Such are the characters by which we recognize the cephalic extremity. But there are two sets of cases in which palpation gives only imperfect information. The first is that class in which the abdominal walls are extremely thick. In very stout women they are so thick that the sensa tions obtained by palpation are entirely confused, and it is hardly possible to recognize the foetal parts. The second is the class of cases in which the abdomen is entirely relaxed and sack-like. The uterus falls down upon the thighs and the fundus is the only accessible part. Only when there is a breech presentation is the head accessible; in case the vertex presents it is necessary to have an assistant raise the uterus forcibly, and even then palpation can be only very imperfectly performed when there is any amount of adipose tissue. But in these cases the smaller festal part, the only accessible one, may be felt in the fundus uteri, and the presence of the head at the other extremity may be deduced, though it may not, in exceptional cases, be perceptible to the touch. We have ourselves re cently seen two examples of this.
Thus we see that the head is easily appreciable. The breech is found opposite to the head.
When the head is below, the examiner places his hands upon the superior portion of the uterus, and searches for the place occupied by the breech. This forms a more or less rounded, voluminous, and resisting mass;—but the proximity of small, prominent, hard and mobile parts, and the absence of one peculiarity distinguishes it from the head. That pecu
liarity consists in the separation of the head from the trunk by a pro nounced furrow, the neck, while the breech is continuous without interruption with the trunk and back of the fcetus. Thus, instead of a rounded body sharply separated from the main mass, we have simply the rounded end of that mass itself. Let us further add that the breech is never so mobile as the head, and this, with its volume and irregularities, will prevent error on the part of an examiner of some little experience.
It is still necessary to determine the position of the back. The fcetus being flexed, the back is necessarily nearer to one abdominal wall than to the other, and it is easy, by pressing down upon alternate sides, to determine upon which one meets with the most resistance. This will be the back, and on the other aide will be felt some small mobile parts, the limbs of the fcetus. Since these always occupy the anterior plane of the fcetus, that will suffice for its diagnosis.
Nevertheless, when the abdominal wall is thick, the foetus very move• able, the amniotic fluid abundant, it is sometimes difficult to decide these points. Budin, in these cases, counsels us to seize the breech with the hand, and to push it against the cephalic extremity so as to accentuate the flexion of the fcetus. The fcetus, thus forcibly curved, applies its back more closely to the abdominal walls, and allows us to outline it very exactly.
We shall see, when we come to consider delivery, the special diagnosis of the presentations and the positions.