No.219.

LONDON, SATURDAY, NOVEMBER 10. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY

DELIVERED AT GUY’S HOSPITAL BY

DR. BLUNDELL.

LECTURE VI.

Of the varinus Modes iia which the Child is trans-mitted through the Pelvis.

THE foetus, Gentlemen, may pass the pel-vis, or attempt a passage, under jour differentpresentations, and four different presenta-tions only, and the presentations I mean arethose of the head, of the feet, of the breech, andthose in which the child is lying acrossthe pelvis. Under one or other of thosegeneral presentations, cephalic, natal, crural,or transverse, the passage of the pelvis mustbe accomplished or attempted.Of all the presentations, the cephalic are

decidedly the most common ; and of the

parts of the head, that which presents mostfrequently, and which forms the presenta-tion in all ordinary labours, is the vertex, orthat part of the summit around which thehair is curvilinearly ranged.

Vertex presentation.—When the vertex pre-sents, as in an ordinary labour, we find, inthe commencement,of parturition, that theface is lying upon the sacro-iliac synchon-drosis, the occiput on the acetabulum, andthe chin upon the chest ; and in this positionthe head descends with facility, as heredemonstrated. In consequence of the facelying in this manner towards the one, andthe occiput towards the other side of thepelvis, the long length of the head stretch-ing from before backward is in correspon-dence with the long diameter of the brim,which reaches, as already demonstrated,from side to side, the two diameters, as youperceive, here agreeing with each other.If the face lie forward, in the way here il-lustrated, the head will not descend with

equal facility, the long diameter of the headbeing opposed to the short diameter of thebrim. From the natural situation, therefore,evident advantage is derived, the face lyingtowards the sacro-iliac synchondrosis, andthe occiput being opposed to the acetabulum,the long diameters correspond.

In a labour that is natural too, the vertexpresenting, we further find the chin in thismanner depressed upon the chest, so that thetwo parts are brought in to contact with eachother : observe the model. The chin thus

placed upon the thorax, the occiput de-scends, and you bring the shortest of thethree long diameters, or axes of the head,-that I mean which is stretching betweenthe upper part of the forehead and lower

part of the occiput,-to bear upon the longdiameter of the brim ; a great deal of clearspace, into which, as you may see, thewhole mass of my fingers may be pass-ed, being retained in this manner on theside of the pelvis. If the chin be sepa-rated from the chest, so that the longest ofthe three diameters of the head, namely,

the stretching between the chin and thevertex, is made to correspond with the longdiameter of the superior aperture, a largerspace is occupied in consequence, and (ex-cuse the levity) the brim becomes brim full.Thus we find, on examination, that in thisnatural position of the head, the craniumlies in fact in that exact situation which,of all others, is the most favourable fortransmission through the brim, the chin

being brought upon the chest, the face uponthe synchondrosis, and the occiput upon theacetabulum ; under these favourable posi-tions plenty of room is obtained, and thehead of the foetus readily descends.When the head reaches the outlet of the

pelvis, we then find it emerging under thefollowing situation : the vertex presenting,the occiput lies out under the arch of thepubes, the face, and part of the os-coccy-gis and forehead, are deposited in the hol-low of the sacrum, and the sagittal suturestretches along the perineum, or that portionof the softer parts which is interposed be-tween the genetal fissure and the anus, and ofwhich I shall hereafter treat. Now if youexamine this position of the head at the

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outlet, in comparison with those propertiesof the inferior aperture, which I formerlyexplained, you will see that nature, in anordinary labour, places the head in the posi-tion the most favourable for passage. Theface and forehead lying in the hollow of thesacrum, the occiput lying out under the archof the pubes, the long diameter of the headaccords with the long diameter of the out-let, for the long diameter of the outlet liesbetween the pnbes and the coccyx, whencearises a great facility to the passage of thehead. If the face had been to the oxie andthe occiput to the other side, difficulty musthave arisen, for the long length of the headwould have been opposed to the shorter

length of the outlet, and the passage wouldhave been thereby obstructed ; it is clear,therefore, that when the head passes intothe pelvis under the vertex presentation, aturn is accomplished, pre-eminently calledthe turn; and by this the occiput, in thefirst part of labour on the side of the pelvis,is carried forward under the arch of thepubes. Suddenly the occiput may start for-ward into this position, but more frequentlyit turns gradually, so that unless you arecontinually examining, you may scarcelyknow when the evolution is effected.

