should be able to speak, and to understand what is said to her. This intermittent administration constitutes the peculiar safety of chloroform administered in labor, and it is a fortunate circumstance that there are very few cases on record of death during the inhalation of chloroform for obstetric purposes. This is obviously due to the effect of each inhalation passing off before a fresh dose is administered.

The effect on the pains should be carefully watched. If they become very materially lessened in force and frequency, it may be necessary to stop the inhalation for a short time, commencing again when the pains get stronger; this effect may be often completely and easily prevented by mixing the chloroform with about one-third of absolute alcohol, which, originally recommended, I believe, by Dr. Sansom, increases the stimulating effects of chloroform, and thus diminishes its tendency to produce undue relaxation. The amount administered must vary, of course, with the peculiarities of each individual case and the effect produced, but it need never be large. As the head distends the perineum, and the pains get very strong and forcing, it may be given more freely and to the extent of inducing even complete insensibility just before the child is born.

Ether. In cases in which chloroform has lessened the force of the pains, ether may be given instead with great advantage. It certainly often acts well when chloroform is inadmissible on account of its effects on the pains, and, so far as my experience goes, it has not the property of relaxing the uterus, but, on the contrary, has sometimes seemed to me distinctly to intensify the pains. Of late I have used a mixture of one part of absolute alcohol, two of chloroform, and three of ether, This is less disagreeable than ether, and has not the over-relaxing effects of chloroform, and, on the whole, I believe it to be the best anæsthetic for midwifery practice.

Bearing in mind the tendency of chloroform to produce uterine relaxation, more than ordinary precautions should always be taken against post-partum hemorrhage in all cases in which it has been freely administered.

In cases of operative midwifery, it is often given to the extent of producing complete anesthesia. In all such cases it should be administered, when possible, by another medical man and not by the operator, because the giving of chloroform to the surgical degree requires the undivided attention of the administrator, and no man can do this and operate at the same time. I once learnt an important lesson on this point. I had occasion to apply the forceps in the case of a lady who insisted on having chloroform. When commencing the operation I noticed some suspicious appearances about the patient, who was a large stout woman, with a feeble circulation. I therefore stopped, allowed her to regain consciousness, and delivered her without anaesthesia, much to her own annoyance. Just one month after labor she went to a dentist to have a tooth extracted, and took chloroform, during the inhalation of which she died. This impressed on my mind the lesson that no man can do two things at the same time. The partial unconsciousness of incomplete anaesthesia, in which the patient is restless and tossing about, renders the application of forceps, as well as all other

operations, very difficult. Therefore, unless the patient can be completely and fully anæsthetized, it is better to operate without chloroform being given at all.

[In the United States the dangers attending the use of chloroform in obstetric practice have, in large measure, banished it from the lyingin chamber. Some obstetricians in our chief cities still resort to it with little hesitation, believing that by great carefulness in its adminis tration, and by the substitution of ether in exceptional cases, all danger may be avoided. Others have a very great fear of it, and universally trust to the safer anæsthetic. It is an error to suppose that the parturient state robs chloroform of much of its danger, the apparent immunity being due to its intermittent and incomplete administration; complete anæsthesia being but a fraction less dangerous than in surgical operations upon women who are not pregnant. Dr. Lusk, already quoted, after a large experience with the use of chloroform, says: "Patients in labor do not enjoy any absolute immunity from the pernicious effects of chloroform." It is much to be regretted that this more pleasant anæsthetic is so much more dangerous than ether as an inhalant; but in consideration of the difference of risk, that of their relative effects upon the nose and trachea is scarcely to be considered. Chloroform acts upon the respiratory centres just as ether does; and this is an element of danger in each, but is capable of being counteracted by artificial respiration. But, beyond this, chloroform is far more dangerous, in acting upon the motor ganglia of the heart and producing sudden death. According to the experiments of Vulpian upon animals, not more than one case of cardiac failure in forty can be restored by artificial respiration. He affirms that there is danger at the commencement, during the course, and at the close of chloroformization, and even some hours or days subsequent to it. Nélaton made the important discovery that the cerebral anæmia produced by chloroform, with its accompanying death-like condition, might be remedied by long perseverance in artificial respiration with the patient turned head

downward.

