No. 227.

LONDON, SATURDAY, JANUARY 5. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY

DELIVERED AT GUY’S HOSPITAL BY

DR. JAMES BLUNDELL.

LECTURE XIII.

Extraordinary Difficulties in PreternaturalPresentations.

IN the abstraction of the child. Gentle-men, under the crural presentation, it some-times happens that unusual difficulties oc-cur, when the abdomen, or the arms, or thehead, are brought through the pelvis ; and tothe consideration of these difficulties I shallthis morning proceed.irom air, the abdomen is sometimes en-

larged considerably, the bowels being tym-panitic ; rarely, however, without a putres-cence of the foetus, indicated, perhaps, bythe desquamation of the cuticle and otherchanges of those parts which lie under theeye. Lowder once met with a case in whichthe peritonaeum of the foetus contained a

gallon, and I regret that I cannot, at themoment, mention the name of a gentlemanwho showed a foetus whose abdomen con-tained two or three pints, that had accu-

mulated in the urinary bladder; the pos-session of which I owe to his liberality.Meddlesome midwifery is bad. When

the abdomen is enlarged, it does not followthat active operations are necessary. Thoughthe foetus in Lowder’s case contained a gal-lon of water, it came away unopened ; thepelvis may be large, the powers may begreat, the foetus may be yielding ; co-operat-ing with the pains, careful not to lacerate theperinaeum, (the part most in danger,) carry-ing the foetus from the sacrum towards theabdomen of the mother; humouring, lead-ing, you get the child away. When, how-ever, the pelvis is small, or the parts arerigid; or the abdomen bulky in the last de-gree ; or the pains are feeble ; reduction ofsize may become requisite. If there bedropsy, the swelling must be punctured if

inflation, perhaps the abdomen must be laidopen more extensively: but accumulatedgas can, I conceive, but rarely require theoperation. That a child is dead, we maypresume when the chord is flaccid and coldfor an hour or more without pulsation ; thatit is dead, we may infer with certainty when.the body is begun to decay. In the general,with dead children only can it be justifiableto lay open the abdomen when the enlarge-ment is gaseous. The blood chills and cur-dles at the thought of tearing out the intes-tines of a living foetus. By the people ofEngland-the censor and monitor of nations- wild beasts are caged, but, worse thanthese, the accoucheur, meddlesome and vio-lent, yet responsible to none, has been

unwisely let loose upon society, with allhis instruments of destruction about him.

" Quale portentum neque militarisDaunia" ......

But I am digressing.When bringing the child into the pelvis,

you ought to be very cautious to keep thearms in the back of its cavity, and as nearto the face of the child as may be. Wherethis rule is neglected, however, and some-times from other causes, the arms may be-come fixed in the pelvis, and most frequent-ly between the symphysis pubis and thehead. In difficulties of this kind, it ought tobe your first endeavour to extract those armsin the ordinary manner,-the different partsof the operation, however, being performedwith more than ordinary nicety and energy ;thus you bring the axillse to a level with theexternal parts; you throw the body tho-roughly out of your way,-an operation ofmuch importance, at the same time givingit that position which may favour the de-scent of the arm athwart the face. Thenplacing all your fingers on the arm, aboutthe bend of the elbow; for in so doing, youobtain a forcible bearing there, providedthe obstruction is not unusually great, youmay bring down the arm with tolerablefacility. But what is to be done in thosemore difficult cases, where attempts of this

kind fail ? Why here, I conceive, the onlyremaining recourse is, to lay open the era-nium with the perforator, when the arms

