especially in primiparæ, is regarded as due entirely to some external abnormal factor or factors. Most prominent in the list is the pressure of corsets and clothing. Others are the weight of hands and arms, unhealthy positions to avoid notice of condition, coitus, etc. A common cause assigned in primiparæ, the tense and unyielding condition of abdominal walls, he is not inclined to admit, not believing nature unable to provide for her own physiologicalc onditions.

Should this pathology of the pregnant state be true, it follows that transverse presentations should be quite free from the compli cations under discussion. Few authors comparatively have observed the matter from this standpoint, yet there is much convincing evidence, after all, to be found. Dr. King presents an array of cases from various sources amounting to 194,018 reported in full, and enough cases of eclampsia alone to represent 106,000 additional labors, making a total of 300,018 cases with but a single case of eclampsia distinctly reported as occurring in a case of transverse presentation during labor. Some few other cases may be considered as doubtful, but in even this one there is nothing making it absolutely certain that some other abnormality did not exist to account for it. An occasional anomalous distribution of the branches of the aorta may explain some obscure exceptions to this. Certainly the coincidence in these cases is remarkable and serves to place this explanation of puerperal eclampsia upon a basis more secure than any other so far projected.

Much of value in explanation of these points is purposely omitted on account of time for its consideration.

If this theory be true, the treatment deducible therefrom will be in the direction of studiously removing all sources of trespass upon the gravid womb that may change this normal obliquity and correct the displacement, should it occur late in pregnancy, by posture, or manipulation or both combined. Various authors have noted the cessation of convulsions when a position has been secured to relieve the pressure upon the blood-vessels before alluded to, and this should be promptly done should occasion demand it, if only for a little time to relieve temporarily the puerperal state.

It is not claimed that descent of the head into the pelvic cavity will always cause renal troubles, but that those troubles will not occur when the child remains transverse above the pelvic brim.

The author modestly concludes by saying that while his views in

the main are theoretical, and require careful and extensive clinical observation to prove or disprove them, he yet feels confident of their

correctness.

Much more could be noted in this report, such as a paper by Herman, "On the Productions of the Shape of the Oblique Pelvis of Nægele;" by Duncan on "Contraction, Inhibition and Expansion of the Uterus and Elasticity, Retraction and Polarity of the Uterus ;" by Phillips on "Spurious Hermaphroditism;" by Doran on "Malformation of the Fallopian Tubes;" by Champney on the "Uterine Bruit,” etc, etc., but time and your kind forbearance will not allow of its presentation.

ARTICLE VI.

OBSTETRIC ANÆSTHESIA.

BY N. M. DODSON, M. D, OF BERLIN,

Member of the Committee on Obstetrics and Gynecology.

You will remember, gentlemen, that on the 19th day of January, 1847, Dr. Jas. Y. Simpson made the first trial of anaesthetics in midwifery, using sulphuric ether in a case where turning was required on account of a deformed pelvis, and that the next day he announced its complete and triumphant success to the Obstetrical Society of Edinburgh. In November of that year he employed chloroform in his obstetrical practice with the same happy results. This discovery was hailed with delight throughout the civilized world, and at once adopted by many leading obstetricians, with the effect of confirming the truth of Simpson's announcement and of establishing the inestimable value of this new means for the relief of human suffering. Yet, though anæsthetics have been used in many thousand cases, and though the experience of forty years has abundantly confirmed their safety and value, their use in cases of normal labor, unless I greatly mistake, is to-day the exception rather than the rule. The feeling seems to obtain, both with the profession and the public, that it is judicious and proper to resort to their use only in exceptional

cases.

And yet, if we refer to the experience and teachings of the most eminent obstetricians, no good reason will appear for this reluctance on the part of the mass of the profession to adopt this most important and efficient of all our means for the relief of human suffering. Dr. Simpson believed the use of anaesthetics to be absolutely safe, and that it would soon become universal. Little has occurred since his untimely death that would have changed his opinion as to their safety in obstetrics, but alas! how much there has been of unneces sary and unrelieved suffering.

