and  possess the requisite amount of
resistance; if the child be dead, it is easier  to turn a large
than a small child.
   One paramount advantage of version  by external manipula-
tion is the rectification  of a  malposition without the always
more or  less  hazardous passage of the whole hand into the
uterus.   Whenever  we  can avoid  the  possible injury of the
endometrium, or  the introduction of septic matter into the
uterus, we should always  do  so, if another method presents
itself for  attaining our object.  Another scarcely  less impor-
tant advantage is the conversion of the transverse position into
a  cephalic  presentation  (internal  version being generally,
from necessity, podalic), that is, changing a position in which
a mature, living fetus can  ordinarily not  be born, into a natu-
ral one.   Not only the safety of the mother, but also that of
the child, is, therefore, enhanced by external version.
   As by internal manipulation, so may the position  be changed
by external version to a head or breech.   Practically, cephalic
version is, as a rule, the only one to be advised in the cases in
which external version is feasible, for the reason that we wish
to bring about a normal position and a natural labor, and that
in such cases there is no necessity for hastening delivery.
   Whenever delivery should be rapidly effected, we would not
trust to the efforts of nature, but perform internal podalic ver-
sion and extraction at once.
   Judications.—Whenever during the last month of gestation,
or during labor before the rupture of the membranes and fix-
ation of  the presenting part, examination reveals a transverse
position of  the fetus, the attempt should be made to  convert 
84       Munde : Diagnosis and  Treatment of

the  abnormal position into one of the head by external mani-
pulation.  Should palpation show that, even after the discharge
of the liquor  amnii, the child  is but loosely grasped by the
uterine walls, a like endeavor should be made.   The  trial can
do no possible damage, if carefully employed, and may suc-
ceed even hours after the evacuation of the waters.   During
gestation the  measure  will usually be  futile, the  fetus soon
resuming its abnormal position; in that case it should be re-
peated, and particular directions left by the physician  that he
be sent for at the first sign of  labor.  As it  occasionally hap-
pens that the membranes  rupture unexpectedly before notice-
able pains have occurred and before the os is dilated,  it is  ad-
visable to caution the patient to send for her physician as soon
as either pains  set in or water comes  away.  By not antici-
pating such an occurrence, and therefore omitting to give other
directions than to be scnr, for when pains came on, it happened
to me several years ago that. I was not sent for until twelve
hours after the waters had burst, when  the first distinct pains
showed themselves.  In consequence, I found the child closely
wrapped in the uterus, all the  liquor amnii drained away, ex-
ternal version impossible, and myself compelled to perform a
very difficult internal version.
  Following in the lead of Mattei and Hegar, Pinard1 has recom-
mended the conversion of every breech into a  head presenta-
tion by external version.  Although his view is not shared by
the majority of writers, it  is in my opinion unquestionably
good practice  to endeavor to avoid the  anxiety to mother and
physician, and the danger to the child always accompanying a
presentation of  the  inferior extremity (collection of various
authors, mortality of mothers, 3 per cent; children, 22 per cent),
whenever the presentation is detected sufficiently late in preg-
nancy or early in labor to render its conversion into a head
presentation useful or practicable.  That it is likely to be rather
more difficult than in a transverse position should not deter us
from making the attempt.   The breech  once fixed in the pelvic
brim, or  the  liquor amnii discharged, there will be very little
prospect of our being able  to dislodge and  press up the  pre-
senting  part.   Those cases in which the  head, in transverse
positions, shows a spontaneous  tendency to glide toward  the
                           1 L. c. 
        Obstetric Cases by External Manipulation.    85

pelvic brim—oblique positions;   or  the  presenting  breecli
rests on the ilio-pectineal line; or the  feet present, instead of
the breech;  or  there is an abundance of liquor amnii, will
prove  specially  favorable  for external  version, as is  also
the case with a second twin child.  Oases  of contracted pelvis
of a moderate degree form  an exception to the rule of cephalic
version.   In these cases it is generally considered  safer to turn
on  the  breech or feet, as it has  been demonstrated that an
after-coming head, being shaped like a wedge, will usually pass
through a narrow pelvis more readily than the broad  vertex of
a presenting head.
   Counter indications.—The only actual counterindication to
the attempt of external version is  the necessity of a rapid ter-
mination of the  labor. Tenderness, thickness or tension  of the
abdominal walls, the  small  amount or discharge of the  liquor
amnii, fixation of the presenting part,  unusual size or death of
the child, are not properly  counterindications  to  the attempt,
but rather obstacles to the success of the operation, which may
occasionally be overcome.
  That  I do not consider a breech presentation a counterindi-
cation to  external cephalic version, whenever the version can
be safely performed,  I have already stated.
   Operation.—An accurate knowledge of  the exact position of
the child is absolutely indispensable to the rational  perform-
ance of external version.   This  knowledge can  be  best, and
often only, acquired by palpation and auscultation, as described
in Part  I.  In transverse positions, indagation, at the time ex-
ternal version is feasible, usually shows us merely the absence
of a presenting part, but does not tell us on which side the
head lies or whether  the presentation  is oblique or transverse.
As already stated, the operation may be performed at any time
during the la'st month of pregnancy, and during labor, so long
as the child is not too firmly grasped by the uterine walls.  But
the time of election for the operation is during the first stage of
labor, before the membranes have ruptured,  and  when  the os
uteri is  approaching complete dilatation.
  The physician having diagnosed the position of the child, and
ascertained particularly the whereabouts of its head and breech,
proceeds to perform version in  the following manner: The
woman being placed in the  position on her back employed for 
86       Munde: Diagnosis and Treatment of

palpation (see p. 20), with empty bladder and rectum, the opera-
tor stands  at her side (choosing preferably the side on which
the breech  is situated, in order to secure the greatest  amount
of purchase on the  two fetal extremities), and placing one open
hand on the abdomen over the head of the child, the other over
the breech, grasps them gently, but firmly, and endeavors by a
sliding, pushing motion to  direct them toward the  desired
point, the head downward, the breech upward.   In doing so,
he will usually be obliged to  press deeply into the abdomino-
uterine wall and, as it were, push it in  the desired direction.
Frequently, deep frictions in opposite directions over the head
and breech are required to dislodge  the parts  and help change
the shape  of  the uterine cavity to the  normal  longitudinal
ovoid.   Thus, if  the presentation is a I. transverse, 1st sub-
division, the head in the left iliac fossa, the operator stands on
the right side of the patient, places his  right hand  over  the
head of the fetus, his left over the breech, and while he pushes
the breech  up toward the fundus, presses the  head down into
the pelvic brim.   If labor have already commenced,  of course
this is done only between the pains, during which the  handa
hold  the two fetal antipodes firmly  fixed  in whatever position 
       Obstetric Cases by External Manipulation.    87

they may have been moved.  The pains themselves, by contract-
ing the uterine walls  around the child, aid in correcting and
fixing  the  position, when once rectification has begun.  It is
very probable, as Fritsch says, that at first the whole uterus is
pushed up with the  breech, while the head seeks a central sup-
port in the brim of  the pelvis; as soon as  this is  gained, the
force is transmitted to the breech,  which then assumes its nor-
mal antipodal position at  the fundus.   These manipulations
must be continued until  either the purpose is obtained, or its
impracticability demonstrated.  Occasionally  an attempt made
at one period fails, and after an interval succeeds.
  When the rectification of the position has been confirmed by
a vaginal  examination (during which  the  head is firmly held
down by the hand of an assistant) and the  head is felt in the
pelvic brim, the woman is directed to  lie on the side where the
head formerly was, and a firm pillow may be applied over the
ilio-lumbar region on that side, to prevent  the head from again
slipping into the iliac fossa.  Pinard in his recent work recom-
mends a peculiarly padded abdominal bandage for this purpose,
and claims to have  secured the  retention  of  the head in the
pelvic brim by this means, even when the  woman was up and
about.  In the review of Pinard's book already referred to, I
find it stated that he rectifies the position as early as the eighth
month,  and at once applies his bandage, even though the head
be still above  the  brim.   It  is spoken of as  " une sorte  de 
88       Munde: Diagnosis and Treatment of

