CONJOINED MANIP17LATION.
This is a fourth mode of obstetrical exploration which the Germans, true to their instincts, have endeavored to appropriate, giving it the name of combined exploration. It consists in the association of external and internal palpation,—that is to say, while the finger in the vagina is ex ploring the cervix and inferior uterine segment, the other hand, applied on the abdomen, grasps the fundus uteri. We thus obtain very precise information regarding the development and mobility of the uterus, and regarding its contents. Combined exploration is particularly useful early in pregnancy, and allows the establishment of a diagnosis at a period when, the certain signs being absent, the probable ones are alone available. While the finger in the vagina perceives the slight cervical changes, its beginning softening, the enlargement of the lower uterine segment, and its weight, the hand placed on the hypogastrium feels, after the end of the second month, or at the middle of the third month, the round, elastic fundus of the uterus a little below the superior strait, or, at the third month, on a level with the same. If we endeavor to raise the uterus with the finger in the vagina, an impulse is transmitted to the hand upon the hypogastrium. If the hand on the abdomen is now made to press upon the tumor; and to depress it within the pelvis, the finger in contact with the inferior segment perceives this depression, and the accoucheur thus definitely decides that the uterus is indeed included between the palpat ing hands. If, in addition to the uterine enlargement, the rational signs of pregnancy are present, one is almost justified in diagnosticating preg nancy, which is the most natural cause of uterine development. Con joined manipulation also renders great service in cases of real or threatened miscarriage. This will be again referred to in the article on Abortion. Rectal and vesical touch should be reserved for cases where they are ab solutely indispensable, as in examination of girls claiming to be virgins but who are possibly pregnant, in extra-uterine pregnancy, uterine retro version, fibroids, and other tumors. Vesical palpation must be preceded by dilatation of the urethra, and is very rarely necessary.
It thus appears that the certain signs of pregnancy are four in num ber: active fa-tal movements, perceived by the accoucheur; ballottement, whether abdominal or vaginal; the fatal souffle. Of these signs, only one is infallible, viz. the foetal heart-sounds. The others may be wanting. We
hold that one cannot affirm the existence of pregnancy until between the middle of the fourth and the beginning of the fifth month—that is, after the time when the tetal heart-sounds are heard. We shall see in the article on Diagnosis, that these sounds may be absent on account of death of the Aetna, and that the diagnosis then becomes very difficult.
[There is a further sign of pregnancy which, in our experience, ought to be classed amongst the infallible, and this is the sign for which we are indebted to Heger, and which is called after him. For about two years we have examined in the neighborhood of fifty women, primifiara3 and multiparce, for this sign, and have never as yet failed to find it where it had a right to be—in pregnancy—nor have we ever found it in the absence of pregnancy. The sign is perfectly apparent as early as the sixth week, in one case we found it unmistakably at the fourth, and, in our ob servations,we were always careful to verify, by after examination, the truth of our diagnosis. By means of it, we have made the diagnosis where all rational history was purposely withheld from us by the patient.
The sign depends on the fact that, during the first eight weeks of gesta tion, the body of the uterus enlarges, particularly in the antero•posterior diameter, out of proportion to the cervix, which, beyond a little softening at the tip, may not alter at all. In making the bi-manual, then, and this is a sine qua ncn, the lower uterine segment is found to project over the cervix, and, further, this segment seems boggy and compressible. In a paper on this sign, published in the Medical Record (New York) early in February or March of this year, we likened the shape of the uterus to " an old-fashioned fat-bellied jug "—and this describes it very well.
This peculiar shape of the uterus is not simulated by anything else. In subinvolntion, the body of the uterus is enlarged in all its diameters: in hyperplasia, the body is dense, not elattic, doughy, resilient: in hy peremia, from obstructed circulation due to marked flexion, compressibility is absent, and the uterus is not spherical: fibroid in the anterior wall will project over the cervix, but it is dense and uneven.
Being able thus to differentiate every other condition, and the sign never having failed, or misled us, we naturally are inclined to consider it. as positive of pregnancy.—Ed.]