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will become liberated by the collapse of thebones. This operation, however, can neverbe necessary, till you have ascertained byrepeated, well-directed attempts, thatextri-cation by the fingers is impracticable. This

operation, too, can never be necessary tillthe child is already dead,-the death beingeasily ascertained by the coldness, flaccidity,and, above all, the total cessation of the

pulse in the chord, which lies immediatelyunder the touch. To perform this opera-tion, take this instrument, the perforator,-unfortunately of too easy use,-and plantingtwo fingers on the occiput, in the way of adirector, perforate the cranium ; and after-wards separating the blades, enlarge the

opening as much as may be, in the man-ner here demonstrated. This accomplished,passing the crotchet into the cranial vault- moving the instrument in every direc-tion, lacerate the membranes and pulpifythe brain ; so that, soft as panada, it mayreadily issue at the opening ; when you willgenerally find, on pulling with the crotchet,that the head descends without previous ab-straction of the arms : though on the whole,perhaps, it is better, pursuing the generalpractice,-first to extricate the superior ex-tremities, and then to bring away the head.

In the abstraction of the head, in thesecases, sometimes unusual difficulties occur,divisible into four classes : those, I mean, inwhich the obstruction arises from an unfa-vourable position of the head; those casesin which it is produced by a slight defi-ciency of room in the pelvis; those cases,in which the deficiency of room is moreconsiderable ; and those cases, lastly, rarein British and well-conducted midwifery,in which the head is pulled away fromthe body, the cranium lying detached in thecavity of the uterus.Where the pelvis is small, or the head

large, or the practitioner is unskilful, itsometimes happens that the abstraction ofthe head is attended with much difficulty,in consequence of its unfavourable position.In speculation, cases of this kind might bemultiplied usque ad nauseum—but, in prac-tice, they may be reduced to three principalvarieties, with all of which you ought to beacquainted. When the head is at the out-let, the face and occiput lying on the sidesof the pelvis, the chin may lodge on one

set of sacro-sciatic ligaments, and the occi-put on the other. In cases of this kind,if the pelvis be large, or the cranium small,or the uterine efforts frequent and power.ful, the child may escape notwithstand-ing ; but if the pelvis be small, and thehead large., not understanding the natureof the difficulty, you may go on pulling tillyou actually tear the head from the body ; ;whereas, if you turn the face into thehollow of the sacrum, and the occiput to

the symphisis pubis, drawing the chin a

little downward and forward upon the chest,the whole difficulty vanishes at once, as thisapparatus shows, and the head passes easilyenough. Again, when the head is at thebrim of the pelvis, it happens sometimesthat the chin of the child lies over the sym-phisis, and the occiput over the promontory;the long length of the head lying, as Inow show you, over the short length ofthe brim; so that, unless these langths begreater than ordinary, the head cannot bebrought away. Understanding the natureof these difficulties (easily ascertained byexamining the position of the body, whichlies through the outlet, under the eye of theoperator), to remove it, in some cases, is byno means difficult, provided the accoucheurbe resolute and dexterous. Grasping, as Inow do, the body with the left hand, andthen conveying the abdomen of the fostusgradually to the back of pelvis, acting on thehead through the intervention of the neck,you endeavour to turn the chin to one side.In doing this, however, as the tender com.pages of the neck may suffer from con-

tusion, if the bearing there be too forcible;it is better, if practicable, to lay the fingersof the right hand on the side of the cranium,and with well directed pressure there, toassist the movement of the face to the side,the two hands mutually co-operating. Shouldrectification, however, be impracticable bygentle means, you may then endeavour toabstract the head by raising the occiput,and depressing the chin upon the chest; sothat, of the three longer axes of the head, theshortest, little exceeding four inches, maybe brought to bear upon the short diameterof the brim. In this position, if the pelvisbe capacious, the head may descend, withthe face throughout the labour upon the sym-physis pubis, as seen in this apparatus ; or,if delivery cannot be accomplished in thismanner, you may then lay open the craniumat the occiput. This tremendous and heart-

sickening operation, however, can never benecessary in these cases, till the fcetal life isextinct. Thou shalt do no murder. Thesewords cannot too often tingle in obstetricears. But to proceed.The passage of the head is sometimes ob-

structed in consequence of your not draw-ing in the axis of the pelvis, when the cra-

nium is at the brim ; and as this is an error,which you are very likely to commit whenoff your guard, I am the more anxious toimpress it indelibly on the mind. In thedemonstration here given, the head is in aposition favourable enough to the passageof the superior aperture ; the occiput lyingon one side of the pelvis, and the face uponthe other ; but if the head be large, andthe pelvis small, and I am seated near thefeet of the woman, consoling, encouraging