ceinture" (Fig. 7).   The pressure by it is gradually increased,
and when the head is fixed, it may be removed.  It is said to
give no inconvenience, and the theoretical objection advanced
by Tarnier, that the compression exerted by it might  predis-
pose to eclampsia, is disproved by Pinard himself and  the
reviewer, Thevenot, who sought for albumen in  the urine of
several  women who had worn the bandage from  twelve to
fourteen days, and found no trace of it.   The efficiency of the
supporter was demonstrated by Pinard in twenty-six cases.
   I certainly have found cushions and pillows ineffectual, unless
the proper lateral decubitus was employed at the same time;
and even  then the head required to be pushed  down  repeat-
edly and  held there before I could be sure of its fixation by
the pains.  Ellinger' doubtless gives the most effectual means
of keeping the head down, when he insists on its being held
by the hand of an assistant until the uterine contractions force
it into the pelvic brim, or the  membranes rupture, or the os is
sufficiently  dilated to allow of their  being  ruptured;  such
an assistant can be found in any intelligent person, the hus-
band, nurse, or female friend; all that is required being sim-
ply to  exert  steady downward pressure over  the hypogastric
region.   Of course, his  remarks apply only to the first stage
of labor.  When  the  os is sufficiently dilated,  that  is, at
least one-half, the best means of  fixing the  head permanently
are to rupture the membranes.  Until the  head has  become
firmly engaged in the pelvic cavity,  the woman should  occupy
the lateral  decubitus,  as above stated, on  the side  where
the head  formerly was.  To  avoid possible prolapse  of the
funis, the membranes should be ruptured during the interval
between the pains, and the head then fixed  by exiting uterine
contractions by frictions of the fundus, or, in default of these,
by steady downward pressure on the breech of the child.   Once
fixed, the  woman assumes the lateral decubitus corresponding
to the occiput of the child.  Occasionally, in cases of extreme
mobility of the fetus, and in oblique positions,  the same lateral
decubitus may alone succeed in restoring  the longitudinal posi-
tion of the child.   Fritsch2 mentions a case where he saw a first
face presentation (forehead left) change voluntarily to, and the
child born in, an L. O. A. presentation, when the woman  was
laid on her left side.
              1 L. c.             2 L. c, p. 154. 
       Obstetric  Cases by External Manipulation.    89

  The conversion of a breech into a head presentation differs
only from that  described, in  that it may be necessary to  lift
the breech out of the pelvic  brim with one hand, before  the
head  and shoulders will yield to the downward pressure of the
other hand.
  Podalic version by external manipulation can  be indicated
only in cases where the child  is very movable,  the  os but very
slightly dilated, and the inferior extremity lower in the uterine
cavity than the head, the  membranes being intact or not; such
cases are, particularly, the early stages of placenta previa, when
it may be desirable or imperative to use the thighs and breech
of the child  as a hemostatic  or wedge.  It is this class of
cases to which the Wright-Braxton Hicks method  is  peculiarly
applicable.1
  The version once completed,  the labor is conducted  on  pre-
cisely  the same principles as  those  governing  an ordinary
presentation  of the kind.

     2.  Conversion of a Face into a Vertex Presentation.
  From  Osiander and Baudelocque  down, various obstetric
authors (chiefly Cazeaux  and Hodge) have recommended  the
conversion of face into  vertex presentation by internal manipu-
lations, passing two or more fingers into the cervix  after  rup-
ture of the membranes, and first pushing up the chin, and then
rapidly grasping and drawing down the  occiput.  While recent
writers, of such prominence as  Scanzoni and Schroeder, do not
mention this maneuvre at all, others, like  Barnes, refer only to
acting on the chin as a fulcrum, with two lingers in the cervix
during the pains, in order to  secure a  depression of the vertex;
and others again, like Playfair,  Leishman, and   Spiegelberg,
while briefly enumerating the intrauterine manipulations above
referred to, express doubts as to their  facility  and safety,  and
think that (with the exception of the early stage in very favor-
able cases) internal podalic  version would be scarcely more
difficult  and  hurtful, and  a  decidedly more certain  means of
delivery.   While the older authors started from the idea  that
face presentations were in themselves  dangerous, and  should

  1  I do not describe this method here, because I have briefly pointed out
its features in the historical sketch in Part I., and because, being a com-
bined maneuvre, it really is not in the scope of this paper. 
90       Munde : Diagnosis and Treatment of

always be converted into  vertex, all modern obstetricians are
fully aware that, as in breech, so may a living child be readily
born in a face presentation, by the unaided efforts of Nature.
But statistics  show us that, while  in  vertex  presentations  5
per cent of the children, and  scarcely £ per cent of mothers
die (Pinard says, only 2 per cent of children, and £ per cent of
mothers), in face presentations the mortality  runs as high as
13 per cent of children and 6 per cent of mothers.1  Evidently,
the length of the labor, the pressure on the head and neck of the
child  and the  soft parts of the mother, exert their evil influence
on both, not to speak of the defects of rotation and extension
(chin  backwards; and  brow presentations), and  consequently
instrumental deliveries frequently occur in these cases.
  To diminish this mortality, and at the same time avoid the
injurious and  often ineffectual internal manipulations recom-
mended for the purpose, the ingenious  brain of  Prof.  Schatz,
of Rostock, has  devised a method of correcting the presentation
by purely external efforts,2 a method of which  Spiegelberg, in
his recent excellent work  on Obstetrics, says : " The only relia-
ble plan of rectifying a face presentation  is that by external
manipulations, as described by  Schatz, which  is well worth
consideration."
  Schatz says verbatim :  " The conversion of a face to a vertex
presentation, by purely external manipulations, should be under-
taken chiefly in  the first stage of labor (exceptionally, perhaps,
also during pregnancy), and is  intended to avoid the dangers
of face presentations,  without incurring inconvenience or danger
to mother and child."
  The method is as follows  : Above all, the operator must be
proficient in external obstetric examination,  and be able to
diagnose easily and positively every projecting portion of the
child, and recognize the face presentation by its protruding hard
forehead on one side, and  the broad resistance of breast and soft
projection  of shoulder on  the other (see Part I., p. 39).   In the
interval between the pains, the operator seizes the shoulder and
breast of the child with  one hand, and pushes  both upwards
and to the side where the back lies (Fig. 8, i.  e., the same
side towards  which  the  brow points,  left in  I., right in II.
presentation); as soon as breast and shoulder have been brought
  1 Winckel: Pathologie  der Geburt, 1869.    2 Arch, fur Gyn., 5, 187:3. 
        Obstetric Cases by External Manipulation.    91

into the long axis of the fetus, the pressure is directed no
longer upwards, but towards the back of the child (Fig. 9), at
the same time the other hand firmly grasps the fundus uteri with
the breech, and pushes it towards the side to which the  thorax
points ;  but care must be taken not to antagonize the direction
of the first hand,  but rather  press perpendicularly towards it
(Fig.  9) ;  and later,  when the  shoulder is in  the long  fetal
ovoid, parallel to it, but in the opposite  direction.   Then the
pressure of the second hand should  be  directed  laterally and
downwards, or directly downwards  (Fig. 10), in order to re-
move the thorax and shoulder as far as possible from  the  long
fetal axis to the side where the  back lies.   Thus, in the pre-
Fl<>- 8.                Fig. 9.             Fig. 10.
sentation  shown by the diagrams, the II. face, the shoulder
and thorax are first pushed upwards and to the  right,  then to
the right; then with the left hand the breech is pushed to the
left and downwards, and finally straight downwards.  In case
the brow should again seek to slip upwards on the (in this case^
right) ilio-pectineal line, the hand of an assistant must supply
the left lateral pelvic wall, and by pressure prevent this  evasion.
The accompanying three diagrams, taken from Schatz's article,
will illustrate  the. mechanism of each step of this maneuvre.
  The great advantage  of this method is, that it can be under-
taken before the rupture of the  membranes, while the face is
still at the brim ;  and that, if it fails, it has at all events done
no damage.  Schatz relates, in  detail,  one case  in  which this 
 92       Munde: Diagnosis and  Treatment of