Under presentation of the vertex, the faceof the foetus may lie on the symphysis pubisall through the labour, and in consequenceof this unfavourable position, no small dan-ger may arise ; the mother herself not un-frequently suffers, and the foetus often dies.When the vertex presenting the face liesforward in this manner throughout the la-bour, in the passage of the superior aper-ture, considerable difficulty may be occa-

sioned, the long diameter of the head beingopposed to the short diameter of the brim.If the head be larae, or the pelvis small, itcannot be transmitted through the aperture ;and even when the head is smaller and thepelvis more capacious, the chin of the child

lying on the chest, so that, of the three longdiameters, the shortestis opposed to the shortdiameter of the brim, it is not without stronguterine effort and many pains, that the de-scent is effected, and the bladdergut andvagina are all of them liable to suffer fromthe severe pressure to which they are

subjected; besides the face lying forward,you may perceive that no part of the headlies out under the arch of the pubes, as

in ordinary labour, nor does the occiputlodge itself in the hollow of the sacrum,without that loss of room which in this ap-paratus is so well demonstrated. You mayobserve, moreover, when the head emerges,that on the rectum and perineum, the occi-put must bear most forcibly, and in thosecases, especially in which instruments areunskilfully employed, contusions, lacera-

tions, and slougliings, will not improbably

be produced. To’all which we may add,that, occasioning so much compression, thehead is itself forcibly compressed ; the fœtusnot uncommonly perishing in consequenceof cerebral contusion.

Important as this case is, I shall demon-strate the different parts of it again in the

way of brief recapitulation. The vertex

presenting, and the face lying forwardthroughout the labour, there is difficulty atthe brim, because the greatest length of thehead does not correspond with the greatestlength of the aperture ; the head, however,being frequently forced down by the strengthof the pains, but not without much sufferingfrom resistance and pressure. Further, thevertex presenting and the face lying forward,there is great difficulty at the outlet, arisingfrom three causes, first, because no part ofthe head lies under the arch of the pubes;secondly, because the occiput does not fit innor commodiously adapt itself to the hollowof the sacrum ; and thirdly, and very prin-cipally, because the back part of the heador occiput is making so much pressure onthe perineum and rectum, that it occasionsbruising, laceration, and sloughing, withmuch resistance of those parts.

It seems, then, that where the face

throughout the labour is lying forward onthe symphysis, many difficulties are ocea-

sioned ; what is it then, that the accoucheurcan do in order to diminish, surmount, orremove them? What is there that he canwith prudence do, and without committingthe unpardonable sin of midwifery, the sin-I mean, of those obstetric reprobates, themeddlesome and the pragmatic That turn-ing the child is universally unjustifiablewhen the case is indisputable, the dex-

terity great, and the circumstances are

conducive. I will not venture to assert.

And when the softer parts are lax, and thepelvis is capacious, and our dexterity fromlong practice such that we can introducethe hand into the cavity of the uterus,and lay hold of the child’s legs, and bring itaway with facility, by the operation of turn-ing : I will not say that under such circum-stances, we may not now and then be justi.fied in making the attempt. By this opera.tion we clear ourselves of the malpositionof the head, the vertex becoming changedinto the crural presentation. Decidedly,however, and in the strongest language I

can use, I would reprobate this turningas a general practice in these cases, be-cause you will be conttising the vagina,if you are needlessly pushing the hand up

the uterus, because you will be tearing thewomb, pulling the head from the body-

: meddling. Remember also, that until you! acquire the dexterous use of the fingers,you must frequently be deceived when en-deavouring to ascertain the situation. Often

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you might fancy the child’s face is forward,when it is not; often, if you were to mak6a practice of turning, you would perform theoperation without need, and when, perhaps,the child’s head was lying in the positionthe most favourable for parturition.

If the softer parts are lax, the pelvislarge, and the fingers dexterous, I will notassert that you may not be justified in doingwhat I myself sometimes have done, I meanrectifying position. Finding that the faceof the child is forward, that the head isabove the brim, that the passages are re-laxed and capacious, you may put your handinto the uterus, you may lay hold of thehead, asyouwouldlay hold of any other body;and you may gently place the head with theface in the side of the pelvis ; all this, I say,may be done; may be commended, perhaps,sometimes,-but beware, lest you rashlycontuse or lacerate the softer parts. So,again, if it be clearly ascertained that theface of the foetus is lying on the symphysis,when experience and practice are not want-ing, if you have a pair of forceps, or a lever,you may endeavour to rectify the positionwith these instruments, proceeding, how-ever, as I here show you, cautiously andwith reflection, remembering that you areoperating upon the softer sex ; then having isecured the cranium by means of one or

other of these instruments, when the headis at the brim, you may lay the face on theside of the pelvis, and when it reaches theoutlet, you may deposit it in the sacrumbehind.

