face of the child and the upper third of the vagina, which, in this case, is already greatly expanded, and that the extremity of the blade is separated from the peritoneum only by the mucous and condensed cellular coat of the tube. Now, no man can absolutely know the precise degree of inclination his patient will give to the plane of her superior strait, while in pain; an inclination to be modified by every movement of her body and limbs. Under such absolute uncertainty, the best guide of the accoucheur is the reply of the patient to his interrogatory, "Does it hurt you?" The patient's reply, "Yes," or "No," is worth a thousand dogmas and precepts, as to planes and axes, and curves of Carus. I cannot, therefore, deem myself justified in casting away my safest and most trustworthy diagnosis, for the questionable equivalent of ten minutes' exemption from a pain, which, even in this case, is a physiological pain.

Having thus, in my own defence, and not as attacking your opinion, set forth the motives that have hitherto served to restrain me from the administration of chloroform, I desist from giving you any farther trouble in this line of thought. I have, Sir, a far more pleasing duty to perform, in saying that your name is as well known, perhaps, in America as in your native land, and to congratulate you on the extension of your fame. I had the pleasure to read your interesting letter to my class, consisting of several hundred young gentlemen, who listened to your words with the same respect they would have paid to you, had they been pronounced by your own lips. They will disperse themselves in a few days hence, over all the States of the Union, and thus will have it in their power to report the latest dates of your opinions as to chloroform. I shall also allow it to be published on the first proximo, in a medical journal of extensive circulation. You will herein perceive the readiness with which I assist in disseminating your views. It is not without regret that I find myself opposed to your opinions in the case. That difference ought not, however, in the least degree, to affect those sentiments of respectful consideration and real esteem with which I am, dear sir, very faithfully, your obedient

servant,

PROFESSOR SIMPSON, &c.

CH. D. MEIGS.

Having reprinted the foregoing in this new edition, in order that the reader might see what I said and thought, in a Journal, in 1848, I have now to state that I adhere, in 1852, to these opinions, and consider them sound and just, and recommend them with a clear conscience to my readers.

Since the date of my letter to Prof. Simpson, I have been induced by many motives to administer ether (never have I given, nor will I ever give any person chloroform), in a considerable number of cases: many of the women were delighted with its operation after they had recovered from the intoxication, but about an equal number appeared to have been disgusted with, or indifferent to its effects. I have certainly observed, in most of the experiments, that it lessened the frequency and power of the pains; and, in some of them, I was obliged to lay it aside wholly, until the motor powers of the womb, recovering from the stupefying influence of the intoxication or dead-drunkenness of the woman, allowed the labor to proceed, or to be terminated by a forceps operation. I have lost two children in labor because of the anæsthesia, as I fully believe; and some of my patients have had affec tions and post-partum symptoms, the remembrance of which makes me well content to remain among the opponents of the practice.

I say these things, not with any feeling of disrespect, nor with a desire to disparage those of my medical brethren who habitually employ the anaesthetics in Midwifery, but in order that I may speak the truth as it appears to me, and let that truth pass for as much as it is worth, and no more. I shall only add that I sincerely regret the introduction of anesthetics into Midwifery; not because they are not useful and laudable in some rare cases, but from a conviction that the use of them has become a great abuse, which I believe will become greater until the day-no distant one-shall arrive, when mankind, and the profession also, shall have been convinced that the doctors have made a mistake on this point, in this part of the nineteenth cen tury.

In Sept. 1856, I remain unconvinced of the propriety of using ether in all labor cases, indiscriminately. Since 1852, I have allowed several of my patients to take ether, on account of pain that seemed excessive. All my experience leads me to hold to the opinions expressed in my letter to Dr. Simpson. I am still quite convinced that the discovery of anaesthesia in midwifery, has done more harm than good, and I believe its use will decline, and not increase. I think it is de clining already.

CHAPTER XI.

FACE PRESENTATIONS.

In cases in which the usual dip of the occipito-frontal diameter fails to take place, but, on the contrary, is reversed, so as to allow the chin to depart far from the breast, the head may be actually turned over backwards, permitting the child's face to fall down into the pelvis.

In face presentations, as delineated in Fig. 78, annexed, the chin is on one side, and the top of the forehead upon the other side of the pelvis. The face seems to be looking directly downwards into the excavation of the lower basin. This could not be the case without complete departure of the chin from the breast (see the figure), and an absolute overset of the head backwards, as in a person who should be looking upwards at an object directly overhead.