 theoretically devised plan succeeded perfectly.  Fritsch ' reports
 another instance in which an attempt at conversion of a second
 face into a vertex presentation by external and internal mani-
 pulations after the rupture of the membranes failed ; but a
 second attempt by the external method  of  Schatz succeeded
 completely.  A slight aid which he gave to  the rotation with
 a finger of the other  hand  in the  cervix, Fritsch thinks not
 essential to the success of the operation, and cites  the case as
 an  evidence  of its utility, even in difficult cases ; he thinks it
 should be  practised more frequently.  One great obstacle is
 tension or obesity of the abdominal walls.  Welponer, assistant
 to Prof. Carl Braun, reports2  a  third case (so far as  I  know,
 these are the only three published) of a primipara with a justo-
 minor pelvis, in which a 1. face presentation was at the fourth
 attempt rapidly  changed to a L.  O. A. position, the mem-
 branes rupturing at the same moment.  The child was born
 spontaneously five hours later in a R.  O.  A.  position, the head
 having rotated.
   Having  no experience with this method, I give it on the
 representation of such reliable obstetricians as  Schatz,  Fritsch,
 and Welponer, believing that it is not familiar to the profes-
 sion in this country.

              B.  THE EXPRESSION OF  THE FETUS.
  It has already been  mentioned,  in the historical part of this
 paper, that manual  expression of the child was known to the
 ancient Romans, the Arabians, and the obstetricians  of the
 middle ages.   But after the  sixteenth  century  it  appeared to
 have fallen into disuse with civilized  nations.   Among semi-
civilized and  savage peoples, however, it  constituted and still
constitutes the chief active interference  employed. Thus, among
the Japanese, Siamese, American Indians (Diggers 3),  Mexi-
can Indians, Kalmucks, methodical external pressure by means
of the arms or bandages,  or  kneading  the abdomen with the
hand, sitting  on it, or even treading on it  with  the  naked feet
(Mexicans), is still in common use.
  From time immemorial, friction of  the abdominal  parietes
during tedious labor has been employed as  a  stimulant  to
          1 L. c, p. 157.          2Arch.  f. Gyn., XI., 2.
          3 Bost. Gyn. Soc. Trans., 1870, Vol. III. 
       Obstetric Cases by External Manipulation.     93

the regular uterine contractions, and has proved  itself a safe
and efficient  auxiliary, safer and more prompt than ergot or
other oxytocics, and more  effectual than the hot bath, cold
sponging, or active motion.   It is a practice familiar to every
nurse or  widwife,  and  probably made  use of to  a greater
or lesser degree in  the  majority of labors.   It is particularly
useful and effective at the close of the labor, etc.  By exciting
or increasing uterine contractions, the normal expulsive force of
the uterus is increased,  and  abdominal friction, therefore, must
be considered merely as an  oxytocic, a promoter of the natural
expulsive power of the uterus.  Expression of the  whole or
part of the fetus is, however, a totally different thing.  It was
designed by its advocates to entirely supply the place of uterine
contractions, the fetus being literally pressed out  of  a passive
uterus by manual  pressure  alone.  Besides, its use  was to be
extended to  intensifying feeble contractions by the rhythmic
compression  of the fundus uteri, in which capacity it acts pre-
cisely like the frictions mentioned above.
   The first to revive the practice  of  propelling the child by
manual  pressure was Ritgen,1 of  Giessen, who, in a paper
entitled  " Delivery by  Pressure instead of Traction,"  based
entirely  on theoretical  reasoning, put  and  answered the very
pertinent question, " Why do we always drag, and never  push,
out the fetus ?" by  arguing  that the force  exerted by  Nature
in the expulsion of the  child is one of  expression,  a vis a tergo,
while that employed in the universal means  of  instrumental
delivery, the forceps, is a vis  a fronte, therefore contrary to
Nature.   On the strength of this reasoning he recommended
that the  fetus be expelled by pressure  on its upper  extremity
through  the abdomino-uterine  walls.   Nothing came  of this
advice, however, until Kristeller,2 of Berlin, in 1867, reported  a
series of cases in which, by  systematic rhythmical pressure on
the fundus uteri, he had succeeded in effecting  the delivery of
the child.
   By means of a dynamometric forceps of his  own invention,
he demonstrated that the  force necessary to extract  a  head
that has lain immovable for hours is often not more than 5-8

  1 Von RhVen, " Ueber das Entbinden durch Druck, statt Zug," Monats-
schr. f. Geb., 8, 1856.
  * Berl. Klin. Wochnschr., No.  6, 1867, and Mon. f. Geb., 29. 
94       Munde:  Diagnosis and Treatment of

pounds, and concluded therefrom that the force required to
express the same  head could not be  very great.  According
to Poppel's ' previous experiments, the force needed to effect
an easy delivery does not exceed four pounds.  The propulsive
force necessary to  expel a child must equal its weight; adding
about the same amount for friction, an  estimate  can thus be
had of the average amount of force required to express a child
from the uterus, i. e.,  about twenty pounds.   Kristeller did
not restrict  his method to head presentations, but used it to
expedite the delivery of the shoulders  after expulsion of the
head, of the breech or  shoulders and head  in head-last labors,
and to  aid the forceps or hands in extraction.
  The  thoroughness of Kristeller's article, and  the explicit
directions based on practial  experience  given  by him for the
performance of the operation, induced numerous  obstetricians
to give it a trial, and commendatory reports by Ploss,2  Abegg,a
and Playfair4 soon appeared in the journals.  In the last edition
of his text-book,6 Playfair still expresses himself very favorably
of the operation,  and  says  that "its  effects  are often very
remarkable, especially  in women of slight build, where there
is but  little adipose tissue  in the  abdominal  walls, and  not
much resistance in the pelvic tissues." Schroeder,6 Barnes,7 and
Spiegelberg8 approve of the method, and  admit  its efficiency
in many cases where the forceps are commonly used, and par-
ticularly in head-last labors.
   Within the past year a new advocate for expression in head
presentations has arisen in the person of Prof. Bidder,  of St.
Petersburg, who reports9 81 cases in which he employed  it suc-
cessfully.  As regards puerperal convalescence, its results sur-
passed those obtained  in  simple, uncomplicated forceps de-
liveries.   Of the 81 women delivered by expression, 34 made a
perfectly normal  convalescence, 38 showed slight deviations
from normality, 7  were very ill, and 2 died.  Of 75 simple for-
ceps cases (the head being low down in  all), 13 made a normal
convalescence, 34  were slightly ill, 20  seriously,  and 8  died.
Prof. Bidder advises the method  to be used as  soon  as the
  'Mon. f.  Geb., 1863.
  'Zeitschr. f. Med. Chir. u. Geb., 1867.    6Lehrb. d. Geb., 1876.
  3Zur.  Geb. u. Gyn., Berlin, 1868.  ' Obstetric Operations, 3d ed., 1876.
  4 Lancet, 1870.                       8 Lehrb. d. Geb., 1878.
  sMidwifery, 2d ed., 1878.     9Zeitschr. f. Geb. u. Gyn., III.,  3, 1879. 
       Obstetric Cases by External Manipulation.     9

