In order to reach the cervix, one must remember that its characters are changed by utero-gestation, which, while it leaves the length of the cer vix unaltered, modifies considerably its consistency, its direction, its situ ation, and its form. Even these modifications are not identical in pr.mi pane and multiparre. The cervix is found at the fundus of the vagina, and, according as the uterine axis is directed forward, backward, to the right or to the left, the cervix is carried more or less downward, upward, to the left onto the right. It forms a more or less soft prominence of varying length, having the consistence of jelly, and is therefore easily mis taken for the soft parts around it. At the summit of this gelatinous mass is a more or less marked depression, the os externum. One must accus tom himself to recognize the cervix by its exterior. Unfortunately, stu dents rarely do so, and beginners, for the sake of certainty, introduce their finger into the orifice. This is a gross blunder, for the introduction of the finger, although generally harmless, may have serious results. One should never introduce the finger into the os, unless it be dilated by par turition, and even then, the utmost gentleness and caution should be 'employed. How, then, may one surely reach and recognize the cervix ? Budin advises to follow the anterior vaginal wall from before backward, and then by a movement of circumduction, to make the finger traverse in succ'ession, the left lateral cul-de-sac, the posterior cul-de-sac and the right lateral cul-de-sac. If the cervix is not thus encountered, it is easy to find it in the centre of the circle thus described. Our method is as follows: The fundus of the uterus is most often inclined to the right, so that the cervix is on the left. The uterus is also inclined forward, and the cervix is therefore directed backward. We must, therefore, seek the cervix to the left and behind. We advise the student to follow the left lateral vaginal wall up to the bottom of the vaginal cul-de-sac. In carry ing the finger thence toward the right, anl in flexing the two first pha langes upon the third, one almost necessarily encounters the cervix on the way. There is, however, a slight difference between primipane and multipane, and according to the given period of pregnancy. Up to the sixth month, indeed, the cervix ocupies about the same position both in multipane and in primipane. The uterine inclination is not yet pronounced, the foetus has not yet engaged, and the cervix is approximately in the median line, but more or less displaced backward. After the sixth month, the uterus inclining more to the right, the cervix is carried more to the left; but there is another cause in primipane, the engagement of the festal head. The finger is then arrested, before reaching the cul-de-sac; by a hard, round, prominent object which fills this vaginal vault, and around which the finger must pass to reach the cervix. We more easily reach the left lateral cul-de-sac by following the left lateral vaginal wall. If the cervix be not found in this cul-de-sac, the finger will inevitably en counter it in passing around the posterior surface of this hard and promi nent object. In multiparai, the foetal engagement being absent or less pronounced, the cervix lies further forward, lower, and nearer the me dian line. The same conditions obtain in primiparm, when the foetus does not engage. Having found the cervix, the accoucheur seeks to as certain its form, its consistency, its length, its volume, its direction and its situation. We should then proceed to examine the inferior segment of the uterus. It appears as if widened and expanded. Its consistence is soft, like India rubber, and its weight is augmented. It is no longer so mobile as when empty, and is displaced with some difficulty. In this _ inferior uterine segment we find the festal parts, and ascertain the pres entation. If the head present, and the patient be a primipara, we feel, after the sixth month, a hard, round, prominent object, recognizable sometimes by the sutures, and sometimes by a parchment-like or osseous resistance. In multiparm, as a result of the failure of foetal engagement, we must reach higher to make out these points, and must, in some cases, depress the fundus uteri in order to render the foetus accessible. If some
other part of the fa-tus present, as the breech, face or trunk, it is fre quently out of reach, and the diagnosis can only be made during labor. At the end of pregnancy the cervix is often very difficult to recognize. We have seen that it is obliterated. In the place of the projection previ ously found, one now encounters in multiparEe only a little elevation, pierced by an orifice and continuous with the inferior segment of the uterus. In prindparse the cervix is still more difficult of detection, for, at the same time that the cervix is effaced, the lower uterine segment grows thinner, and the cervix is only represented by a depression with out an opening, and with borders no thicker than a sheet of parchment or of thick paper. The untrained finger may pass over it without recogniz ing it. It is only after the recognition of the cervix that we recommend the movement of circumduction of Budin, which shows the form, consis tency and the true situation of the cervix.
BALLOrrEMENT.
Vaginal touch gives another peculiar sensation known as the vaginal ballottement. While Pajot considers vaginal ballottement analogous to abdominal ballottement, consisting in a displacement of the foetus, en 'name, with the sensation of impulse due to its return, Depaul holds that this impulse is only exceptionally observed. We feel the displacement of the fcetus, according to him, but not its return against the examining finger. This difference in interpretation is due to the fact that Pajot understands, by the term ballottement, a total displacement of the foetus, while the ballottement of Depaul merely consists in a partial foetal dis placement. Moreover, while Pajot's ballottement and returning shock or impulse, are hardly perceived except between the fifth and eighth months, Depaul's ballottement may be observed up to the very end of pregnancy, and even in some cases at the beginning of labor. In order that the ballottement with impulse be perceptible, it is necessary, in fact, that the foetus be very mobile, that it be not too large, and that there be enough amniotic fluid to allow of its being entirely displaced. For De paul it suffices that one of the foetal parts, especially the head, be mobile, and this condition exists almost constantly, unless the head is well en gaged. In order that ballottement be perceived, the woman may be standing or lying down. It is of the utmost importance to place the fin ger in front of the cervix, at the point of junction between the cervix and the inferior uterine segment, and not behind the cervix, in the pos terior cul-de-sac, and on the posterior uterine segment. The finger, ap plied as directed, imparts, by its pulp, a brisk movement to this inferior segment. Impelled by this movement, the foetus is sent upward, in the uterine cavity, and falls back upon the finger, imparting an impulse to it. This is the ballottement of Pajot. For Depaul the method is the same, but the impulse is absent, and, if the foetus on returning comes in contact with the finger, it is not suddenly, but slowly, and without any shock. Whether there be a shock or not, ballottement is, when perceived, an almost pathognomonic sign of pregnancy, for the cases cited by Pajot and Cazeaux, of ballottement obtained in non-pregnant persons, are so ex ceptional as only to confirm the rule. The absence of ballottement should not cause us to conclude that pregnancy does not exist, for different con ditions may prevent it from being observed. In order that ballottement be made out, the presenting foetal part must be accessible, and mobile in the amniotic fluid. Now certain conditions remove the fcetus from contact with the finger, or limit its mobility. Some of these conditions are, an excessively large foetus, a very small one, hydramnios, multiple pregnancies, faulty insertion of the placenta, and abnormal presentations_ In some of these cases, if we cannot obtain Pajot's ballottement, we may get that of Depaul.