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her, of course, in drawing the child, I urgeit downwards and forwards on the symphysispubis. Now, under these circumstances, ifthe head be small, or the pelvis large, thecranium may pass notwithstanding ; but if thehead be large, or the pelvis small, as in thisapparatus, you see I may draw till I pull thispelvis out of the hands of the gentleman whoholds, yet the head may not be broughtaway. You smile, and not without reason :an ignorant midwifery is a comical tragedy ;the whole difficulty is of my own making,it arises from my drawing out of the axis ofthe brim. Let me quit the feet and ap-proach the loins, let me draw in the axis ofthe superior aperture downward and back-ward towards the coccyx, careful not to

injure the perinseum, the head comes awayeasily, and safely enough. An unluckycase !-an unfortunate case ! Like the two

Amphytrios in the comedy, Mis-fortune andMis-manage.ment (excuse the levity) are

so like each other, that their nearest ac-

quaintance cannot always distinguish theone from the other. But enough of this.

In bringing away the head of the child,again, you have sometimes to contend withdifficulties at the brim, arising most fre-quently from want of room between thefront and back ; to the consideration ofwhich we will next proceed.Eight or ten crural presentations, with

deficiency of room at the brim, have fallenunder my notice, the want of space beingascertained in these instances, not by nicelymeasuring the pelvis, but by the detentionof the head at the superior aperture ; not-withstanding, the position was favourableand a full abstractive force was employed.When the feet are presenting and the headis lying in the brim, the body being thrownout of the way into a commodious position,a dexterous operator might, I have no doubt,apply the longer forceps or even the leverto the head of the foetus, and draw downwith great effect. Steel, however, like thenerves of a rude accoucheur, is apathetic,and has no sympathies. The steel of theinstrument-maker is sometimes as fatal asthe steel of the armoury-and Laundy andPerkin may perhaps vie with each other.In difficulties of this kind your instrumentsare not in general needed, and therefore Iconceive ought not to be employed. The

delivery in many cases may be effected asfollows :-Availing yourselves to the utmostof your knowledge of the forms of the headand the pelvis respectively, agreeably to

principles so often stated, you place thehead at the brim as I now place it, with theface and occiput in the sides of the pelvisand the chin upon the chest; careful to

draw in the axis of the brim, that is, in aline extending from the navel to the coc-cyx.

To secure the command of the head whenpracticable, you place the two fingers onthe chin, the rest of the hand bearing on theshoulders and chest in front-while theother hand, resting on the shoulders andchest behind, you pass a finger as high asmay be on either side the occiput, obtain-ing that bearing on the child which I heredemonstrate. The child thus secured, yourequest an assistant to take place at thebed side, near the’loins of the patient, and,with the interposition of a cloth, graspingthe body of the fœtus, to draw obsequiouslyunder your direction. These preliminariesobserved, when a pain occurs you drawdown in co-operation,-perhaps swaying thebody a little from front to back, careful ofthe perinaeum, however,-till the head,brought to its bearing as here, you say toyour coadjutor, stop-lie on the pull-let ussuffer the head, under moderate compression,to mould itseif-let us wait for another

pain ; look at the countenance- count thepulse-reflect :-after pausing in this man-ner for one or two minutes, during a pain,if there be any, you draw as before, ad-vancing the head a little further, and againpausing, with the same caution as before,allowing the head to become further mould-ed and compressed. And proceeding inthis manner, pulling at one moment, paus-ing at another, you gradually work thehead through the brim, when further diffi-

