my observation within the last year twenty seven obstetrical cases; twenty-three of these were in my own practice, the other four in the practice of others. In all of my own cases I saw the patient from one day to one month before confinement, and made a careful examination of the abdomen by palpation to diagnose the position of the child. In only one case was I in doubt as to the diagnosis, on account of the great tension caused by the amniotic fluid. In the first nineteen cases I found a normal position and presentation, as was afterward verified at the delivery. I began to think it was a case of "love's labor lost," but the twentieth case proved to be an occipito-posterior position, and on being called by telephone two weeks later, when the first pains of labor began, before the waters were broken, I succeeded by combined internal and external manipulation in rectifying the malposition and delivering a living child two and one half hours later. By inserting two fingers of the left hand into the vagina to push the fetal head up and out of the pelvis, then by proper manipulation with the right hand on the side of the abdomen, working of course in the intervals between pains, the operation was not difficult.

The four cases seen in the practice of other physicians had each advanced too far to hope to rectify the abnormal position, for they were all abnormal. One case was an occipito-posterior, delivered with forceps after much difficulty (still-born fetus). One footling and two breech cases, all very protracted, with a still-born fetus in all. I do not wish to be dogmatic in my assertions, but believe that the majority of these malpositions can be rectified if seen early in labor before the waters are broken. The diagnosis of the normal position, right or left. occipito-anterior presentation, is comparatively easy, and is determined in the following manner: With the patient in the dorsal position, with the legs flexed, having the abdomen exposed or only covered by a thin garment, we first find the breech by making deep pressure over the uppermost fetal pole with the outer edge of the hand, which is placed transversely to the axis of the patient's body. Having recognized the breech by grasping it as nearly as we can in the palm of the hand, remembering that it is smaller than the head and less resisting and not so round in outlines, we next pass the palm of the hand along the back of the child (which is recognized by its broad, long, and resisting surface) until we reach the anterior shoulder, which is distinguished by its prominence as well as its anatomical characters. Next, to find the head, place the tips of fingers of each hand just above the symphysis

pubis somewhat apart, making deep pressure down into the pelvis at an angle of forty-five degrees. We recognize the head as being hard and round and by our ability to rotate the same easily, also by finding a sulcus between the head and shoulder. Finding at what point the fetal heart sound is heard most distinctly will assist us still further, as it locates the lower angle of the left scapula, and in a normal presentation should be heard in the lower uterine segment.

Now, having outlined the method of recognizing a normal position, I shall, for the sake of brevity, only give a few leading points in the recognition of abnormal positions, for this is a subject that each one must study for himself at the bedside in a practical manner.

Should there be an occipito-posterior position we would fail to find the child's back anteriorly, but instead the small parts of the child presenting themselves to the palpating hand, and in a relaxed abdomen they can be distinguished easily. We would also find an undue cephalic prominence at the lower uterine segment.

In a breech, knee, or footling presentation, whether it was a sacroanterior or posterior, we would recognize the head at the upper segment of the uterus by its round outline and hardness and our ability to rotate same, and we would be able to find the sulcus between the head and shoulder; while at the lower segment of the uterus we would find the breech not so hard nor so regular in shape.

Transverse presentation will present but little difficulty.

Twin pregnancy is indicated by the large size of the abdomen with lack of motion in the uterine contents, great width of tumor, greater number of prominent parts to be felt: perhaps two dorsal planes or three or four fetal poles; but, as multiple pregnancy occurs so seldom, I would caution you not to mistake the placenta for a fetus, for often the placenta makes itself very prominent in these examinations, especially when a uterine contraction is excited.

With regard to other abnormal presentations, such as face, brow, hand, etc., we could gain very material assistance from a vaginal examination.

I shall not undertake in this short paper to give the various methods of rectifying these abnormal positions and presentations, but will say that by diagnosing an abnormal position before confinement, and then before the waters are broken, with proper external or combined external and internal manipulation, many children may be saved who would otherwise be still-born; and although you may examine many cases

before finding an abnormal presentation or position, yet when you have found one and rectified the same you will be in the frame of mind of the Good Shepherd who rejoiced more over the one sheep which was found than over the ninety and nine which went not astray.

We all feel proud of the reduction in the maternal mortality from childbirth, which has been brought about by a knowledge of what constitutes surgical cleanliness in obstetrical practice; but in our, rejoicing over this triumph I hope we will not forget that the infant mortality is still too high, and it is to be hoped that with a better knowledge of the female pelvis, with accurate measurements of same before labor, combined with an early diagnosis of the position and presentation of the fetus, we will gain another victory in the reduction of the infant mortality in childbirth.

To be forewarned is to be forearmed, and it is a principle of warfare never to underestimate the forces of your antagonist. So the conscientious, painstaking obstetrician, who is called to attend a woman* in labor, when he has beforehand measured the pelvis and diagnosed the position of the child, is not handicapped like his fellow-practitioner who has neglected these precautions. This satisfaction of feeling that you know your case, and are thereby master of the situation, will afford you a feeling of security and satisfaction that will amply repay you for the time spent in getting that information; although it is well to allow the proud father to moderate his excessive joy by making still further compensation for the extra attention given.