Anaesthesia in labor is much less popular, both with obstetricians and patients in this country, than it was soon after its introduction. Improvements in the purity of sulphuric ether have made the narcosis more reliable, but the general effect upon patients varies very decidedly, being all that can be desired in some, and just the reverse in others. Some of the undesirable effects I have witnessed are intoxication, with cessation of labor, hysterical excitement, nightmare, and post-partum inertia and hemorrhage. I have also witnessed the most delightful results from ether that could be desired. In a small, delicate multipara whose mother died of phthisis, and to whom I had been obliged to administer stimulants in the first and much of the second stage of labor, the use of ether had the effect of revolutionizing her condition. Her pulse became strong; her expulsive power increased; she had no suffering; the placenta was expelled without accompanying blood; and there was no subsequent uterine relaxation. But such cases are, unfortunately, exceptional.-ED.]

[1 Opus cit.]

CHAPTER V.

PELVIC PRESENTATIONS.

UNDER the head of pelvic presentations it is customary to include all cases in which any part of the lower extremities of the child presents. By some these are further subdivided into breech, footling, and knee presentations; but, although it is of consequence to be able to recognize the feet and the knee when they present, so far as the mechanism and management of delivery are concerned, the cases are identical, and, therefore, may be most conveniently considered together.

Frequency.-Presentations coming under this head are far from uncommon; those in which the breech alone occupies the pelvis are met with, according to Churchill, once in fifty-two labors, while Ramsbotham estimates that it presents more frequently, viz., once in 38.8 labors. Footling presentations occur only once in ninety-two cases. They are probably often the mere conversion of original breech presentations, the feet having come down during the labor, either in consequence of the sudden escape of the liquor amnii, when the breech was still freely movable above the brim, or from some other cause. Knee presentations are extremely rare, as may be readily understood if it be borne in mind that to admit them the thighs must be extended, hence the vertical measurement of the child must be greatly increased, and therefore it could not be readily accommodated within the uterine cavity, unless of unusually small size. As a matter of fact, Mme. La Chapelle found only one knee presentation in upward of 3000 cases.

The causes of pelvic presentations are not known. They are probably the same as those which produce other varieties of malpresentation, especially an excess of liquor amnii and slight pelvic contraction; and it is not unlikely that, in certain women, there may be some peculiarity in the shape of the uterine cavity which favors their production. It would be difficult otherwise to explain such a case as that mentioned by Velpeau, in which the breech presented in six labors.

Prognosis. The results, as regards the mother, are in no way more unfavorable than in vertex presentation. The first stage of the labor is generally tedious, since the large rounded mass of the breech does not adapt itself so well as the head to the lower segment of the uterus, and dilatation of the cervix is consequently apt to be retarded. The second stage is, however, if anything, more rapid than in vertex cases; and even when it is protracted, the soft breech does not produce such injurious pressure on the maternal structures as the hard and unyielding head.

The result is very different as regards the child. Dubois calculated

that one out of eleven children was stillborn. Churchill estimates the mortality as much higher, viz., one in three and one-fifth. The latter certainly indicates a larger number of stillbirths than is consistent with the experience of most practitioners, and more than should occur if the cases be properly managed; but there can be no doubt that the risk to the child is, even under the most favorable circumstances, very great. Even when the child is not lost, it may be seriously injured. Dr. Rugé has tabulated a series of twenty-nine cases in which there were found to be fractures of bones or other injuries.'

The chief source of danger is pressure on the umbilical cord, in the interval elapsing between the birth of the body and the head. At this time the cord is very generally compressed between the head of the child and the pelvic walls, so that circulation in its vessels is arrested. Hence the aeration of the foetal blood cannot take place; and, pulmonary respiration not having been vet established, the child dies asphyxiated. There are other conditions present which tend, although in a minor degree, to produce the same result. One of these is that the placenta is probably often separated by the uterine contractions when the bulk of the body is being expelled, as, indeed, takes place under analogous circumstances when the vertex presents; the necessary result being the arrest of placental respiration. Joulin thinks that the same effect may be produced by the compression of the placenta between the contracted uterus and the hard mass of the foetal skull. Probably all these causes combine to arrest the functions of the placenta; and, if the delivery of the head, and consequently the establishment of pulmonary respiration, be delayed, the death of the child is almost inevitable. The corollary is that the danger to the child is in direct proportion to the length of time that elapses between the birth of the body and that of the head.

