WOMAN.
The first questions relate to the dis eases from which the pregnant woman suffered during infancy, to the present age, and to the age at which the woman began to walk. The last question is extremely important, and may furnish precious indications. Rickets causes arrested development and softening of the bones, which re tard the infant's first steps, and leave in the lower limbs more or less marked traces of incurvation. These traces coincide almost always with pelvic contraction. In the woman, therefore, who began to walk late we should examine the lower extremities for evidences of rickets. At the same time, we should assure ourselves that the woman does not limp, has no spinal curvature, and was not subject to coxalgia in infancy. If these lesions exist, the woman must be made to understand that a more com plete examination is necessary. The first duty of the accoucheur being to respect the modesty of his patients, his examination should only be made when absolutely indispensable, at as late a date as is compatible with safety, and in the presence of the mother or of the husband of the woman.
Passing to the subject of menstruation, the obstetrician inquires when the menses were first established, the conditions attendant upon the first menstruation, and upon the subsequent ones, such as the quan tity, quality, duration, regularity, and accompanying •henomena. He then ascertains whether he is dealing with a primipara or with a multi para, and in the latter case, obtains information concerning earlier preg nancies and confinements, and about the date of the last confinement.
The next point is to ascertain the fact of existing pregnancy, and the stage of uter•gestation already reached. Passing the probable signs in review, the accoucheur will obtain information about the last menstrua tion, the nausea, digestive disturbances, etc. If pregnancy is far advanced, the date of quickening is to be ascertained. The history of any compli cations, such as oedema, varicose veins, hemorrhoids, digestive difficulties, constipation, circulatory or respiratory disturbances is to be taken. After these preliminaries, the physician proceeds to the direct examination of the patient, which should be made early if the woman has already had difficult labors, or if one suspects her pelvis of being deformed. He must never forget to examine the urine of all pregnant women, particularly of primiparte, in order to seek for sugar, and particularly for albumin. Pro ceeding to the direct investigation, which should be made with the woman recumbent, he examines the lower limbs, the spine, the chest if necessary, and the breast, if the woman intends nursing, all with the least possible exposure. The examination of the abdomen will reveal its shape, volume, pigmentation, the striae, the oedema of the abdominal walls, the state of the umbilicus, and possibly, supra-pubic oedema. Palpation will next
convey exact information regarding the development of the uterus, the attitude of the foetus, its volume, its presentation, its position, the quan tity of amniotic fluid, the number of fcetuses, the mobility of the foetus or of the fcetuses, abdominal ballottement, the greater or less engagement of the foetal parts, the foetal movements, the foetal shock, the occasional fluctuation, etc. Auscultation will furnish data concerning the life of the child, its presentation and its position. It will confirm suspicions aroused by palpation, of possible multiple pregnancy, and will reveal the uterine souffle, the foetal souffle when it exists, the bruit produced by fatal movements, etc. Percussion will, in certain cases, aid in the recog nition of ascites, ovarian cysts, putrefaction of the foetus, etc.
If the data already obtained suffice, we may reserve the vaginal exami nation for another occasion. But, if one has the least doubt, he must not hesitate to overlook the natural repugnance of the patient, and must make her comprehend the necessity of the examination. The vaginal ex amination alone can show the state of the cervix, its softening, its situa tion, its length, its effacement, the state of its orifices, the degree of foetal engagement, the presentation, the position, the condition of the inferior segment, the integrity of the membranes, the vaginal secretions, the state of the vagina, the shape of the pelvis, etc. The examination should always be done by progressive stages, and an absolutely complete examination should only be made, at the first visit, in cases of urgent necessity. Let the physician acquire, first his patients' confidence, accustom them to the measures he must adopt for their benefit, treat them with consideration, ask, at first, simple questions, and finish by asserting his authority. It is the accoucheur's duty to explain-the necessity of more careful examina tions, and then to undertake them with all the consideration, propriety and gentleness possible. Having availed himself of palpation, ausculta tion and vaginal touch, he ought to have obtained all the necessary in formation, and should not repeat his examination, particularly vaginal touch, until the last days of pregnancy. He will then encounter less re sistance than before, because the women, being impatient to know when and how they are to be confined, will often request the examination which they so dreaded at the outset of pregnancy. If, however, the interests of mother or child demand the repetition of the examination, the ac coucheur must himself request it. since it alone can prepare him for the assumption of entire responsibility.