These are what are denominated Face Presentations: a sort of labors

Fig. 78.

that are now thought to be less unnatural and dangerous, than in former times. I am clearly of opinion that face cases may well be included among the natural labors, except where some failure in the powers of the woman should cause us to convert them into preternatural ones, feeling obliged to turn and deliver by the feet; to restore the vertex by some serious operation; or to extract with the forceps, or other instrument.

The foetal head being an oval, five inches long, from the vertex to the chin, and more than three and a half inches wide at the widest part, it ought to make no difference, as far as the mere head is concerned, whether the chin or the vertex advances first in labor, because,

in either case, the same circumferences of the head are presented to the planes through which they are to be transmitted. The foramen magnum of the occipital bone being nearly equidistant from the vertex and chin, and situated on one side of the oval, the peculiar difficulties and hazards of these labors are attributable, rather to the nature of the articulation by which the neck and head are conjoined, than to the form of the head itself, when advancing with the face downwards. The nature of this articulation is such, that extension of the head cannot take place so well as flexion; hence the requisite dip of the occipito-frontal diameter is not effected in face cases without difficulty, and the consumption of much time.

Let the reader figure to himself the state of the spinal column of a child, urged on in labor by powerful uterine contractions, directed to its expulsion with the face in advance. The inferior-posterior part of the head is pressed against the back of its neck, or betwixt its scapulæ, which could not be the case without bending the cervical spine backwards, like a bow, while the dorsal and lumbar vertebræ are curved in the opposite direction, causing thus a double antero posterior curve, on which, in consequence of the elasticity of the two arches, much of the expulsive force is vainly expended; so that, though the power may be as great as in a common labor, it produces much less effect than in a common labor-a great part of every pain being expended in reproducing the greatest amount of curvature; for the elasticity of the two curves is such that they are straightened, at least, in some measure, as soon as the pain subsides, while the rest of the pain is used in pushing the face onwards.

A child in utero ought to be in a state of universal flexion, as I have already remarked. It cannot be in extension, as supposed by the old authors, whose rude cuts, accompanying their crude descriptions of labors, are calculated to excite a smile of pity in any modern obstetrician. In this state of flexion, the chin approaches or even touches the breast. Such a flexion in a head labor always gives us a vertex position. But if the chin, instead of approaching, depart from the breast, there is a tendency towards the face presentation. Let the Student consider that when the chin departs from the breast, it does so by slow degrees, and not suddenly, nor wholly, at once. Hence he should in face presentations, whose whole progress he has opportunity to supervise, expect to touch at first the top of the forehead as the lowest point, or presenting point. As the labor goes on, the head continues to turn over more and more completely until it is at last quite overset backwards; as may be seen in the annexed draw

ing (Fig. 79), in which, in addition to a face presentation, there is a

prolapsion of the left foot. If, in such

a labor as this, the foot were thrust back into the womb during the absence of a pain, we should have a very bad case of face labor, with the chin to the sacrum, and the forehead to the pubis.

When the face presents, the head does not enter the excavation with the fronto-mental diameter parallel to the plane of the strait. On the contrary, the frontal extremity of that line is lowest at first, but the mental extremity of it comes at length to be lowest,

Fig. 79.

at least as regards the successive planes through which it passes in the lower part of the pelvis, as may be seen on reference to the neat figure which is annexed.

The direction taken by the face, as it proceeds, in such a labor, is worthy of the closest attention of the practitioner. Should the chin enter the superior strait near to the acetabulum, it will afterwards rotate toward the arch of the pubis, and, escaping under that arch, will rise upwards over the pudendum, so as to allow the under aspect of the chin and the throat to be applied to the arch, and to the front of the symphysis, while the remainder of the head is evolving

Fig. 80.

itself from the os externum. In such a birth, the part that first emerges is the chin; then the mouth, the nose, the forehead, the crown; and, last of all, the vertex, which escapes over the fourchette, whereupon the flexion of the head immediately becomes complete again.

This is the most favorable direction for the face to take, and it will generally be found that a well-formed pelvis is capable of transmitting a child of moderate size almost as speedily and safely, in such a labor, as if it were a vertex presentation. Let it be remembered that the symphysis of the pubis is only one inch and a half long, and, of course, if the chin should escape under the arch, the neck is so long that the