There is yet another practice proposed byDr. Clark, and which seems to be excel-

lently adapted to cases of this kind, recom-mending itself to our attention by its easeand safety. When the face lies forward,and the head is descended into the cavity ofthe pelvis, you may lay two fingers on thecheek, and pressing gently when the wombis in action, you may gradually transfer theface from the front to the back of the pelvis,gaining a little progress with every pain,and this, too, without injury to the delicatestructure of the female, unless turbulenceand violence unfit you for the duties of anaccoucheur. So that to recapitulate inthose cases in which the vertex presentingthe face is on the symphysis, we maysometimes, though very rarely, attempt toturn the faetus by the feet, or sometimeswhen the head is above the brim, we mayeffect the rectification by the hand, forceps,or lever, as demonstrated ; or sometimes,lastly, and most securely, by laying the twofingers on the cheek, and gradually withevery pain bringing the face towards the side,and ultimately into the hollow of the sacrum,a rectification of the unfavourable situationmay not unfrequently be accomplished.

But what is to be Fdone, should neitherthe rectification of the situation of the head,nor the turning of the child be deemed thepreper practice? You cannot rectify per-haps : to turn the fcetus is impossible.-Why, in cases like these, Gentlemen, thegeneral rule should be your guide : first,give a fair trial to the natural efforts, whichthe wise accoucheur who has seen much,and thought much, never hastily distrusts.If, therefore, no dangerous symptomsmanifest themselves, let the womb act

powerfully for four-and-twenty hours afterthe discharge of the liquor amnii, and not-withstanding its unfavourable position, thehead will frequently descend. But if dan.gerous symptoms appear, the bladder be.coming obstructed, the parts about the neckof the womb inflaming, the pulse rising infrequency, and remaining between the painsat 125 or more in the minute ; or, if inde-pendently of these or other symptoms, thewomb have been in strong action for twenty-four hours, the head not advancing-withtenderness and prudence the lever or forcepsmight be tried ; or, lastly, should these in-struments be unavailing, or should symp-toms of danger manifest themselves, (to beeffectually relieved by delivery only,) or

even independently of such symptoms, shouldthe head make little or no progress, thoughthe womb have been in action after the dis-

charge of the liquor for six-and-thirty, oreight-and-forty hours, compelled by an in-exorable necessity, you must have recourseto the perforator, your reluctance beingsomewhat diminished by the recollectionthat, under such circumstances, the foetus,even when unopened is generally born dead.In every labour attended with difficulties ordangers, there must be need for the exerciseof a corresponding discretion ; by individualcontingencies, general rules must be modi-fied, but adhering to the directions which Inow prescribe to you, I am persuaded youcannot wander far from the correct line ofpractice.To conclude then with a summary : when

the vertex presenting, the face lies forwardthroughout the labour, and this is ascertained;in some cases you may turn, though with atrembling hand ; in some casesyou may rectify,always justified in trying that simple methodof rectification, by lateral pressure with thefingers, as before mentioned. In the ma-

jority of cases, however, and especially ifyou are as yet inexperienced in the practiceof midwifer3-, you may trust with confidenceto the natural efforts; these failing, youmay have recourse to the lever or the for-

ceps ; and these not availing, the perforator.Under the best management, (unless you canrectify,) these are bad cases, as the bruising,lacerating, and sloughing of the parts, andthe death of the child, are to be apprehended.

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Face Presentation.—When the head of thechild presents, you sometimes have the facelying over the centre of the pelvis, the chin,I believe, usually lying on one side of thepelvis, and the vertex on the other, so thatthe greater lengths of the head, and the supe-rior aperture, reciprocally correspond. Underthe efforts of the uterus, the face present-ing, the head is gradually worked down,and, at last, we find it lying in the outlet ofthe pelvis; the chin, at this time, usuallytaking its situation under the arch of thepubes, and the vertex and occiput in thehollow of the sacrum and coccyx, and uponthe perineum ; the child, when about to

emerge, lying in the situation in which Inow place it, with the ears on the side ofthe pelvis, the chin under the arch, and theocciput and vertex in the hollow of thesacrum and perineum, as before described,The head advanced thus far by a con.