Dr. Gillette advises in the first stage of labor, an anesthetic to the obstetric degree- that is, to the extent of dulling the pains without destroying sensibility. Charpentier says that in the great majority of cases where an anæsthetic is required, chloroform is the one to be given, and that if given to the full surgical extent, it does not seem to involve increased risk, as it does in surgical cases. The explanation of this, he thinks, is to be found in the physiological hypertrophy of the heart in the pregnant woman, and the great abdominal pressure due to the pregnant uterus. Burr believes that chloroform has a beneficial action on the heart. Barnes says that with rigidity of the os uteri in the first stage of labor, chloroform is of great ser vice in that it first annuls pain, restores the equilibrium of the nervous system, and removes disturbing influences; the sphincters relax, the body of the uterus contracts as it should do, and the labor proceeds to a favorable termination. Vergely states that cardiac diseases do not forbid the use of anæsthetics, which may be given prudently. Parvin teaches that disease of the heart does not necessarily contraindicate their use, and gives the.n in hemorrhage with slow dilatation of the os uteri. In eclampsia he advises their very free administration during the paroxysms, keeping up the anesthesia moderately between them, and increasing it as necessary; he says there has not been a single death that can be fairly attributed to obstetric anæsthesia, notwithstanding the immense number of cases in which anæsthetics have been administered. But a single case is on record where chloroform produced death in natural labor, and in this there was lack of post mortem confirmation. Three others are mentioned in obstetric literature, but at second hand, and without confirmation or particulars.

Lusk says that the result of his experience during the past sixteen years has made him a warm advocate of the use of anesthetics, though he emphatically enjoins caution. He has had comparatively few cases in which he has not employed ether or chloroform in some stage of the labor, and Bedford says that as a general rule they may be used during parturition with safety to both mother and child. Our own Dr. J. K. Bartlett, in his able report to the American Medical Association, after quoting Dr. Barker's statment that he had given chloroform in several thousand cases, and had met with but a single instance of post partum hemorrhage, says for himself that if post partum hemorrhage, injury to the child or other than benefi

cial results are ever produced by obstetric anesthesia, experience tells us that it must be due to the impurity of the anesthetic, or to the lack of that care and discretion in its use which is necessary not only here but in the use of all our therapeutic measures for the relief of suffering. And Dr. Claiborne, in his report to the same society, reaches the following conclusions: that the duration of labor in all stages may be shortened by the use of chloroform; that the pains of labor may be entirely, yet safely obtunded by the use of chloroform, and that the accidents of labor occur less frequently under its use.

Now, if these conclusions are fully established, and it be true that the great amount of human suffering resulting from the process of parturition is unrelieved in the majority of cases, by anesthesia, are we not, as a profession, criminally negligent and indifferent to the sufferings of the gentler portion of our clientage, whose only appeal is to us, in these hours of supreme and agonizing suffering? It is probable that with all the suffering which comes under our notice, as medical men, we yet fail to fully comprehend and appreciate the agonizing terrors of this terrible ordeal through which some woman passes almost every time that a human being is born into the world. Simpson says that custom and prejudice, and perhaps the idea of inevitable necessity lead both the profession and the laity to look upon the pain encountered in natural labor as far less worthy of consideration than it really is.

Viewed apart, and in an isolated light, the pain of natural labor, in most cases, is fully as great as that attendant upon most surgical operations. I allude particularly to the excessive anguish attending the passage of the child's head through the outlet of the pelvis and the perineum.

Speaking of common or natural labor, Dr. Merriman thus describes this dreadful suffering: "The pulse increases gradually in force and quickness, the skin grows hot, the face becomes intensely red, drops of sweat stand upon the whole forehead, and perspiration, often profuse, breaks out over the whole body; frequently violent tremblings accompany the last pains, and, at the moment the head is extruded from the vagina, the extremity of the suffering seems beyond endurance." Nagele observes of this stage that the pains are more severe and enduring, return at more frequent intervals and take a far greater hold than those of the preceding stage. Their severity increases so much the more from the additional suffering