Touching or Examination.—If the patient's assent can be obtained, after the proper reasons for asking the privilege of making an examination per vaginam have been laid before her, we should have two principal objects in view, while performing that operation; one of these is, to note the presentation, and the other, the position. There are other observations to be made at the same opportunity, such as the situation of the internal parts as to place, and the softness or relaxation of them-their moisture or dryness-the state of the rectum, and the sensibility of the organs concerned in the parturient process, as natural or morbid.

Upon obtaining the patient's consent to the examination, she should be requested to lie on the bed upon her left side, with the hips near the side or foot of the bed-being about eighteen inches from the edge or end-and with the knees drawn upwards towards the abdomen, a small pillow being placed betwixt them. Except upon occasions of the greatest emergency, a third person should always be present; and the physician ought to refuse to perform the operation of Touching, except in the presence of a third person, who should be some elderly individual, acting as nurse for the occasion.

Let the attendant provide a napkin, and a small quantity of pomatum, lard, or other unctuous substance, and a basin of water for the hands, which must always be bathed before performing the office of Touching. When a smart pain comes on, the left hand of the prac titioner being pressed against the sacrum of the patient, outside of the bedclothes, the forefinger of the right hand, properly anointed, should be introduced into the vagina, nearest to, and pressing slowly upon its posterior commissure, taking care not to bruise or irritate the pa tient by any rough or hasty proceeding. The finger should be bent so as to let the knuckle pass in to the orifice first, after which the point may be extended. This advice was inculcated by Saccombe.

Old Paul Portal, at p. 3 of his Pratique, &c., says, you must proceed to this operation "commençant aux parties supérieures de ces levres, et descendant le long du clitoris; l'on prendra soigneusement garde de blesser l'urethre qui se trouve située au dessous," &c. &c. This old author could not have given a worse advice in this matter, and I recommend to the Student to follow my directions, and not his.

If the point of the finger be now carried along the posterior wall towards the upper extremity of the vagina, the os uteri may be felt, and its degree of dilatation ascertained. When the finger comes to the os uteri, if the pain still continues, let the greatest care be taken not to rupture the chorion or bag of waters, as it is called, especially

in a first labor. These membranes become extremely tense during the pain, which forces them down through the opening of the womb, forming a segment of a sphere of greater or less size, according to the greater or less degree of the dilatation; if they should be too rudely touched while in a state of tension, they might burst, and permit the liquor amnii to escape, an event unfavorable in the early stage of labor, which it both retards and renders more painful. There is no need for pressing against the bag of waters during the pain, because by waiting until the pain subsides, the bag becomes relaxed, and can then be pushed back again within the mouth of the womb, so as to enable the finger to touch the presentation. For the most part, we only ascertain, in such an examination, the presentation, and being satisfied with that, we wait until a great dilatation, or the discharge of the waters, allows us to discover the position.

This examination is commonly called taking a pain, and we seize the moment of pain mainly for the purpose of avoiding to embarrass the patient, whose mind, fully occupied in perceiving the painful sensation, is at the moment somewhat diverted from the awkwardness of the situation. Hence, let the Student understand that he is to pass the index finger while the woman is in pain, but to make the exploration after the pain is gone.

During the operation of Touching, we also endeavor to learn the condition of the orifice of the womb, as to whether it is rigid and unyielding, or soft and dilatable; whether it be thick and dry, or thin and moist, with an abundance of glairy phlegm. We also ascertain whether the os uteri is in a favorable position, that is, in the middle of the pelvis where it ought to be, or on one side; or high up behind, towards the sacrum; and we rectify its position, if need be, by changing the situation of the mother to her back, or to either side, according as we may judge most fitting to bring the mouth of the womb into its proper place. Thus, suppose the mouth of the womb inclined altogether to the right side of the pelvis, the patient being on her left side; let her turn on to her back, or quite over to her right side, and the axis of the womb will be brought more nearly to the middle line, or axis of the pelvic canal. We are, also, in this operation, to form an opinion as to the probable resistance to be made by the vagina, perineum, and labia, so as to make up our prognosis, which it is best, however, to keep as a secret not to be divulged for the present.

At length, the pains having opened the os uteri to the greatest extent (as in Fig. 76), and driven down the bag or bladder of waters almost to the orifice, the membranes burst and the fluid of the ovum escapes with a gush, which is called the breaking of the waters. As

soon as practicable after the escape of the liquor amnii, the Touching should be repeated, and now there is little difficulty in determining the position of the presentation, though it may often be ascertained beforehand, through the unruptured membranes.

In general, that side of the pelvis in which the head can be felt at the lowest level is the one to which the vertex points; for the vertex must dip, in order to enter the bony canal. But if, upon feeling the scalp with a finger firmly pressed upon it, a suture is discovered, which, upon being traced, is found to meet with two other sutures, and only two, that point of meeting will be the posterior fontanel or vertex; and it will be in the first position if it be near the left acetabulum; in the second position if it be found near the right acetabulum; and in the third position if it be directly behind the symphysis of the pubis. But if, instead of three sutures, there be four, with a large membranous or soft space betwixt their points of union, it will be the anterior fontanel; and if it be near the left acetabulum, the head will be in the fourth position; in the fifth if it be to the right acetabulum; and in the sixth if it be near the pubis. Let not the Student forget that when the head presents in a flexed attitude, it is a vertex presentation, no matter to what segment of the excavation the vertex may be addressed-nor that, in the first three vertex positions, the posterior or triangular fontanel is to be felt, while the quadrangular or anterior fontanel only is met with in the three last-videlicet, the fourth, fifth, and sixth positions.