culty does not usually occur. As the headmay, as here, slip suddenly through thebrim, be prepared to relax as suddenlywhen pulling, or the head may dash throughthe outlet and tear the perineeum. Decapi.tation will be the effect of sudden pullingor jerking ; but if the cranium be a littlesoftened by putrefaction, you may, withoutrupturing the neck, exert in a gradualmanner a force so great that the vertex

opens and the brain escapes. These higherdegrees of force, however, in the general,are neither safe nor justifiable; the safetyof the mother is paramount, and is bet-ter secured by the use of the perforator.The birth of the child, though not to behurried, must not, however, be needlessly

procrastinated, as the chord is under pres-i sure and death must ensue. Under thebest management, most of these children

are still-born.’ In higher degrees the pelvis may be con-tracted, when the abstraction of the fœtusmust be attended with difficulties still> greater, to be surmounted by laying openthe cranium,-the operator proceeding inthe method before described. When the;head is laid open and the brains have been)pulpified, frequently the foetus descendswith facility, the cranial bones becomingcollapsed. Notwithstanding this reduction

of bulk, however, the descent of the head.

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may still be impeded, when it becomes ue-cessary to observe the following cautions :-Make the opening into the cranium as ca-pacious as may be by the action of thecrotchet, diligently employed, let the cere-bral mass be pulpifiedwith more than ordi-nary care ; in drawing, place the basis ofthe skull parallel with the symphysis pubis,and, which you may easily do, bring- downthe occiput as the most depending part.The cranium here exhibited to you con-sists of the facial bones and basis, with thebones which form the upper part in a stateof collapse ; though thus reduced in sizethese remains of the head, when placedwith the basis parallel with the plane ofthe brim, nearly fill the aperture and passwith some difficulty, as this apparatus de-monstrates ; but you perceive it drops rea-dily through the pelvis when the basis is

placed parallel with the symphysis. If thebasis lie against the symphysis, the face be-ing the part most dependent, the facial bonesand neck, a large mass, must pass the con-tracted pelvis together; but if as advised,and as indeed you will find most easy, the

occipital bone be drawn down by the crotchet,you perceive here that the facial boneswill pass the pelvis alone, the occiput andneck of the child descending through thecontracted pelvis in one mass, of bulk byno means considerable. Observe again thisapparatus. Before you operate, the death of Ithe child may be known by the continued wantof pulsation at the root of the chord, not tomention the desquamation of the cuticle,and the putrescence of the limbs; and I

may repeat a remark made in an earlier partof the Lecture, I mean that it never canbe necessary to perform this horrid opera-tion while the foetus is alive.The decapitation of the foetus is not, I

think, a common occurrence in well-managedBritish midwifery ; but, in a few rare cases,in general perhaps ill conducted, the headbecomes detached from the body; and thisconstitutes the fourth difficulty of whichI proposed to treat. To get the commandof the head, is in these cases the principaldifficulty; and different instruments con-

trived for this purpose are lying on the tablebefore you. The courtly St. Amand, Ithink it was, contrived a net to inclose thehead when in utero. I am not sure that hecalled his invention the obstetric fool cap,but the designation would not be very inap-propriate. Spreading it over your fingers,you carry it into the cavity of the uterus,if you can; in doing’ this, you avoid burstingthe womb or vagina, ?/ you can; there is

always danger, and here you have choice ;then, having got thus far, you are to laythe cap over the child’s head, if you can ;ultimately, by means of this invention,abstracting the head, if yotc can. This

inauspicious impedimental,« if you can,"throughout the operation meets and em-barrasses you at every turn. The rats, in

council, resolved that some measure shouldbe taken to secure them from their arch

enemy : an orator, garrulous and much ap’plauded, conceived it would be advisableto append to her neck a bell,-silver andchased of course, and of a form at once clas-sical and elegant; aye, if you can, ex.