membranes are ruptured and the head has engaged in the di-
lated  os.   He thinks it  less liable to cause inflammatory or
septicemic trouble than  the forceps,  as it produces less local
injury.   He considers that the method has fallen into disrepute
merely because it has not been properly employed.
  As already stated, the manual expression of the fetus attains
its object in two ways:   1. Direct compression of the uterine
cavity ;  2. Excitation of  uterine contractions.  The first of
these means is analogous to the  natural compression of  the
uterus by  the abdominal  muscles during labor, the  so-called
" bearing-down," and supplies the place of this factor in delivery.
The efficacy of this auxiliary during the closing phases of  the
second or expulsive stage of labor is familiar to all who have
ever intelligently assisted at a labor.   Another effect of mus-
cular, and therefore also of manual, pressure is the rectification
of the usual dextral inclination of the uterus, whereby the pre-
senting part is brought more into  the axis of  the  pelvic  canal
and its mechanism facilitated.
  Advantages and Indications.—Kristeller claims the follow-
ing advantages for fetal  expression :   1.  It shortens the dura-
tion of labor ; 2. The normal position of the child is preserved;
3. The application of the forceps  is frequently rendered unne-
cessary ;  4. It thereby aids in protecting  the perineum;  5. It
facilitates and hastens the nevertheless often necessary forceps
delivery;  6. It prevents the upward extension of the arms in
breech deliveries;  7. It  hastens the expulsion of the shoulders
after birth of the head.
  Indispensable conditions for  the method are: 1. A vertical
position of the child, either in head or breech presentation ; and,
2. The absence of any inflammatory affection or unusual hyper-
esthesia of the abdomen; 3. No sign of a twin pregnancy.
  The indications, according to the authors of the method, are:
1. To expel the ovum  in  abortion;  2. The induction of pre-
mature labor ; 3.  In molar pregnancy ; 4. The necessity of a
rapid termination of the labor, even though the pains be good,
as in placenta previa; 5. Weak or deficient labor pains, in nor-
mal pelves, up  to  the expulsion  of the shoulders; 6. As an
aid to the delivery  of  the head  in  head-last cases,  together
with podalic extraction; 7. As an aid to  the  delivery of  the
head in forceps cases. 
96       Munde :  Diagnosis and Treatment of

  Of these indications, the second and fifth seem to us rather
problematical : there are certainly  better, quicker, and less
painful  methods  of inducing  premature labor than  by the
systematic persistent compression of the uterus ; and if we need
to complete delivery so rapidly as frequently becomes necessary
in placenta previa, we would scarcely resort to the always more
or less tedious and uncertain measure of manual expression of
the child, unless indeed the membranes be ruptured and the os
uteri so widely dilated as to permit the presenting part to be
pushed through it, and thus act as  an immediate  hemostatic.
Indication  1 will  also be found doubtful, inasmuch as but few
women will bear the amount of pressure  required to squeeze
an ovum, or part of one, out of the uterus;  at least those women
on whom I have tried it, objected very decidedly to its continu-
ance.  The same holds good for molar pregnancy, although the
larger the uterine  cavity, and  therefore the thinner its walls,
the easier will  their compression and the expression of their
contents usually be.  With the ardor of an inventor, Kristeller
has, of course, endeavored to extend  the  limits of  his method
as far as possible,  and has sought to  apply it as a rule in cases
where  its success  would be  a rare exception.   He  found an
enthusiastic follower in Dr.  Abegg, Sanitary Councillor in
Danzig, who writes 1: " What the bimanual method of Braxton
Hicks is for abnormal presentations, that is Kristellers opera-
tion for natural  positions—the  safest,  most  efficient,  most
natural, and therefore most rational."
  The three last  indications, on the other hand, admit of no
dispute.   I will discuss them separately :
  Indication 5, Weak or deficient Labor Pains.   Playfair says :
" It is not, however, as replacing absent pains, but as a  means
of intensifying and prolonging the effects of deficient and feeble
ones, that  pressure finds its best application. .  . . The cases
suitable for its application are those in which the head or breech
is in the pelvic cavity, and the delay  is simply due to a want of
sufficiently strong  expulsive  action."  Barnes  and Schroeder
express substantially the same opinion.
  That steady pressure on the fundus uteri will, when theosis
thoroughly dilated,  advance the presenting part  toward the
floor and outlet of the pelvis  can  readily be demonstrated in
                          ' L. c. 
       Obstetric  Cases by External Manipulation.    97

any suitable case ; to be sure, the presenting part recedes when
the pressure ceases, but  with each  succeeding pressure  the
advance will be slighly greater, until, everything being favor-
able, the vulva  is distended and the part  expelled.   Besides
the indispensable conditions to the success of expression men-
tioned above (vertical position of child and  absence of ab-
dominal tenderness), there are four other conditions which are
quite as essential, viz.: a normally shaped pelvic canal, a well
dilated os uteri, a  ruptured bag of waters, and, finally, a low
position of the presenting part.
  Partial dilatation  of the os and the persistence of the mem-
branes will not absolutely contraindicate the operation; but,
to be  effectual in such cases, it would have to be continued so
long as to become exceedingly painful to the patient and ex-
hausting to the operator.
  All authors agree that the  cases particularly suitable to Kri-
steller's method are those in which the presenting part rests on
the floor of the  pelvis or even presses against  the  perineum,
and for want of efficient pains  does not advance, or  advances
but to recede.   A very large percentage of primiparous labors
belong to  this category.   In these cases,  there are  but two
other means left to the medical attendant—the production of a
vis a tergo by internal oxytocics, notably ergot (the well-known
dangers of which should absolutely prohibit its use at any time
between the rupture of the membranes and the birth of the
presenting part),  and  the  forceps.   It  is in these  cases
that the so-called " pocket" forceps, so much lauded by many
physicians, come into play, and with one or two gentle tractions
overcome the obstacle.   In  such cases Kristeller claims, and,
no doubt, justly, for he is supported by eminent authority, that
three or four, or more, intermittent, firm, downward compres-
sions  of  the'body  of the uterus will accomplish the expulsion
of the head and shoulders; and that this is accomplished with-
out special pain or  discomfort to  the  mother.   Playfair  and
Abegg both report  precisely such cases, and the former says
that, out of the large number of  cases in which he has used it,
he has never seen  one in which it proved hurtful.
   In  breech  presentations I  believe  the method to be  vastly
more valuable than  in head  labors, and I refer particularly to
cases in  which the breech becomes impacted in the pelvis in 
98        Munde:  Diagnosis and Treatment of

such a manner that extraction by fingers or instruments is  a
matter of impossibility or great difficulty.  Here the forceps
have been applied successfully, but their introduction is fre-
quently hazardous, and their grasp often an insecure  one.  If
now by expression we can succeed in reaching the flexure  of
the thigh, the extraction becomes like any ordinary one.
  The advantages claimed by Kristeller for his method are not
to be denied, to a certain extent;  but as regards the range of
application of  expression, I think he goes decidedly  too far.
When his paper appeared, I had abundant opportunity to test
the method,  and found it both painful  to the woman and
fatiguing to myself, in all cases where  the head did not rest
directly on the perineum.   While  I have very  frequently ex-
pressed the head so situated with but little trouble, as, of course,
every experienced accoucheur has done, I confess  I should much
rather give a few whiffs of chloroform and  extract the head
with a half-dozen easy forceps-tractions, than endeavor to ex-
press  it when it  is still  situated  in the cavity  of the pelvis.
The typical cases for expression are  those, so frequently met
with in primiparae, in which with each light pain  the presenting
part bulges forward the perineum and perhaps distends  the
vulva, only to recede again and again, until after several hours
of  this delay the  woman becomes  exhausted  and  demands
relief.   With the breech and  after-coming head the matter is
quite different.  Still I am disposed to agree substantially with
the rule laid down by Abegg, that "whenever  there  is delay
in the  expulsion of the head, Kristeller's expression should be
tried, before applying the forceps."   Should it fail, it will at all
events serve  to push the head  deeper and fix it more firmly in
the pelvic cavity, and thus facilitate its extraction with forceps.
   The Counter indications to manual expression  have  already
been referred to in the preceding section ; they may briefly be
enumerated  as follows:  Fetal position other  than  head  or
breech; imperfect dilatation of os ; persistence of membranes;
high stand of presenting part; contracted pelvis, except expres-
sion of after- coming head in the  minor degrees; inflammation
or hyperesthesia of utero-abdominal tissues; unusual tension or
obesity of abdominal wall; necessity for rapid delivery.
   Indication 6.  Expression   as  an aid  to  the delivery  by
manual extraction of the head, in  head-last cases.  The expres- 
       Obstetric  Cases by External Manipulation.    99