-tinuance of the pains, and the occiputbeing gradually rolled out from the hollowof the sacrum, the head is pushed into theworld, the perineum, and all the softerparts, being stretched dreadfully, so thatthere is great danger of laceration, especi.ally if you accelerate the escape of the

occiput by the use of the lever or the forceps.I will suppose, then, that you are called to acase in which the face is presenting. What isto be done must you meddle must you useinstruments? must you turn the child? Now,in the face presentation, as in the case al-

ready described, in which you have a pre-sentation of the vertex, the face lying for-ward throughout the labour, I do allow thatin occasional and exceptional instances,when the pelvis is large and the softer partsare lax, the accoucheur skilful and confident,and, above all, judicious, may carry thehand into the uterine cavity, and bring thechild away by the operation of turning, lay- I,ing hold of the feet as before described, andabstracting it under the crural presentation.As an exception to a general rule, thismethod of delivery may be proper enoughbut observe, as a general rule of practice inface cases,with the whole weight of authoritywhich I may possess with you, I condemn it.Do it ninety-nine times, and successfully,and I condemn it still ; because you are med-dling, because you are cramming your handinto the uterus without any sufficient cause ;because you are, as it were, doing your bestto tear the vagina; because ninety-nine ope-rations undeservedly successful may lead tothe hundredth, and the destruction of yourpatient. It is the same with respect to

rectification ; if you find the pelvis large, thesofter parts lax, and your fingers very adroit,under such circumstances you may ventureto introduce the hand, for the purpose of

rectifying the position of the head, an opera-tion sometimes perhaps accomplished with

facility, while the head lies at the brim. Inthese cases, operating as I now demonstrate,’ with the fingers or the lever, you may makethat which was facial, a vertex presenta-tion. But understand again clearly, that thisis an exception from a general principle-apractice unfit for the novice, though con-ceded occasionally to the adroit and experi-enced accoucheur. In presentations of theface, the stoical rule will apply; a rulewhich might with advantage be whisperedinto the ear at all times, when you are at thebed side—naturam sequej’e; delivery is a

natural process, give therefore a fair trial tothe natural efforts. When, then, you find aface case frequently, nay, generally, you havelittle to do ; you need not send for anotherpractitioner ; you need not allow your mindsto get into a state of perturbation, as if youhad some mighty feat to achieve. Youhave only to sit quietly at the bed side, tosupport the confidence of the woman, to letthe uterus act, to protect the perineum, toopen your hands, as it were, and receive thechild which nature deposits in. them. If,however, the head be large, or the pelvissmall, it may be in this, as in the vertex

presentation, that the natural efforts fail;and, in such cases, you may try thelever or the forceps, but with gentleness,with caution, as on your dearest friend,bewaring lest you occasion a laceration or

sloughing of the softer parts ; and these in-struments failing, should delivery be pe.remptorily requisite, you must then layopen the forehead, and discharge the con-tents of the cranium, when the head willreadily descend.

Forehead Presentatimc.- Under presenta-tions of the head, we sometimes find theforehead lying over the centre of the pelvis,instead of the face. And this presentation,made out in the way hereafter described, bya careful examination, can rarely, I believe,occasion much difficulty ; for after therehave been a few pains, the head turningsomewhat, the vertex or the face descends,the case being afterwards managed by rulesalready prescribed. Ear presentations alsooccur, but they are so rare, or so easily

I conducted on the principles already laiddown, that I consider it unnecessary to en-large on them.

Foot or Crural Presentation.-By the Gal-lic accoucheurs, the crural or foot presenta-tion is divided into no fewer than six va-rieties, in practice conveniently reduced totwo kinds only, those in which the abdo-men is lying anteriorly more or less, andthose in which it is placed on the back ofthe mother, whether it bear a little to the

right or left, or fall directly on the promon-tory of the sacrum.Of all the crural presentations, the easiest

and most simple is, that in which we find

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the abdomen of the child lying towardsthe back of the mother. Now, in cases ofthis kind, the mode in which the child

passes the pelvis is this: Under the strongaction of the womb, the legs are graduallypushed beyond the outlet of the pelvis,when the thighs coming within reach,the accoucheur lays hold of them, a nap-kin being interposed, in order to renderthe hold more secure. The thigh grasped,he next draws down in the axis of the ’,pelvis, which, as you may recollect,