claimed a quadruped, a Phocion of the as-sembly, and demolished the orator. ByLevret, the instrument here exhibited wascontrived. Its structure and action I heredemonstrate ; Smellie’s improvement I nowhold in my hand ; it admits of more ready ap.plication to the cranium, being more obe.dient and obsequious to the operator. ByGregoire, an instrument probably prefer.able to either has been contrived ; the makeand action of it I here demonstrate. Bear.

ing on the firm margins of the foramen mag-num occipitale, this instrument, properlyapplied, gives a secure hold of the head;nor do I think that the annexation of sometwo or three vertebrae to the head, wouldpreclude the introduction of the blades, nor,would it be difficult, if necessary, to pullthese vertebræ away by means of a properinstrument.A meddlesome midwifery is bad. When

by mismanagement or otherwise, the headbecomes detached from the body, the un-aided efforts of the uterus will sometimes

push it away ; and, therefore, unless thecontracted state of the pelvis show that suchhope is vain, these efforts should be fairlytried. When, however, the detached headis to be abstracted by the accoucheur, hemay first endeavour to fix it in the brim ofthe pelvis by well-directed pressure fromthe hand of an assistant, applied above thesymphysis pubis; and then taking a largestrong perforator, like that here exhibited,he may either enlarge the foramen magnum,or make a large opening through the occi.put, abstracting the brain at the aperture,afterwards drawing down by the crotchet,-the head readily descending after its bulkhas been reduced. Should pressure on theuterus above the symphysis be insufficientto fix the head firmly, we must then obtaincommand by means of one or other of theinstruments just demonstrated.

Transverse Presentations.-Wben neitherthe superior nor inferior parts of the childare lying over the centre of the brim, thehead, I mean, or the nates, the knees, or feet,

I the foetus lying across the pelvis, furtherdifficulties arise, to the consideration of, which we will next proceed.

In Burn’s excellent work, I find referenceto a very extraordinary case, in which thewomb and abdominal coverings becoming, torn open at these apertures, the child was

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spontaneously expelled, the woman ulti-

mately recovering. More frequently, whenthe birth of the fcetus is obstructed, theuterus gives way, the foetus escaping intothe peritoneal sac, lying there for the restof life, forty or fifty years, for example, be-coming converted into a mass of bone, andoccasioning little further inconvenience, ex-cept that which results from its bulk andweight. To Dr. Cheston, very distinguishedpractitioner, a case of this kind occurred.The woman lived subsequently forty or fiftyyears. After death, he found that the fmtuswas ossified ; and in the Museum of the

College of Surgeons, under the direction ojthe very able and obliging conservator Mr,Clift, this presentation may now be seen.In transverse presentations, it still more

frequently happens that the uterus dis-rupted, the child escapes into the peritonealsac, and is brought away through the pelvis,by the operation of turning. Carrying hishand into the peritoneum, through the lace-rated opening, the accoucheur, careful notto lay hold of the intestines, seizes the feetof the child, and draws them over the centreof the pelvis. A case very similar to thishas fallen to my own care ; it was not, in-deed, a transverse, but a vertex presenta-tion ; the pelvis was narrow, spontaneouslythe womb gave way. My hand was carriedthrough the opening in the front of the neckof the uterus opposite to the bladder (thebladder being uninjured). Cautiously andslowly the feet were drawn down, the childwas abstracted dead, but the mother ulti-mately recovered. That there was a ruptureof the uterus, and that the child had escapedinto the peritoneal sac, was without doubt.I felt the contracted womb ; I felt the in-testines ;’I felt the large pulsating arteries ;I felt the edge of the liver; and this duringthe progress of my hand towards the feet,which lay near the ensiform cartilage : nor,though curious, is the case by any meanssingular.When the presentation is brachial, there