sion of the head  during  its delivery by  manual traction on
the body has been in use since the introduction of podalic ver-
sion and  extraction,'and was recommend* <1 by Celsus at  the
time of Augustus, and  after the revival of obstetric medicine
from the  abyss  of the middle  ages, by Pare (1560), later by
Pugh (1753), and  Wigand (1800), and  in our own time by C.
Braun, E. Martin, and all writers on obstetrics.  It is a mea-
sure of the greatest utility  and importance, and  may enable us
both to  avoid the forceps  (always a difficult and  often an un-
successful operation in the haste of the moment), and save the
life of the child at  the  critical period when its cord is being
compressed between the impacted head and the pelvic brim.
   The valuable influence of expression as an aid to the delivery
of  the breech and body of the fetus has already been pointed
out.  Kristeller reports a case in which he expressed the shoul-
ders and head (the rest of  the body having already been born)
by five  compressions in two  minutes.   But Schroeder  very
properly remarks  that this could have been done by  traction in
the ordinary manner in one-half a minute, and that sole reli-
ance should, therefore, not be placed on expression.  It is as an
aid to the passage of the after-coming head through the pelvis
that it is of the greatest value, particularly in cases where there
are no uterine contractions whatever, and especially where there
is a disproportion of minor degree between the head and pelvic
canal.  In this latter class of cases, moderate pelvic contraction,
the method has recently again  found  an able and enthusiastic
advocate in Dr. William  Goodell, of  Philadelphia, who in a
paper on " Turning in  Pelves Narrowed in  the  Conjugate
 Diameter,"' relates a number of cases in which the greatest
assistance was rendered in the  manual extraction of the head
 by suprapubic  pressure exerted by the hands of an assistant,
the children being extracted alive.  In one case, the true con-
 jugate measured 2.82 inches, and the child weighed  8 lbs. 6 oz.
 In another case the c. v. measured between 3  and 3^ inches,
 and the child weighed 5 lbs. 6  oz.  Another, c. v. 3.32 inches,
 child 7 lbs. 10 oz., and so on.  Dr. Goodell sums up his experi-
 ence by  saying that " by  the  conjoint use of two very nearly
 equal forces, viz., that of  suprapubic pressure by the hands  of
 an assistant, and  that of traction on the body of the child by
                  1 Am. Jour. Obst., VIII., 1875-6. 
100     Munbe : Diagnosis and Treatment of

the physician, there can be safely  brought to bear upon the
hind-coming head an extractive force fully as great as that by
the forceps on the fore-coming head. Thus in case VIII., Dr.
Roberts and myself together exerted a force of certainly not
less  than 200 pounds.  In  case IX., Dr. J.  F. Wilson's vis a
tergo and my  vis a fronte must, unitedly, have equalled fully
150 pounds.   For want of a better place, let me here say that
the supra-pubic pressure  possesses  another helpful  property
besides that of propulsion.   If directed downward  and back-
ward, as it should be, it flattens the head literally against the
sharp edge  of the promontory, and  aids in the process  of
moulding."
   The immense  value of expression is shown by these state-
ments  of so exact  and reliable an  observer  as Dr. Goodell;
another advantage, also mentioned by him, is the possibility of
directing the head so that its  largest diameter enters into the
largest part of the contracted pelvis, that is, the broad occiput
into the lateral portion of the pelvis, and  the small bitemporal
diameter into  the narrow conjugate.
   This suprapubic pressure may be  exerted with  considerable
force ; but there is a limit to this, for, aside from a possible in-
jury to the soft parts of the mother,  the child's head may be so
firmly  compressed against the pelvic brim as to  cause  contu-
sion and fracture of the skull and intracranial effusion.  I have
a recollection of seeing a case reported of fracture of the skull
produced in this manner (I forget the journal), and one  lately
of intermeningeal apoplexy,  occurring  in a  labor witn con-
tracted pelvis  (3 inches conj. vera).1
   Indication,!.  Expression  as an aid to the delivery of the
head in forceps cases.—It is an established rule in forceps ex-
tractions to make traction only during the  pains, if, indeed,
there be any present.  The reason for this is obvious, viz., to
secure the vis  a  tergo force of the  uterine  contraction, as an
aid to the vis a fronte force of  the forceps.  Precisely what is
done by the contractions, it is designed  to do by methodical
pressure on the fundus uteri, when they are absent or deficient ;
and it is advisable to exercise the pressure even when the pains
are active.
  1 Kucher : The Forceps to the After-coming Head.  Wiener Med. Wo-
chenschr., Aug.  9th, 1879. 
       Obstetric Cases by External Manipulation.    101

  A  most efficient method for preserving the  perineum in
primiparae, to be recommended in all such forceps cases where
a delay of ten to fifteen minutes in delivery  is  not counter-
indicated, is to remove the forceps as soon as the occiput pro-
trudes under the  pubic arch, apply expression  until the  chin
can be reached by the fingers in the rectum ; and then gently
and  gradually aid the extension of the  head,  until  the  face
slips over the fourchette.   This maneuvre may occupy fifteen
minutes  or longer, and beginners are particularly  cautioned
not to hasten the process, and to exert only the  very gentlest
traction  on the chin with  the intra-rectal fingers,  while  sup-
porting  and even repelling the occiput with the other hand,
until the perineum is thoroughly distended.
                           Fig. 11.

  After what has been said in the previous  section, it is evi-
dent that  supra-pubic  pressure in the  rare  cases  of  forceps
extraction  of  an after-coming head is of even greater impor-
tance than  in  the case of the presenting  head.1
   Operation.—Kristeller describes it as follows :2 " The patient
being in the dorsal position, the operator maps out the uterus and

  1 Schroeder in his Obstetrics, and Kucher (1.  c.) both proscribe the use
of the  forceps  in head-last cases as unnecessary and dangerous, since
manual extraction (by the methods of Veit, Smellie, Prague) is perfectly
competent to extract any  head that will pass uncrushed through the
pelvis.  I think this condemnation too sweeping ;  and certainly have
saved the lives of  several  children with the forceps so applied.  It is
chiefly indicated in a moderately contracted brim.
  2 Abegg, 1. c. 
 102      Munde: Diagnosis and  Treatment of

moves it into the axis of the pelvic'brim, if it should have deviated
to one or the other side.   He then grasps the uterus with both
hands on the  same plane, with their ulnar border directed to-
ward the pelvis, the palm  pressing on the fundus or the  sides
near by, the thumb pointed toward the median  line, and the
fingers striving to encompass  the uterus  as much as possible.
First the abdominal walls are gently rubbed against the uterus,
and then, the hands retaining  their position, slight, gradually
increasing downward  pressure is made, which is  kept up for a
time at its acme, and then gradually diminished.  The pressure
should last five to eight seconds, and be repeated at  intervals
of one-half, one, or three minutes, according to the stage of labor
and  the sensitiveness of the patient.   The points  of pressure
                          Fig. 12.
should be changed, alternating between the fundus and one of
the horns of the uterus.   The less the os is dilated, the more
should lateral  compression be made;  the more dilated and the
softer is the os, the more is the compression indicated  and the
more effectual will it be."
  The simplicity of the operation is apparent.   The necessary
conditions are  really, strength on the part of the physician, en-
durance on the part of the woman, and patience on the part of
both. 
       Obstetric  Cases by External Manipulation.   103

   1 he mode of pressure in the expression of the after-coming
head  differs  from  that described, in that firm, steady down-
ward  and backward pressure is made without intermission on
the fundus and head above the pubes, both hands being placed
close  together  over the fundus, until the face glides  over the
perineum.   In case it is desired  to press  one portion of the
head  into  a certain part of the  pelvis, the direction  of  the
pressure may require slight modification.   Of compression dur-
ing an ordinary forceps operation, it  is necessary only to say,
that it is contemporaneous with the tractions.