The risk to the child is greater in footling than in breech cases, because in the former the maternal structures are less perfectly dilated, in consequence of the small size of the feet and thighs, and, therefore, the birth of the head is more apt to be delayed.

Diagnosis. Inasmuch as the long axis of the child corresponds with the long axis of the uterus in pelvic, as in vertex presentations, there is nothing in the shape of the uterus to arouse suspicion as to the character of the case. Still it is often sufficiently easy to recognize a pelvic presentation by abdominal examination, if we have occasion to make one. The facility with which it may be done depends a good deal on the individual patient. If she be not very stout, and if the abdominal parietes be lax and non-resistant, we shall generally be able to feel the round head at the upper part of the uterus, much firmer and more defined in outline than the breech. The conclusion will be fortified if we hear the foetal heart beating on a level with, or above, the umbilicus. The greater resistance on one side of the abdomen will also enable us to decide, with tolerable accuracy, to which side the back of the child is placed. Information thus acquired is, at the best, uncertain; and we can never be quite sure of the existence of a pelvic

1 Bull. gén. de Thérap., August, 1875.

presentation until we can corroborate the diagnosis by vaginal examination.

[In view of the greater risk to the life of the foetus in a delivery by the breech over that by the vertex, it is advisable, when the position is determined while the membranes are still intact, to change the presentation from pelvic to cephalic by external bimanual manipulation.-ED.]

The first circumstance to excite suspicion on examination per vaginam, even when the os is undilated, is the absence of the hard globular mass felt through the lower segment of the uterus, so characteristic of vertex presentations. When the os is sufficiently open to allow the membranes to protrude, although the presenting part is too high up to be within reach, we may be struck with the peculiar shape of the bag of membranes, which, instead of being rounded, projects a considerable distance through the os, like the finger of a glove. This is a peculiarity met with in all malpresentations alike, and is, indeed, much less distinct in breech than in footling presentations, because in the former the membranes are more stretched, just as they are in vertex cases. When the membranes rupture, instead of the waters dribbling away by degrees, they often escape with a rush, in consequence of the pelvic extremity not filling up the lower part of the uterus so accurately as the head, which acts as a sort of ball-valve, and prevents the sudden and complete discharge of the waters.

Often on first examining, even when the membranes are ruptured, the presentation is too high up to be made out accurately. All that we can be certain of is, that it is not the head; and the case must be carefully watched, and examinations frequently repeated, until the precise nature of the presentation can be established. If the breech present, the finger first impinges on a round, soft prominence, on depressing which a bony protuberance, the tuber ischii, can be felt. On passing the finger upward it reaches a groove beyond which a similar fleshy mass, the other buttock, can be felt. In this groove various characteristic points, diagnostic of the presentation, can be made out. Toward one end we can feel the movable tip of the соссух, and above it the hard sacrum, with its rough projecting prominences. These points, if accurately made out, are quite characteristic, and resemble nothing in any other presentation. In front there is the anus, in which it is sometimes, but by no means always, possible to insert the tip of the finger. If this can be done, it is easy to distinguis it from the mouth, with which it might be confounded, by observing that the hard alveolar ridges are not contained within it. Still more in front we may find the genital organs, the scrotum in male children being often much swollen if the labor has been protracted. Thus it is often possible to recognize the sex of the child before birth. The breech might be mistaken for the face, especially if the latter be much swollen; but this mistake can readily be avoided by feeling the spinous processes of the sacrum.

The knee is recognized by its having two tuberosities with a depression between them. It might be confounded with the heel, the elbow, or the shoulder. From the heel it is distinguished by having two