is yet another way in which the foetus maypass, occasioning but little anxiety to theaccoucheur ; for the pelvis being large,the fœtus small, the womb active, andthe feetus under six months of age, thechild may be pushed away without inter-ference of the accoucheur. Understand,however, clearlv, that where the foetus andthe pelvis are both of standard size, youcannot succeed by this method of abstrac- Ition Fracture of the arm, and disruption,I have seen in consequence of rude at-tempts to bring away the child in thismanner-and this, too, (hear it, I en-

treat, Sir Anthony !) by the fair andgentle hands of a female accoucheur. Theonly cases in which you ought to confide thedelivery to the natural efforts of the uterus,

are those cases where you perceive ob-viously, from examining, that the child is

coming down into the pelvis ; examining thefirst time, you observe a small descent ;examining a second time, you find it de-scended a little further; examining again,further descent is observed, the fœtus ad-vancing perhaps with every pain.

There is, too, another principle fromwhich your indication may be taken-Imean the age of the fcetus, ascertained bythe " calculation or reckoning," as it iscalled, and by the dimensions of the pro-truding member, allowance made for thatenlargement which results from compressionand intumescence. In general, if the pel-vis be of standard capacity, if more than sixmonths old, the foetus cannot be trans-mitted under the brachial presentation; ifless, it may pass. Pelves, however, mayexceed or fall below the standard dimen-

sions, and the rule must, of course, be modi-fied accordingly. All this may be illus-trated by the models here shown.When the child is lying transversely,

it is worth our knowing that evolutionssometimes occur, and more especially inbrachial presentations ; a truth, for the

knowledge of which we are particularly in-debted to a very amiable and very excellentman, I mean Dr. Denman. Under thisevolutionary descent of the nates, Denmansupposed that the arm ascended, but Gooch,a practitioner full of talent, has shown that,in some cases at least, the arm scarcely risesin the uterus at all. For myself, afterbeing present at two or three spontaneousevolutions, I am persuaded, that in most, ifnot all cases, as Gooch has suggested, thearm remains at the same, or nearly the sameelevation, pushed a little to the side of thepelvis, while the body of the foetus, relaxedand softened sometimes during life, moregenerally in consequence of extinguishedvitality under strong and repeated uterineeffort; first, the thorax of the child, thenthen abdomen and flank, ultimately the hipand breech, are urged through the brim ;the parts, not without incurvation of thesoftened body, successively following eachother into the pelvis. Observing these" spontaneous evolutions," as he significantlycalled them, and unwilling to interfere

during parturition without need, Dr. Den-man advised that, in arm presentations, weshould always confide the delivery to the

natural efforts, abstaining from the intro-duction of the hand into the uterus.

When, in conformity with this opinion, inseveral cases these presentations were

trusted to the unaided efforts of the uterus,in many cases, no doubt, the expected evo-lutions did occur ; but, in some, perhaps I; may say many cases too, the evolution, failed, and turning became requisite. To this

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may be added, that, under spontaneous evo- Ilutions, the children were almost invaria ;bly born dead, nine out of ten, for ex-

ample, or nineteen out of twenty. For thepurposes of practice, the fact itself is suffi-cient, and it constitutes some objectionto Denman’s recommendation ; but it maynot be amiss to add, in the way of ex-

planation, that the death of the foetusis rather the preparative than the effectof the evolution; in order that the fostus

may be evolved, flexibility is necessary,and this flexibility, in general, does notexist, unless the child is wholly, or in

great measure, dead. Now, on both theseaccounts, because the foetus is so often borndead, and because there is a fear that the

powers of nature should fail her, as a gene-ral practice it is improper to confide deliveryto the spontaneous evolution; bat if the

tendency to evolution be shown by your feel-ing the descending ribs or abdomen, or if

you have made attempts to turn the childwithout success, either from want of skill,or from the insurmountable dilficulties ofthe case, then, indeed, this mode of de-

livery should, I think, be fairly tried. Iwas called once to a case in the iieiglibour-hood of town, where two or three ac-

coucheurs of talent had attempted to turnthe child, but could not succeed, and, ontrying myself, I failed too. Under thesecircumstances, we deemed it prudent to

wait; and, in the course of two or threehours afterwards, the child came away bythe spontaneous evolution.