I

stretches downward and backward at the I

brim; careful not to lacerate or bruise theparts, and swaying the fmtus from side toside, or a little backward and forward, asthe motion one way or other may most fa-cilitate the delivery. If the pains are fre-quent, the accoucheur co-operates withthe pains, but if the pains are unfrequent Ior wanting, he draws notwithstanding ; forwhen the delivery is once begun, and theumbilical chord is brought down, so as to becompressed between the fcetus and the va-

gina, delivery should be promptly accom-plished, because, when there is much andcontinual pressure on the chord, the childdies. But of this hereafter. In cases ofthis kind, when the breech is passing, takecare that you do not lacerate the perineum.When the breech is abstracted, the abdomenbegins to appear : lay hold of the umbilicalchord, and draw it forth a little, so as to pre-vent extension during the further abstrac-tion of the child. When the thorax beginsto descend, lay your finger in the side of the Ipelvis, and if you find, on examination,that an arm be disposed to come down, Idraw it out at full length, and lay it alongthe side, so as to prevent it from starting atan angle, and lodging against the brim ofthe pelvis. In general, however, the arms do not descend by the side of the thorax, soas to demand this manoeuvre. When theatillfe. are approaching the external parts, ’,a precaution of no small importance becomesrequisite ; I mean} the preventing the armsfrom taking place behind the occiput, andfrom becoming impacted between the frontof the pelvis and the head, so as to renderextraction impracticable. Now, to preventthis accident, prudence requires, when thearm-pits approach the inferior aperture,that you pass up the fingers, so as to geta bearing on the arms, and throw themas much as may be upon the back of thepelvis, towards the face of the child ; andwith these precautions," the axilla of thechild being brought down to a level withthe external parts, the body of the fcetus

being thrown out of the way, and into suchposition as shall favour the descent of thearm, putting all the fingers, if practicable,about the bend of the elbow, and sweepingthe arms in succession over the cheek,

you disengage them from the cavity of thepelvis. When the arms are drawn forth,usually the head descends without furtherdifficulty, more especially if the cranium besmall, or the pelvis be capacious; but shoulddifficulties arise, you may endeavour to

throw the face and occiput at the brim, onthe sides of the pelvis respectively, so thatthe greatest lengths of the head and the aper-ture may correspond with each other ; andthen, bearing the head towards the symphy-sis pubis, yet drawing on the whole inthe axis of the brim, on a line stretchingfrom the navel to the point of the coccyx,you cause the head to come down. The head

descending in this manner, when it reachesthe outlet of the pelvis, put the face intothe hollow of the sacrum, and the occiputon the symphysis pubis, and then drawingdownward and forward, careful not to lace-rate the perineum, you complete the delivery.Now all this, on account of its importance,

I demonstrate afresh. The feet presenting,you suffer the womb to act till the thighsare lying forth in the outlet of the pelvis ;then, gently grasping the legs, you swaythe body a little from side to side, or frombefore backward, careful that the genitalfissure sustain no injury. When the breechpasses, guard the perineum; when the ab-domen passes, draw forth a little the umbi-lical chord, so as to prevent its extensionduring the subsequent descent of the child.When the thorax approaches, cautiously,tenderly, yet effectually, pass the finger intothe side of the pelvis, and if the arm oneither side be descending, extend it, andlay it at length along the side of the trunk,as now shown you. When the axillae beginto enter the inferior part of the pelvis, - ashere, be very careful, as they come for-ward, to press the arms, as demonstrated,toward the promontory of the sacrum, pre--venting their impaction between the headand the pubes, and in this manner facilitat-ing their subsequent descent. The axilla

reaching the outlet, throw the body, as nowshown you, into the position most conduciveto the descent of the arm ; placing three orfour fingers about the bend of the elbow, andin succession swaying -the arms downwardwith a sweep over the face. Afterwards, ab-stracting the head with due attention to itsposition, guarding the perineum, and indeedtaking care that the whole operation be con-ducted with that degree of force only whichmay inflict no violence on the mother or herchild. lir consili expers mole ruit sud. Contu-sion, lacerations, sloughings, decapitation,dislocation, fractures-these are the dreadfulevils to which brute force may give rise.Under the crural presentation, the abdo-

men of the child is sometimes situated an-teriorly, the case being just the converse ofthe preceding. Now when the abdomen,

