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EDITORIAL.

PRESENTATION AND POSITION. ANCIENT AND MODERN TEACHINGS.

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MONG the preserved writings of Hippocrates, his Aphorisms are perhaps the most authentic. Among them we find one of interest to obstetricians:-"The head is the only natural presentation, and when a child either lies across, or presents by the feet, the woman cannot be delivered." As the formulated expression of the prevailing notions and practice of the times, this aphorism is evidence of the dense ignorance that held the art of Midwifery in bondage. There are no records to prove that this formidable error did not prevail and govern practice for ages before Hippocrates formulated his famous aphorism. But there exists sufficient evidence that it prevailed for ages afterward,

nearly two thousand years, as computed by Leishman.

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is also the first, or one of the first records showing that profound scientific minds were taking any notice of parturition. and its accidents. "Observe the effect of this aphorism. The head being thus assumed to be the only presentation in which natural forces could effect delivery, it follows as the corollary of this proposition, that one of the chief aims of operative midwifery must be to convert breech and footling, as well as transverse presentations into presentations of the head. The contemplation of such a practice is too horrible to dwell upon. "(Leishman.)

Hippocrates, in his demonstration with the olive in the neck of the oil jar, failed, profound thinker though he was, to see that an oval body may pass by either end of its long diameter. It is evident that Hippocrates' insight into physical principals was limited. It seems strange, too, from our present standpoint, that he was not brought to see his error, by an occasional spontaneous delivery of a child presenting by the breech. We know that such deliveries

occur to-day. We can account for this only in one way; namely: that he never saw such a delivery, and that if one chanced to be reported, he would receive the tale as a fabrication, wholly unworthy of attention from a dignified philosopher, like himself. This is not improbable, when we consider the fact that the whole field of midwifery was chiefly in the hands of women, ignorant and uneducated, as their times required them to be. Anything they would relate, of so unusual a character, and so improbable, would be received with incredulity, as such tales from midwifes and lay women are received to-day by the learned profession. Aristotle, a man of keener insight and wider culture, corrected the error of Hippocrates, to a certain extent. But to Celsus, a later writer on midwifery, greater credit is due in its correction. In his instructions for the management of transverse cases, we find the following sentence:-"Medici vero propositum est, eum manu dirigat, vel in caput, vel etiam pedes si forte

aliter compositus est." The physician may certainly make (the transverse) straight by the hand on the head or even by the feet if they are together. The teaching of Celsus is in keeping with that of Hippocrates in so far as the head should be the first to be brought into the superior strait. But he goes farther, and advises the feet, as a last resort, to be brought down, and then only if both can be reached and brought down together. How limited the field of operation, how limited the opportunity for saving maternal and foetal life!

It was

The older accoucheurs endeavored only to determine the presenting part. At this time abdominal palpation was unheard of, or ignored, and the vagina remained the only route for the required information. The position of the presenting part received no attention at their hands. not until the time of Solayres and Baudelocque, his pupil in more recent times, that position, or the relation of the presenting part to certain points of the pelvic brim received the attention, and the study, that the subject deserved Since their time, every professor or chief of a maternity has formed a classification of his own.

Tarnier and Cazeaux in their text book on the "Theory and Practice of Obstetrics" give the classification of presentation and position of Baudelocque, and the principal ones that followed shortly after him.

These tables are certainly interesting, as they show not only how quickly the human mind takes up a new idea, when advanced, but the increased interest taken in midwifery as a branch of Scientific Medicine.

Baudelocque primarily divides the foetus into two extremities, vertex and breech, and takes the occiput and forehead as the points on the foetal head for determining the position or relation of the presenting head to the pelvic brim. Baudelocque's classification was very complex and confusing. He described no less than one hundred and two distinct positions. So great a number was soon found to be

wholly useless in practice, and besides it disgusted pupils with the study of widwifery. Several classifications followed that of Baudelocque, though more simple, were still too complex. It remained for M. Naegele to simplify these classifications, much more than they had been ever before.

Dubois and Stoltz of Strassbourg, first endeavored to disseminate throughout France the views of the famous Heidelberg professor. One of the first marked improvements in the classifications of positions was made by Madam Lachapelle and a second by M. Moreau, who adopted most of the ideas upon which the arrangement of Naegele was afterward founded.

Madam Lachapelle and Ant. Dubois held and advocated opinions that furnish the foundation of Naegele's classification, namely, three principle regions are distinguished in the foetus: 1. The head or cephalic extremity; 2. The pelvis, or pelvic extremity; and 3. the trunk. Any one of these parts may offer first at the superior strait. These three regions furnish opportunity for complex and confusing arrangements of the various positions of each presenting part. Confusion still exists, but the tendency of modern thought, and research is to simplify still further. Abdominal palpation has been a great aid in simplifying nomenclature of position. This brings us to a time in our history, when the vaginal route is made secondary to abdominal palpation and auscultation as a means of diagnosis of the presentation and its position, which will be considered in a future issue of the JOURNAL. E. H. ROOT, M. D.

It is with deep regret that we record the death of the beloved mother of our editor, Dr. Lillian G. Towslee, August twenty-third, at her home in Cleveland, Ohio. Our deepest sympathy goes out to this family who have lost that great blessing, a loved and loving mother.

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