False Pains. These are pains that afflict some women towards the end of pregnancy, and which, however severe and regular they may seem, are nevertheless very justly denominated false pains, to be distinguished from the true ones only by Touching.

I have many times been kept out of my house all night, near a patient supposed to be in labor; and having been refused the privilege of making the examination until morning, after so tardy an admission of my request, I have found the os uteri perfectly closed, with a still tubulated or cylindrical cervix; so that I have been obliged to announce not only that the patient was not in labor, but that she had not yet reached the full term of pregnancy by ten days or a fortnight.

It is exceedingly vexatious thus to be baffled by the unreasonable backwardness of the patient to submit to an operation which she knows to be necessary and inevitable; but we shall, in all the early stages of labor, except those where the water comes off at the very commencement, be liable to such disappointment and deception, until we verify our other inferences by the infallible test of Touching.

The similarity of these false pains to the true pains of labor is very great; there is even to be felt the hardening of the abdomen; but, if carefully appreciated, it will be found that the rigidity is occasioned by a contraction, not of the womb itself, but of the muscles of the belly, that are so constricted upon the uterine tumor as to make even the womb appear to be contracted; whereas it is actually only compressed by the abdominal muscles. False pains, then, are essentially involuntary contractions of the abdominal muscles. They are, probably, of the nature of tenesmus, and are caused either by the ventral irritation produced by the distended womb, or else by intestinal irritation from sordes, flatus, acidity, rheumatism, and other causes that would also suffice, in the non-gravid state, to bring on spasms of the abdominal muscles. The difference between those of the non-gravid and those of the gravid state is, that in the former they are paroxysmal, but in the latter they are regularly periodical; which latter character they acquire from some law of the uterine innervation that I am unable to explain.

False pains are, likewise, common symptoms of rheumatism of the womb. This rheumatic disorder is far more common than has generally been supposed; and, when misunderstood, is the fruitful source of anxiety and doubt to the practitioner, besides of insufferable distress which it occasions for the patient herself.

Wigand, Giburt des Menschen, band i. p. 82, says that although rheumatismus uteri is sometimes connected with rheumatic pains of other parts of the body, yet, for the most part, only the womb and organs of generation suffer on such occasions. The causes, he thinks, are to be found in the hyperæsthetic state of the gravid womb, its exposure to cold from its projecting position, and carelessness as to dress during pregnancy.

The characteristic signs of the disorder in labors consist, according to Wigand, in a general painful sensibility of the womb to the touch, which is attended with contractions of the organ that are painful alike at the beginning, middle, and end of the labor-pain. The pain of a contraction in the rheumatic womb differs thus from that of a healthy uterus. In the latter, a normal pain gives no distress during the first half of the contraction (Wehen Cyklus), for the pain of a labor-pain does not commence until the mass of the organ begins to exert its superior power by thrusting the presentation into the dilating cervix uteri and vagina.

I have met with several instances of rheumatic gravid womb, where the woman was tormented with false pains for many days previous to the real attack of labor. In one delicate female, pregnant with her

first child, there was daily pain in the womb for a month before the child was born; and these pains had so far the external characteristics of labor, that the most experienced practitioner might be deceived by them, until he should clear up the diagnosis by the Touch. The Touch alone could convince him that the os uteri was not in the least concerned in the matter; the tubule or cylinder of the vaginal cervix remaining as completely undeployed as in the most perfect repose of the gestation. In all such instances, the globe of the womb is sore to the touch, and only the slight occasional condensations that occur in all wombs towards the close of pregnancy could be looked to as the sources of the patient's distress. It may well be conceived that a rheumatic uterus could not but be painful whenever its parts should be disturbed by the normal contractions of its muscular tissue. This remark, however just and important to the Student, is not new; for Portal, who practised in the middle of the seventeenth century, expressly declares that he met with women in whom the womb became dilated to the size of a piece of fifteen sols, and then closed again; the pregnancy continuing to the full term; when they were delivered without at any time experiencing any serious inconvenience from the circumstance, p. 4. In certain examples of rheumatism of the uterus, I have found the patient with a sore belly, often supposing herself in incipient labor, and as often disappointed; yet disclosing to the Touch a partially dilated os uteri for many days, yea, even for a whole month, before the veritable attack of labor came on.

Let the Student remember that, when he shall be hereafter summoned again and again to a false alarm, as it is called, for the same patient, he will probably have to treat a rheumatismus uteri. Let him bleed such patient; let him keep her in bed, covered rather too warmly than not enough so with bedclothes; let him give her some doses of Dover's powder, or anodyne enemata, at night; let her abdomen be bathed two or three times a day with equal parts of warm oil and laudanum, and let him see to it, that she entertain a soluble state of the bowels by means of gentle aperients, among which pure precipitated sulphur, with calcined magnesia, is perhaps one most to be desired.

CASE.-I advise the Student early to come to the resolution of being cautious in his diagnosis and prognosis of these doubtful cases of labor, for I know there belongs to professional men a disposition to pronounce at once, which, perhaps, arises from a false pride, prompting them to seem to know all things at a glance, or by mere intuition. If the young beginner, being called to a supposed case of labor, should