In the transverse presentation, however,the ordinary method of delivery is by meansof the turning, to which I have so oftenreferred ; and in different ways this opera-tion may be attempted. Laying hold of thecranium, we may endeavour to bring thehead over the centre of the pelvis ; or, lay-ing hold of the breech, we may bring downthe nates ; or, laying hold of the knees orlegs, we may draw down by these parts ; sothat the operation of turning, may be di-vided into three varieties the turning by thehead, the turning by the breech, and thecrural turning. Of these three varieties,the cranial turning is the safest for the

child; because, if we can bring the head overthe centre of the pelvis, there is no dangerlest the umbilical chord be compressed, andthe child is born in the usual manner.-

Though desirable for the child, however,this form of turning is unsafe for the mo-.ther, because difficult for the accoucheur ;for the head, large, rounded, and slippery,escapes from the hand, and the repeatedendeavours to grasp it are not without dan-

ger of laceration. Next to the crural turn,is the turning by the nates ; and I havetold you already, what you have not,I trust, forgotten, that more children are

born alive under the breech presentationthan the crurali In the breech presenta-tion, the lower limbs lying on the abdo-men, there is a groove formed betweenthe thighs, in which the umbilical ehordlies, and is secure from pressure. Nowwhen you introduce your hand to turn

the child, perhaps the nates constitute thefirst part on which your fingers fall, andthis part you may bring over the centre

of the pelvis. Like cranial turning, how-ever, that of the nates is, on the whole,not easy for the accoucheur, and hencethough safer for the foetus it is less securefor the mother, and, as a general practice,ought not to be adopted. When we turn

by the feet or knees, the umbilical chordis exposed to continued and fatal pressureduring the passage of the head and shoul.ders ; yet, notwithstanding this objectionto the crural operation, and though in some

anomalous cases we may, perhaps with ad-vantage, turn by the nates or the cranium,yet, on the whole, this method of operatingby the feet is to be preferred.

In transverse presentations, it has beenproposed to bring away the child by theCiesarpan operation, and after what 1 haveseen of the difficulties and dangers arisingfrom these presentations, I would franklyacknowledge that cases do now and thenoccur in which I conceive it would be less

painful, and on the whole not more dan.gerous to the mother, to have the childtaken out by the Caesarean operation (im.proved as it may be hereafter,) in preferenceto any other mode; but if we once ad.mit the obstetric principle, that the Csesa-rean operation may be performed in trans-verse cases as a substitute for turning, to

the abusive adoption of the Ccesarean mci-sion by the rash and adventurous, therewould I fear be no end, and the greatestmischief might ensue. Against such use ofthe operation, therefore, in the presentstate of knowledge, I feel it a duty to raisemy voice. In transverse presentations Icannot allow that the Caesarean incisionsare ever justifiable, and the man who, undersuch circumstances, rashly performs them,would render himself awfully responsible forthe result. Yemen of genius (if such therebe present,) with minds formed, not merelyto talk about the profession, but to improve

it, never shrink from your duty for fear ofthe blockheads ; formidable as they mayappear at first onset, if left to themselves

they will soon collapse into their naturalinsignificance,

" Quali dal vento le gonfiate veleCaggion avolte poiche l’alber fiacca."

Remember, however, that firmness andrashness, though approximated, are as diffe-rent from each other as vice and virtue, and

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that from the reproaches of our own con-science, it is no cowardice to shrink.Mr. Scott, a very intelligent practitioner

of Norwich, met with a case in which thewoman recovered, although the os uteriwas torn off and came away from the va-

gina. For reasons stated at large in thePhysiological Researches, I feel persuaded Ithat the division of the os uteri wouldnot necessarily prove fatal ; nevertheless,as a remedy in obstructed transverse par-turition, in the present state of expe-

rience, it ought, I think, to be reprobated,as both dangerous and inefficient. If anincision were made, on introducing thehand the opening would most probably be-come enlarged by laceration ; and even

though you passed into the womb with faci-lity, the main difficulty would still remain,I mean, the conveyance of the hand alongthe body of the uterus into the fundus,where the feet commonly lodge.