            C.   THE EXPRESSION OF THE PLACENTA.
   The method of removing the  placenta by manual pressure
alone, now generally known as Crede's, was not originated by
that eminent obstetrician of Leipzig, nor did he make any such
claim.  He  simply revived, systematized, and popularized an
old practice which had fallen  into oblivion, possibly  in conse-
quence, as Abegg says,1 of the reaction following the too active
doctrines  of Osiander," who in 1825 described the expression
of the placenta substantially as it is now practised:  " The ac-
coucheur (having satisfied  himself of the detachment of the
placenta) twists the cord  around  the fingers of  one hand, and
with  the other, pressing it deeply into the abdominal walls be-
hind  the uterus, seizes the  body of the uterus and moderately
compresses it.  This compression is  followed by the easy ex-
pression of the afterbirth, and  the uniform evacuation and con-
traction of the uterus."  Of  traction on the cord nothing  is
 said.   Frictions of the abdomen  are not considered by Osian-
 der as sufficient to cause expulsion of the placenta.
   Petit3 recommended compression of the uterus with one hand
 until the placenta was drawn  out by traction on the cord with
 the  other.   Duges,4  Schmitt,5  Kilian,6  Kiwisch,7 Capuron,8
 Vidart," Navas,10 and Siebold11 all advised  active friction of
 the abdomen, in connection with traction on the cord.  External
 pressure  as a  means of removing the placenta was  first used
   i L. c.           2 Entbindungskunst, 2. Bd., S.  196.
   3 Petit:  Geburtshulfe, transl. by Stark, Erfurt, 1800.
   4 Manuel d'obstetrique, Montpellier, 1840.   5 Geburtsh. Abhandl., 1820.
   6 Geburtshulfe.        'Geburtshulfe.         8 Cours d'acc., 1836.
   9 Arte de Partear, Madrid, 1785.
   io El. del Arte de Partear, Madrid, 1815.    u Geburtshulfe, 1854. 
 104      Mukde: Diagnosis and  Treatment of

 systematically by the  English obstetricians, Wallace  Johnson
 (1769), Charles White, of  Manchester (1772), and Clarke, of
 Dublin.  Still, Robert Lee,1 as late as 1844, advises "gently
 pulling from time to time on the cord," while " compressing
 and squeezing the fundus uteri."  Playfair2 quotes the general
 practice from Churchill's Theory and  Practice of Midwifery,
 " one of our most deservedly popular obstetric text-books," and
 reproduces  a diagram," contained in most obstetric works," as
 " an illustration of what ought not to be done."  Churchill
 says: " When the binder is  applied, the patient may be allowed
 to rest for a while if there  is  no flooding; after which, when
 the uterus  contracts, gentle traction may be made upon the
 funis, to  ascertain if  the placenta  be detached.  If so, and
 especially if it be in the vagina, it may be removed by continu-
 ing the traction steadily in the axis of  the upper outlet at first,
 at the same time making  pressure on the uterus."   Barnes 3
 says that Hardy and  McClintock4  "insist upon  the plan of
 causing the  uterus to contract and expel the placenta by man-
 ual compression," and  that it is  a  practice  long  familiar in
 England.   However this may be, it does not appear  to have
 been sufficiently " insisted   upon," for it certainly did not be-
 come a  universally adopted practice until  Crede in 1853,B and
 again in I860,6 described it in terms  so  clear  and words so
 warm that  it  rapidly  became popular in  Germany and soon
 made its way throughout the world.
  As there  seems to be a disposition to question Crede's claim
 to the authorship of the practice  (Dr. Barnes but recently re-
 ferred to the subject in this sense in a discussion in the Lon-
 don Obstetrical Society), I will quote Crede's words verbatim :
 " A  single  energetic contraction  of the uterus rapidly con-
 cludes the process.  I have succeeded in innumerable cases
without exception, even  with very tedious pains,  within one-
quarter  to  one-half hour after the birth of the  child,  by
gentle, gradually increased friction of the fundus uteri through
the abdominal walls, in producing an artificial and active con-
traction.  As soon as this contraction  had reached its height,
I grasped  the whole uterus  with one hand, so as  to hold  the
  1 Lee. on the Th. and Pr. of Midwifery, 1844.
  2 Midwifery, 1878.              a Obstetric Operations, 1876.
 4 Practical Midwifery, 1848.      6 Klin.  Vortr., Berlin, 1853.
  6 Mon.  f. Geb., April, 1861. 
       Obstetric Cases by External Manipulation.    105

fundus in the palm, surrounded by all five fingers, and exerted
gentle compression.   I  invariably felt the placenta slip out of
the uterus from  under my fingers, and usually with  so much
force as to be expelled from the vulva."
  The now generally adopted English method, which was in-
troduced into Germany by Spiegelberg,1 and is still advocated
by him in a modified form, differs from that of Crede, in that
no effort is made to excite  uterine contractions, but the hand
merely follows the uterus down during and after the expulsion
of the child, until the placenta is felt to leave the uterine cavity.
Playfair (1. c.) describes the process as follows:  After caution-
ing against undue haste in expressing the placenta and advis-
ing an interval of fifteen to twenty  minutes after the birth of
the child, in order  to give time  for the formation of coagula
in the uterine sinuses and for the complete detachment, of the
placenta, before  proceeding to  remove that body, he says :
" During this interval the practitioner or nurse should sit by
the bedside, with the hand on the uterus, to secure contraction
and prevent  distention; but  not kneading or forcibly  com-
pressing it.2  When we judge that a sufficient time has elapsed,
we may proceed to effect  expulsion.  For  this  purpose the
fundus should  be grasped in the hollow of the left hand, the
ulnar edge  of  the hand being  well pressed  down behind the
fundus, and when the uterus is felt to  harden, strong and  firm
pressure should be made downward and backward in the axis
of the pelvic brim.   If this maneuvre be properly carried out
and sufficiently firm  pressure made, in almost every case the
uterus may be made to expel the placenta into the bed, along
with any coagula that may be in its cavity.  .  .  . If we do
not succeed at the  first  effort, which is rarely the case, if ex-
trusion be not  attempted too soon after the birth  of the child,
we may wait until another contraction takes place, and  then
reapply the pressure.  I repeat that, after a little practice, the
placenta  may  be entirely expelled in this way  in nineteen
cases out of twenty, without even touching the cord, and the
bugbear of  retained placenta will  cease  to be  a source of
dread."
   This difference in  the two methods entitles Crede to the
priority  of having established  a systematic process for  pla-
  i Wurzburg. Med. Zeitschr., 1861, Bd. 2.         2 Italics are mine. 
106      Munde:  Diagnosis and Treatment <f