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as examination shows, is situated on thefront uf the pelvis, there-are two modes inwhich the child way be extracted, thoughnot with equal facility ; and first, we maydraw down the feet as before, and the axillabeing brought to 4 level with the outlet,we may extiicate the arms by throwing thebody thoroughly out of the way, getting thefingers into the bend of the elbow, and

sweeping the arm out of the pelvis overthe face of the child, behind the syni-physis. Although, however, the child maybe abstracted in this manner, you will findthere is a difficulty in the abstraction of thearms especially, as indeed the machinery atthis moment indicates to my feeling. Nowthis being the case, it is wise to throw theabdomen of the child to the back of themother ; and by laying hold of the thighswith the left hand, and spreading on theback of the foetus the fingers of the right,vou mav sometimes transfer the abdomento the posterior surface of the womb andvagina, making the turn I now demonstrate;when you produce a foot case with the ab-domen seated posteriorly, to be managed bythe rules already given. To make this changeof situation, little skill may be required;but there is one point of nice determination,I mean the selection of the proper momentfor performing the operation ; for before theturn is made, you may, if you please, drawthe head and arms into the pelvis; youmay, if you please, impact them there, andyou may, if you please, unwisely attempt tomake the turn, when you have unwiselymade the operation impracticable. But toproceed Incidit in Soyllam qu-i vultvitare Charybdem,." In avoiding this error,you may fall into the other extreme ; youmay attempt to place the abdomen on theback, when only the tips of the feet arelying within reach, a practice unadviseable,as the turn,though accomplishable, must beeffected with diffioulty, seeing that a forceapplied to the ancles will notreadily act pponthe head and shoulders above. W bat, then,is to be done 1 On the whole, I think thebest time for performing the operation, iswhen the thighs makp their appearancefor in grasping them, you may get commandover the body and other parts, the head andshoulders, still lying above the bones of thepelvis, and of course not being impacted inthe brim. It seems, then, that undercrural presentations, it becomes the officeof the accoucheur to co-operate by drawingdown. the child ; but there still remains aquestion, on which I hope some of youhave been ruminating, I mean, what isthe proper moment at which the co-qpera-tion should ba given 1 And here I maystate to you a maxim of midwifery, on which,hereafter, I shall frequently lay stress Imean, that in selecting the proper time of

giving assistance, the accoucheur oftenshows his judgment, more than in the exe.cution of the manual operation itself. Themanual operations of midwifery are some-times suniciently easy, but much pice discri-mination is required tq seize the moment atwhich those operations should he performed.Let us suppose, for instance, a fqpt presen-tation, a first delivery, the parts rigid, thehead large, the pelvis small, laying hold ofthe legs without reflection, you advance thechild without difficulty, till the thorax enterthe pelvis : but mark the result-in conse-quence of not selecting for your operations

I the proper moment, you find yourself, if I

may be allowed the expression, on the hornsof a dilemina ; the legs have descended easilyenough, the abdomen, too, has opposed butlittle difficulty, but the head and shoulderswill not pass. Now if, anxious to avoid thelaceration of the mother, you wait for arelaxation of the softer parts, the child lyingas here demonstrated, with the legs m theworld, and the head and thorax in the pelvis,its life becomes the sacrifice ; pressure on theumbilical chord occasioning a suffocation, pro.bably, as painful as the death of the felon whoperishes by the. rope. On the other hand,if desirous to preserve the foetus, you drawdown. without delay, you lacerate and bruisethe softer parts of the mother, so that bygiving assistance at an improper moment,you endanger at once both the parent andher offspring. Aware of this risk, practi.tioners have endeavoured to lay down plainrules, which may enable us to decide whenwe ought, and when we ought not to inter-fere ; and there are some who, not withoutreason, take their indication from the laxityof the parts, and the expansion of the osuteri; and if on examination they find thatthe parts are lax, and that the dilated osuteri is as broad as the disk of a crownpiece, they commence the delivery, refrain.ing frpm manual operations if the parts arerigid, or if the mouth of the womb be shut.There are others again, as Denman, for ex-ample, who ascertain the moment of inter fe-rence by the descent of the child. If thebreech is at the outlet, they deliver, and if itlie at the brim, they wait; the chord is notunder pressure ; the life of the fcetus is notin danger; a meddlesome midwifery is bad,and there is as yet no need for acceleratingthebirth. There are, again, other practitioners,who judge by a rule which, if of easy ap-plication, would perhaps be preferable to tbeformer, and this rule is taken from thestate of the umbilical chord. If the chordbe pulsating strongly, they let labour pro-ceed without interfering, considering thatthere is no danger of suffocation, as the. foetal heart is in full play ; but if pulsation inthe chord be weakened or suspended, they

endeavour to abstract the faetus as promptly

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as may be, unless they believe it to be lostbeyond recovery.