I trust the time is coming when a physician, meeting with an abnormal position of the fetus or finding a necessity for a cesarean section or a symphyseotomy after labor has begun, and not anticipating the same by having diagnosed the condition beforehand, will be placed in the same category with the one who has a case of puerperal fever to contend with from neglect of cleanliness.

During the past year I have derived much pleasure and profit from the study of obstetrics, both theoretically and practically, and to those of you to whom obstetrical practice has been an uninteresting task, I would say, devote more study to the subject, and I assure you that your increased knowledge will lend a new charm to that branch of the practice, and, by giving your obstetrical cases more attention before confinement, thereby hoping to reduce the infant as well as the maternal mortality.

RICHMOND, Ky.

DISCUSSION.

Dr. Frank C. Wilson, Louisville: I was very much interested in the paper of the essayist, and the subject is one to which I have given considerable attention in years past, and one that I have taught for a number of years. There is one point in the paper that I noticed, and that is that Dr. Foster placed no reliance upon auscultation at all, but he seems to rely entirely upon palpation. We can derive a great deal of assistance from auscultation, and I think it ought not to be set aside. The position which the fetus occupies in the cavity of the uterus is one of an ovoid mass. It is folded up, as it were, as an ovoid mass, in one half of which is located the heart, and of course in whichever segment we can hear the fetal heart, in that segment we usually look for that half of the ovoid mass. If in the ovoid shape the fetus is folded in the cavity of the uterus, you pass the hand half way between the head and the breech, you will find the heart located. Therefore, in whichever segment of the uterus we can hear the fetal heart distinctly, in that half we usually find the head, and that will give us valuable data from which we can make inference as to the presentation. For instance, if we hear the fetal heart in the lower segment of the uterus, of course the head must be downward; we shall have therefore a head presentation. If, on the other hand, we hear the fetal heart more distinctly in the upper segment of the uterus, the head within, the breech must be down.

Another point is with reference to the position which the child occupies, with the arms flexed upon the chest and the back of the arch, and resting, as it were, against the uterine walls, with the entire anterior aspect of the fetus occupied with amniotic liquor and the folded limbs, the sounds from the fetal heart will radiate in every direction, but will pass through the back with less interruption than anteriorly. With the hand placed over the back the sounds will be heard more distinctly than in front; therefore, when the heart sounds are more distinctly heard at a certain point, we know the back of the child lies in that direction. That is another valuable point from which we can infer as to the position of the child.

It seems to me the doctor did not sufficiently direct our attention to the valuable assistance which these methods of examination might render in a transverse presentation. I would like to have heard him dwell more particularly upon that point. In my own experience, which now extends. over twenty-five years, I can recall a number of instances within the last five or six months in which I was called to see a case prior to the rupture of the membranes. When first engaged upon a case I always suggest the necessity of making an external examination, and as a rule I find no objection urged against it. No woman will object when the matter is explained to her, and more particularly the value of it and the assistance it might render, as well as the comfort which it may give. The knowledge that every thing is natural and normal aids us very materially in case there be any

abnormal position of presentation of the child. In this case I referred to, in making an examination I detected the head very distinctly, it could be felt on the left side and the breech on the right. The back could be felt in front very plainly. The heart could be heard a little to the left side of the median line. That gave us a shoulder presentation unmistakably, with the right shoulder presenting. In a short time the membranes rupturing would have allowed the arm to protrude and would have necessitated manual assistance-would have necessitated passing the hand into the uterus, bringing down the feet, increasing vastly the danger to the mother as well as to the child, possibly sacrificing the child's life in the manipulation. Recognizing this condition, I simply, by placing one hand externally above the head and the other hand below the breech, by manipulation pressed the child around so as to bring the head down and the breech up. Then it was naturally transformed into a normal presentation, the child being delivered without any inconvenience or trouble.

Dr. Carl Weidner, Louisville: I can fully indorse the statements made by Dr. Foster, as well as those of Dr. Wilson. I have been astonished to hear that this method is hardly in vogue in our profession in this country, or is not very much taught in the schools. I do not know how it is to-day, but when I was a student, in my practical studies in obstetrics with Professor Strassburg, every woman to be delivered was first examined externally, and we had to make a diagnosis of presentation by this method of palpation before making a vaginal examination. Furthermore, I will say this, that ever since I have been practicing medicine I make it a rule, if I am engaged to deliver a woman, to see her three or four weeks before that time and make an examination by this method. I would not think of making a vaginal examination except under special indications. I make an examination both by palpation and auscultation, then I wait for the time, and if I find any indication of abnormal position I am on the look out. I think it is a good plan to follow.

SOME FURTHER OBSERVATIONS ON THE RELATION OF PELVIC DISEASES TO INSANITY IN WOMEN, WITH REPORT OF CASES.*

BY JOHN YOUNG BROWN, M. D.

At the last meeting of this Society, in a paper entitled "Pelvic Disease in its Relation to Insanity in Women," I made the statement that I believed that twenty per cent of the female population of our State asylums suffered from some form of major or minor pelvic disease, whose mental and physical condition would be benefited by proper gynecological treatment. This statement was made after a careful,

*Read at the June meeting of the Kentucky State Medical Society, 1895.