cental  expression; the English  method and that  of Spiegel-
berg, now to be described, are but subsequent modifications.*
  Spiegelberg1 describes and recommends a  method which is a
combination of and, I think, judging from personal experience,
an improvement on the other processes.  His book has not been
translated as yet,  and his practice in detail is, therefore, in all
probability unknown to the  profession here.  It includes direc-
tions prohibited by  the followers of  Crede's and the English
method, but which the eminence of Spiegelberg as a practical
obstetrician renders worthy of consideration and  belief.  I
shall, therefore, translate the respective section of his work in
full. After describing the manner in which  one hand supports
the perineum, after the expulsion of the head, while  the other
follows the fundus during its descent and  the expulsion of the
rest of the child, in order to be ready to use expression in case
of delay;  and  after advising the double ligation of the cord, in
order to  retain the  placental  blood, whereby its  expulsion is
facilitated (in  all  of  which,  and the  removal of the child, the
nurse should assist),  he proceeds :
  "In  the mean while the hand guarding the uterus has not
been removed. After the birth of the child, it devotes itself
more particularly to  the uterus, which is  first brought into the
median line, vertically to the axis of the brim. The hand then
grasps  the uterus, the ulnar border pressing in deeply  behind it,
the fundus  in the open  hand, the  thumb on the  anterior sur-
face.   When  a pain now occurs, the anterior uterine wall is
pressed against the posterior and the whole organ slightly to-
ward the  pelvic brim, this pressure being discontinued when
the  pain  cases.  If  the  pains are too scanty and too feeble,
the  fundus is rubbed and kneaded with the flat hand, until a
contraction ensues, and then pressure is made as above directed.
When  this has been  repeated  several times, the flattening of
the  uterine  body   shows  that the placenta has been  expelled
from it.   Then by means of strong downward pressure of the
whole organ, in the direction of the axis of the inlet, the whole
afterbirth can  be driven into and out of the vagina (expressio
placenta?), which maneuvre is  greatly favored by  straining on
the  part of the woman and an elevation of her sacrum.  This
expression out of the vagina is not necessary, however, very
frequently even exceedingly painful, and therefore occasionally
               1  Lehrb. der Geb., 1878 ; I., p. 190. 
       Obstetric  Cases by External Manipulation.   107

impracticable.   It is, therefore, preferable to remove the pla-
centa, when it has left the uterus, by traction on the cord, aided
by pressure on the uterus;  the traction should be backward
and downward, upward only on the extrusion of the placenta.
If  the latter does not readily yield, two  fingers  should be
passed along the cord to or near its insertion, and the placenta
pressed into the  sacral excavation, while  the fingers of the
other hand  draw the cord in the proper direction.   . . . The
extrusion of the  placenta from the vulva should  always be
slow, in order not to tear off the membrances which often are
still retained in utero, etc. .  . . This method of removing the
afterbirth is by no means identical with that known as Crede's.
While in the latter the hand is not placed  on the uterus until
after the complete expulsion of the child; and by friction, etc.,
that is, by irritating the organ, contractions are produced and
the placenta then expressed in the manner described, the method
thus being  virtually an expression of  the  afterbirth—I, after
the example of the Dublin Rotunda, lay especial stress on
speedy regular, that is, uniform, contractions of the uterus, be-
cause they produce the detachment of the placenta, which, and
not its expression, is the main point.   And while I, by constantly
watching the uterus during the whole period of its relatively
rapid evacuation, that  is, from the moment  of the  expul-
sion of the  head, follow it up and thereby irritate it mechan-
ically, I  make the contraction necessarily  accompanying its
sudden evacuation, not only energetic, but  uniform, and  thus
attain speedy detachment, and by  continual watching event-
ually prevent irregularities of contraction.   While with Crede's
method anomalies  of contraction may develop unobserved, be-
tween the expulsion of the child and the commencement of
the method, this is  impossible with mine.   To recapitulate:
Constant supervision of the uterus from the moment of expul-
sion of the head, thereby induction of general contraction and
detachment  of  the placenta—the main object; its  expression
may then follow* necessary it is not.   Indeed, it may often
be  very painful and not  seldom impracticable.   This is  also
the only and most certain prophylaxis against disturbances of
the third stage, so  far as they can be prevented."
  It is apparent from this description that Spiegelberg's meth-
od again  differs from its parent, the English, in that he allows 
108      Mund:e:  Diagnosis and Treatment of

no interval of rest between the complete expulsion of the child
and the removal of the placenta, instead of the fifteen to twenty
minutes advised by Playfair.   Barnes1  even says : " It is ' med-
dlesome ' and injurious to practise it (expression) immediately
after the  delivery of the child," and, " timely applied  ' ex-
pression'  aids  and  is aided  by natural  contractile  efforts."
LeishmanV directions conform very  closely  to  those  of  Spie-
gelberg.
  Fritsch3 advises the immediate expression of the placenta
after the birth of the child, with  no  intermission, keeping his
hand steadily on the fundus, and  compressing the uterus with
one or both hands (if one is insufficient to grasp it) during a
                          Fig. 13.
contraction  in  the axis of the  brim.   He calls this Crede's
method, although it really resembles more  that of Spiegelberg
in being continuous.   Fritsch says that, since he has practised
this plan, he has scarcely observed a case of post-par turn hem-
orrhage; and his  experience extends  over numerous normal
and more than three hundred operative deliveries.  He claims
  1 L. c, p. 522.      « Midwifery, 3d  Am. Ed., 1879.     '"» L. c, p. 330. 
       Obstetric Cases by External Manipulation.   109

that this result is due to the induction by immediate expression
of the definite puerperal contraction of the uterus, instead of
allowing the organ to  dilate and then  exciting it  to  contrac-
tion.  He does not speak of guiding the detached placenta out
by the cord.
  The method which I have been  in the habit of practising
for years is very similar to that  recommended by Spiegelberg.
While, no doubt, in my early obstetric practice  my occasional
failure to express the placenta depended  on inexperience  and
neglect to grasp the uterus thoroughly in the palm  of the hand
and direct  the  propulsive  force  downward  and  backward
(Fritsch explains the usual failure of  students in his clinic, and
the easy success of the assistant  on the same grounds), still, as
my  experience  increased, I found cases in which one hand
alone would not succeed, others in which both hands failed,
and others again in which the placenta  had evidently  left the
uterine  cavity proper, but could not be  expressed from the
vagina.   In  the last-mentioned cases I found gentle,  careful
traction on the cord of the already  detached placenta, which
was either retained in the  cervix  by the internal os, or  had
really passed partly or wholly into the vagina,  to be not only
entirely safe, but decidedly effectual  in securing its removal.
In other cases, prolonged gentle friction of the  uterus was in-
dispensable, to secure  the detachment  of the placenta, before
which  detachment  even the most forcible expressive power
was in vain.   Whether or not the placenta was detached was
readily ascertained by  the palpating hand, which  would  feel
(often the eye could see) one or  the other uterine horn project-
ing  above the other;   evidently the remainder of the uterus
was contracting, while the placental site was passive.   As soon
as the latter also contracted, the  uterus would assume a smooth,
spherical contour, and then expression  would prove effective.
But this friction, with occasional  trials  of expression, might
last fifteen minutes or more; seldom have I found it exceed
the quarter-hour.
   It is, of  course, important to  know when the  placenta is
really detached, and for this purpose  a knowledge of palpation
is essential.   I have repeatedly been  called to remove the pla-
centa, and found it loose in  the cervix or vagina, the medical 
liO      Munde: Diagnosis and Treatment of

attendant having been very properly afraid  to disobey  the
directions of themodern method, and draw on  the cord.
  I have very frequently found it much less painful to the
patient and fatiguing to the physician to  draw gently on the
cord as soon as the palpating and expressing hand shows that
the placenta  has  escaped from the cavity of  the  uterus, and
thus guide it  over the perineum, where  it is received by the
right hand and gently withdrawn with a twisting motion, so as
to make  a cord  of the  membranes,  rather than  attempt to
force the placenta out of the vagina by supra-pubic pressure.
In very many instances  I have been  able  to verify Crede's
statement as to the force  with which the placenta may be ex-
pressed;  indeed, I remember one  case in  which the  placenta
was expressed by the head midwife with such force as to strike
me, who had stepped some two feet from  the  "pony-bed," to
explain the case to the students, full in the back.  But, in my
experience, the  proportion  of cases is quite  large  in  which
gentle traction on the cord will be found a useful auxiliary.
  Briefly, my practice is as follows: When the end of the sec-
ond  stage approaches  and  the head  begins to  protrude the
perineum, the patient is turned on  her left side.   If the case
be a primipara, the nurse is instructed to exert steady down-
ward pressure on the fundus with both  hands as  soon as the
head is expelled, while I  guard the perineum  and  deliver the
head after   the  Ritgen-Goodell  method  above  described,
two  fingers of left hand in rectum,  right hand supporting
the occiput.  If she be a pluripara, I  myself follow the uterus
down with the left hand until  the child is  expelled.  The
woman  is then  again  turned on her  back, a teaspoonful of
fluid extract of ergot given, and  gentle  friction made  by the
hand on  the  fundus  until  the cord ceases to  pulsate, when
the  cord  is doubly ligated and cut,  and the child given to
the nurse; the hand  is  then (its place having been supplied
by that of the nurse during this short interval) replaced over
the  uterus, and gentle friction continued  until the uterus con-
tracts uniformly, as above  described; as soon  as this occurs,
the  uterine sphere is  grasped by the whole left hand, or if
necessary by both  hands, and gently compressed  toward the
axis of the brim; if the placenta is not then  felt to escape
(as shown  by the  immediate decrease in size of  the uterus), 
       Obstetric Cases by External Manipulation.    Ill

