Auscultation reveals the loudest heart-sounds above the line dividing the uterus into the two equal parts, either on the right or left, according to the position.
The presentation being elevated, it cannot be reached; or, as Pajot puts it, " we feel that we feel nothing." The lower seg ment of the uterus is empty; sometimes, however, by forcibly depressing the fundus uteri, the fetal extremity, occupying the level of the supe rior strait, can be brought within reach of the finger, but it is usually im possible to make out its character. In general, it seems softer and less resistant than the head, and in certain cases it is possible to make the diagnosis very well: this is when the small parts which accompany the fetal extremity are not closely applied to the nates; then these small parts are felt to be movable in the inferior segment of the uterus, they float in the liquor amnii, and the finger, which feels them escaping from under it, as if the fetus had drawn them up; this sensa tion can be felt only in pelvic presentations.
During Labor.
Auscultation and palpation give the same results as before labor, only the cephalic ballottement is not distinctly perceptible except in the inter val between the pains, and even then it is not as clear as before labor.
The the beginning of labor, the foetal part being high up, the sensations on reaching it are not clear, and the less so when the bag of waters is very large; but the form of the bag (sausage shaped), taken in connection with the elevated presentation, will attract attention. As in all elevated presentations, it is necessary, above all, to avoid rupturing the bag of waters; when it breaks, it generally does so with a snap, and a great deal of water is evacuated.
After the membranes have ruptured and the dilatation has advanced farther, the diagnosis becomes easier. The fcetal portion being more access ible, the finger comes upon a doughy part, behind which it feels a bony resistance; this part might be mistaken, at first, for the vertex masked by an effusion of blood; but, on the one hand, no matter how high the finger may penetrate, or what extent of the fcetal surface it may pass over, it will encounter neither sutures nor fontanelles; on the other hand, the signs perceived are characteristic. For, if the finger is carried beyond the portion first reached, it encounters a groove, on the other side of which can be recognized a part analogous to that first felt; this sensation will be still more distinct if the finger is moved higher up and backward, then gently forward along the groove: it will discover on one side a small, pointed osseous protuberance—the coccyx; in front of it a small corru gated opening—the anus, which always offers a certain resistance to the penetration of the finger. On following the groove still farther, the genital
organs are reached, and the sex of the foetus may be thus determined. This mode of diagnosis requires some practice. Therefore, though for a moment the nates may have been taken for the cheeks, and the anus for the tumefied mouth, the coccyx will prevent the perpetuation of the error. We may add that, when the coccyx is reached, we can nearly always, on following the point of this bone toward its base, run over some portion of the crest of the sacrum, thus confirming the diagnosis. The presentation of the pelvic extremity is thus recognized, and, since the coccyx always points toward the anterior surface of the foetus, the direction of this bone will give us, not only the presentation, but also the position. Finally, if the finger is introduced into the anus, it will be stained by the rneco nium. If the feet are pressed against the nates, the diagnosis is still easier. When the feet present, whether applied to the nates or alone, they are recognized easily enough: the heel and the malleoli, in fact, form distinct prominences which exist nowhere but on the foot; the toes too are placed in a straight line, but the signs based on the apposition of the thumb in the case of the hand, and on the shortness of the toes, do not seem to us sufficient. Indeed, if we possessed only these two signs, we would often run the risk of confounding the foot with the hand. We may also insert the finger between the great toe and the second toe and separate them; the distance to which they can be spread apart can hardly be compared with that which can be effected betweeen thumb and index finger, but the tyro is still liable to make a mistake. Also, as regards the toes, all writers lay stress on their shortness, but the sensation im parted is not distinctive; they appear long enough at first, and it might be more truly said, that if the toes seem long enough, the fingers appear of extraordinary length. The thickness of the radial border of the hand has likewise been pointed out as a sign. This may also lead to error un less the accoucheur has had much experience. There is, however, an other sign which, if it can be obtained, is characteristic of the foot, but it requires that the greater part of the latter be accessible. It is this: the leg is articulated at a right angle to the foot, while the hand lies in the prolonged axis of the arm, and should the hand by accident be even bent at a right angle to the wrist, such bend will not possess any protuber ance comparable with that of the heel, formed by the os calcaneum.