For myself, I am accustomed, in my ownpractice, to combine these rules, and to actunder the influence of all three. With me,of course, it is a maxim neve7’ to deliverwhile the softer parts are rigid and the osuteri is little expanded ; but if the softerparts are relaxed thoroughly, and the diskof the os uteri exceeds that of a crown

piece, I deem myself so far justified in as-sisting the delivery. But this is not all:

although the softer parts are yielding, andthe os uteri is dilated, under the impres-sion that meddling is wrong, and that thenatural powers are great, I give a fair trialto the natural efforts, waiting, as Denmanadvises, till the breech is pushed downupon the outlet, and the chord becomescompressed; and then, finding the breechin the ouGet and the softer parts relaxed, Iproceed with the delivery, not neglectingthe examination of the chord, advancingmore rapidly if the pulse fall, and in a moreslow and gradual manner if the firm beat ofthe chord indicate that the child is secure,always bearing in mind another axiom ofBritish midwifery, I mean, that the life ofthe child is invariably to be sacrificed tothe security of the parent, and never acce-lerating the birth more than the softer partswill bear.When we meet again, Gentlemen, we shall

resume this inquiry.

LECTURES

ON THE

INTELLECTUAL COMPOSITION OF MAN,

Delivered at the London Medical Society by

DR. HASLAM.

LECTURE IV.

On Reason and Imagination.IF the human mind admitted of a division

into distinct powers and faculties, from be-ing the result of such components, its in-vestigation would be attended with few dif-ficulties: we should proceed directly to its

analysis, ascertain its contents, state its de-finite proportions, and finally display themanner of its operations. In conformity tosuch hypothesis, the examination of thissubject has been usually conducted ; butthese analytic chemists of the human intel-lect have unfortunately disagreed concern-ing the component parts. The elements of

one tribe of philosophers have been viewedas compounds by other sects, and they havecontinued their disputations on assumed

principles, until their readers were con-

fused, and good sense retired in disgust fromthe contest. According to my own views, Ishould not define reason as any inherentfaculty we possess, and which, in the pro-gress of our mental career, is necessarilyunfolded; not a consequent developmentfrom existing germs, but an acquirement,like the rest of our intellectual possessions.If reason were an inherent and original fa-culty of the mind, it might be employed in-discriminately on all subjects of investiga-tion, and be considered as the test or touch-stone of decision; but it can exert no suchintrinsic energies, and requires the sub-stratum of knowledge, as the indispensableconditions of its display. What, for in-stance, could be the reasonings of a man onthe operation for lithotomy, either high or

i lateral, who was wholly ignorant of the ana-tomy of the parts concerned Without ananatomical basis, what would be the amountof our reasonings on physiology Indeed itis evident, that the reasoning on all sub-

jects in our own profession (which is namedas the most obvious illustration,) demandsthe previous attainment of sufficient know-ledge. There must be existing premiseswhereon to institute the estimate, in orderto arrive at the conclusion. P,,easoning,therefore, is not the mere acervation offacts that constitute knowledge, but the

employtnent of that knowledge for particularpurposes. The most skilful and extendedcontrivances of language are inadequate toany precise definitions of quantity andvalue : they may describe certain generalrelations of both, but can attain no accuracy.The utmost that language can perform, is arude and uncertain comparison, whether it beoccupied on heat, distance, magnitude,time, space, value, or aggregates. It can

only state an object to be large or diminu-tive, without any determinate size : it mayindeed, compare substances, but cannot fixany accurate standard, and its range is onlythrough the grammatical and indefinite de-grees of comparisou. Among the many anddiscordant opinions that have been enter-tained on the subject of reason, some insistthat it is the peculiar endowment of man ;and if we speak of its highest operations,this will not he disputed: but there aresome acquirements of animals, the result oftheir experience and practical efforts, whichare, although in an inferior degree, fullyentitled. to the character of reason ; whollysetting aside their instincts, which on afuture occasion will be considered as ten-dencies or impulses, equivalent to reason,expressly furnished. If we consult thatwhich ia termed authority, for the definition