the friction is recommenced, and expression again tried, until
the afterbirth is expelled.   Unless it voluntarily emerges be-
tween the labia, gentle backward traction is made on the cord,
or  even  one finger and the thumb may be passed into  the
vagina, to  seize the nearest portion of the placenta, and start
it.  In no case, of course, is traction to be continued when the
attachment of the  cord is felt  to be slender or yielding.   In
such  cases,  or  if  there is  some  particular reason why  the
fingers should not be passed into  the vagina  (as,  danger of
infection),  two fingers  may be passed into the rectum and the
placenta lifted  out of  the vagina after  the  Ritgen-Goodell
method of delivering the head.
   As soon as the placenta has been  removed, gentle  steady
friction is kept up over the fundus, with occasional  expression
of  coagula,  until permanent contraction ensues, which  may
occupy half  an  hour, or, in doubtful  cases, a longer period^
Then, if necessary, a compress  is laid  over  the fundus, and a
binder applied, which latter article  is used more as  a comfort
and support  to the woman than because it is absolutely neces-
sary for  her subsequent recovery.
   The essentials of success in expressing a placenta  are:
   1. Expression only during a uterine contraction;  and, 2. Ex-
pression in the proper direction, through the pelvic brim.  If
these conditions are properly observed, any person qualified to
conduct  a  normal labor can successfully express the placenta.
The old  method of forcible traction on the cord, which doubt-
less is still  very generally practised by many physicians  and
most midwives, should be utterly prohibited.
    The advantages  of expression of the placenta, as above  de-
scribed,  are obvious.   They may be briefly enumerated as fol-
lows:  The avoidance of the introduction of  the hand into  the
 vagina and uterus, and  of forcible traction  on the  cord, and,
therefore,  of possible direct septic infection, tearing out of  the
 cord and sudden inversion; further, the prevention  of  hemor-
 rhage, and the speedy expulsion of the placenta by propulsion,
 the natural mechanism.
   Disadvantages there are none, except those mentioned in the
next section, and injuries  to the uterus from careful, steady,
 not too violent, expression have not been known to occur.  One
 warning it may be well to mention, and  that is, not to make 
112     Munde: Diagnosis and  Treatment of

unequal pressure on the uterus, particularly not on the relaxed
placental site, which, if the remainder of the organ  chance to
be flabby, might possibly produce partial or complete inversion.
  Difficulties attending expression of the placenta :  The same
obstacles to expression of the fetus—hyperesthesia, inflamma-
tory affections, or  obesity of the abdomino-uterine walls—will
naturally also interfere with placental expression to a greater
or lesser extent.  The chief obstacle to expression of the pla-
centa is its pathological adherence.  When friction and expres-
sion have been exercised  in vain for some time, and the uterus
neither contracts down to a firm, smooth ball, nor is the pla-
centa expelled,  then  we may  fairly  assume  that  it is more
or less adherent.  When the uterus has contracted  down after
the child and has its normal size, the placenta must be detached
and have left the uterine cavity proper.1  Since the adoption
of placental expression, adhesion of the organ has become very
much less frequent than formerly.  Fritsch says : " Crede has
the great merit of having deprived bad  obstetricians  of the
excuse of  adherent placenta.''   Among 9,839 labors collected
by  Ulsamer in  1827 (when expression was  not yet in  use),
there were 143  cases of artificial detachment (12.7 per cent).
Still, only in 3  cases was the placenta adherent  throughout,
and in  12  cases there were  partial or tendinous  adhesions.
Among 3,267 labors occurring at the Wurzburg Maternity from
1863 to 1873 (during three of which years  I was house surgeon)
it was found necessary to detach the placenta  25  times (0.7
per cent), in only  11 of which  cases there  was firm patholog-
ical adhesion.   In the others, hemorrhage and hour-glass con-
traction were the causes.
   Another obstacle to expression is a spasmodic  contraction
at the internal  os, or at either horn of the uterns.   This is
called by Barnes " encystment."  It is not uncommonly mis-
taken  for  actual  adherence.   The placenta  is detached  and
lies loose  above the  constriction, which  cannot be overcome
by expression.  It is  generally necessary  to dilate the con-
striction and remove the placenta manually.   Positive adhe-
sions  must  be severed by the hand in utero;  expression
will  not succeed.   The expression  of  the placenta,  in a
  1 Fritsch, p. 334.  I think this statement should be modified  to read,
" more or less detached." 
       Obstetric Cases by External Manipulation.   113

greatly premature  delivery,  may  occasionally  fail, either
because the organ  is very small and lax, or the child is dead.
  A precaution which  should  never be omitted is, to inspect
the  placenta immediately after its delivery, particularly the
maternal  surface.   Should any cotyledons  be found missing,
search should be made for the missing portion by introducing
the hand into the uterus, where the cotyledon may be fouud
either  adherent or loose.  Fritsch  reports three cases of the
latter  occurrence, after the  ready success of Crede's method,
all the placentas being somewhat pnlpy.
  Supervision of the fresh  puerperal  uterus.  Immediately
after the removal of the placenta, the uterus will be felt by the
palpating hand as a firm, hard ball of the size of a child's head,
some three to  four inches above the pubes.  Frequently, one
circumscribed portion or other of the fundus, corresponding to
the  prominence previously  felt, will now be found depressed
and soft, showing  the slightly inverted site of the placenta.
This Fritsch calls a " normal physiological paralysis of the pla-
cental site."   It soon disappears with the uniform  contraction
of  the uterus induced by gentle friction, which should be con-
tinued for one-quarter to half an hour after delivery, until the
danger of hemorrhage  is past.  Ramsbotham1 and  Osiander,2
as long  as  fifty years  ago,  recommended  steady, tonic, com-
pression of the bleeding  puerperal  uterus, to be continued, if
necessary, for half an hour or longer, and clearly distinguished
it from the friction long practised for the same purpose.  Not
uncommonly relaxation of the  uterus takes place several hours
after labor, and oozing of blood occurs into the uterine cavity,
distending it frequently to double its normal  size.  I have re-
peatedly  expressed  clots of  the  size of a fist from the uterus
three  or  four hours after labor.   But this was at a time when
I was not in the habit of giving ergot simultaneously with the
birth of the head in every case, as I now do.  The advisability,
therefore, of palpating the abdomen of every puerpera at inter-
vals within twelve  hours  after delivery, is apparent.  I always
instruct  the nurse to watch the size and tension of the uterus,
and show her how high the fundus  should  normally stand ; in
the  absence of a nurse, the  patient herself may be taught to
feel and watch over her uterus.
         1 Pract. Obser. in Midwifery, 1821.
         2 F. B. Osiander: Entbindungskunst, Bd. III., 1825. 
114 MuNDi;: External Manipulation in Obstetrics.

  A secondary hemorrhage at a later period than twenty-four
hours post partum generally depends on  some condition not
remediable by external manipulation alone.
  The external compression of the abdominal aorta, which has
been extolled with doubtful  reason as a hemostatic in post-
partum  hemorrhage, is warmly  recommended by  Fritsch as a
rapid analeptic  in syncope from the same cause.   It acts ob-
viously by retaining the blood  in the brain and upper section
of the body.
 
 
 
 
 
 
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