In transverse presentations, 1 have neveryet had occasion to remove the child fromthe uterus by embryotomy, having alwaysfound hitherto, that, with patience and ma-nagement, deliveiy could be otherwiseeffected. Having, therefore, personally butlittle knowledge of the operation, I forbear

copiously to enlarge on it, though a few re-marks may be allowed.

In performing embryotomy, it should, Iconceive, be our first endeavour, from accu-rate observation externally and within, toascertain, as clearly as may be, the positionof the foetus. This point obtained, we mayattempt the abstraction of the child in twoways, by decapitation, I mean, or disrup-tion of the different cavities. For openingthe cavities, I suppose the best instrumentis a long large perforator, in the arm pre-sentation, the most common, to be intro-duced at the thorax, the viscera being after.wards removed at the opening, so as to makeroom for the introduction of the hand andthe seizure of the feet. Although, how-ever, a foetus may be removed in this man-ner, I suspect that extraction by decapita-tion, when this may be accomplished, is de-

cidedly to be preferred ; a practice first re-commended bv Hoorne, and recorded, Ithink, by Heister. I should prefer to a

semilunar knife with cutting edge, a blunthook of soft iron, and not of steel, mountedon a stem, firm yet flexible, so that, in ope-rating, the curve might be accommodated tothe situation of parts. Over the neck thisliook is to be fixed. and then by drawing re-solutely, but rationally, the head is to betorn from the body ; the body of the fostusbeing first abstracted by the arm, and thehead removed from the uterus separatelyafterwards. These operations, calculatedto fill the feeling mind with disgust andhorror, can, I conceive, under no circum-

stances be necessary, unless the fœtus be

dead; and it would be still more satisfactoryto operate when putrescence is begun, asthis would facilitate the dissolution of the

junctures. In brachial presentations, theputrescency is known by the state of thearm, ascertained easily as it lies under theeve of the operator.You will ask me, perhaps, in concluding

the subject, how it is that the transversecases terminate, when committed entirelyto Nature ; the accoucheur, forbidden bythe patient, or being incaeable of accom-plishing the delivery, forbearing to inter-fere. When the child lies across in the pel-vis, it so rarely happens that these cases arecommitted to Nature, that we have reallylittle opportunity of knowing their naturaltermination ; but it is highly probable that,in some few cases, the women would die un-

delivered ; while in others, perhaps mostcaaes, the fcetus, softened by putrefaction.would come to pieces in the cavity of theuterus, or be pushed away by a spontaneousevolution, the mother ultimately recovering,or sinking in consequence of lacerationsand contusions, exhaustion, or the like.Of turning, we shall treat at our next

- meeting.

LECTURES ON CHEMISTRY,BY

PROFESSOR BRANDE.

Delivered at the Royal Institution of GreatBritain.

LECTURE XXI.

On Sulphur, and its Combinations with Oxygen.THE next substance on our list is sulphur,

or brimstone, as it is commonly called, a

body which, in the present state of ourknowledge, is called primary, or elemen-

tary, because it has not been resolved intoany more ultimate elements. Not manyyears ago it was regarded as a compoundof sulphuric acid and phlogiston, and itserves to show us how uncertain chemicalscience often is, even when founded uponexperiment; but the whole of that theoryhas been subverted, and it is now consideiedas a simple body.

It is found native in a great variety offorms, independent of any volcamc origin.It is met with in the crystalline and in themassive forms in great abundance, forminga variety of combinations with the metals ;and in fact the greatest number of the me-tals are found united with it in the form of