tice is shared by all who have had experience in its employment. The introduction of the treatment has so reduced the maternal mortality that, for my part, I believe it is no exaggeration to say that, with the exception of small-pox, there is no disease so preventable as puerperal septicemia.

An interesting debate on this subject is printed among the Transactions of the Obstetrical Society of London.' Dr. Matthews Duncan is reported as having said that the subject of antiseptics in midwifery was the most important of all in the whole obstetric department, but it was receiving very little attention. "The subject was greater than the prevention of epidemics, which came occasionally, while puerperal deaths were constantly occurring in the most valuable members of the community."

Dr. John Williams said that, although we could not overcome by antiseptics all the evils of pregnancy and labor, we may hope to abolish the deaths from puerperal fever. To do this would be to reduce the mortality in childbed to per cent, or 2.2 per thousand.

Dr. Playfair stated that in his own practice antiseptics were as rigidly enforced as it was possible, and he supplied his nurses with cards having printed upon them rules for carrying out the treatment. He was confident that not one man in one hundred used antiseptics in any thorough way.

In conclusion, I wish to state briefly the method adopted by myself for the purpose of securing antiseptic delivery. Simplicity is the first consideration. A stiff nail-brush and a box of powders, each powder containing half a gram of bichloride of mercury, is all the preparation necessary. After entering the bedroom of a woman about to be delivered, no vaginal examination is made until the hands have been cleaned in the following manner:

A solution of bichloride of mercury 1 to 1,000 is made by dissolving one of the powders in a pint of warm water, and the hands are thoroughly scrubbed in it with the nail-brush. All dirt is then removed from beneath the finger nails, and a second scrubbing given the fingers of the examining hand before they are ready to be introduced into the vagina. No lubricant is used. Examinations are not repeated unnecessarily, and every time one is made, the hand is previously soaked in the antiseptic solution 1 See AM. JOURN. OBSTET., vol. xviii., No. ix., p. 989.

which should be kept in a basin near the bedside. Occasionally the use of the nail-brush should be repeated. The accumulation of bloody mucus around the vulvar orifice must be prevented by bathing the part with the antiseptic solution.

After the birth of the infant, two important rules are kept in mind to secure firm contraction of the uterus, and not to introduce the finger into the vagina.

A teaspoonful of fluid extract of ergot is administered, the fundus of the uterus followed down with the hand, and the placenta expelled by compression.

It often happens, in consequence of the exertion caused the woman by removal of the soiled linen, that a uterus which had been firmly contracted becomes relaxed, and the fundus reaches as high as the umbilicus. To avoid this, the woman should be moved about as little as possible while being changed, and pressure must be kept up on the uterus until she is ready to be bandaged.

If the uterine tumor becomes enlarged in spite of these precautions, or if there is any tendency to excessive flow, I give a vaginal injection of a solution of the bichloride (1 to 4,000) as hot as it can be borne, and during its administration squeeze the uterus in order to secure firm contraction of the organ, and to press out any blood-clots from within the cavity.

When the surgeon has performed an operation according to antiseptic rules, he does not remove and reapply his dressings two or three times a day for the purpose of washing the surface of the wound with an antiseptic lotion. On the contrary, the dressings are put on and left until the wound is healed. And so, after this treatment has been carried out, the use of vaginal injections during the puerperal condition becomes unnecessary.

The truth is, unless especially called for, they may do harm in other ways than that already mentioned. Not only may germs be conveyed into the vagina by the nozzle of the syringe, or by the unintentional admission of air; but the tube, introduced ever so carefully, may destroy recent granulations which are Nature's barriers against the admission of septic matters into the system.

The only after-treatment advisable is cleanliness. The vulva should be washed several times a day with a warm antiseptic fluid, using for the purpose either a syringe or a soft

linen cloth. Sponges ought to be banished from the lying-in chamber.

An unpleasant odor to the lochia demands the employment of antiseptic vaginal injections. The development of fever after the first day is to be considered pathological; the cause must be looked for, and appropriate treatment begun without delay.

It is not within the limits of this paper to consider the more complicated antiseptic precautions which may be demanded in certain cases. When operative interference becomes necessary, or when puerperal septicemia is prevalent, the same care is called for that should always exist during the delivery of women surrounded by hospital influences.

SYNCOPE OR ANEMIA OF THE BRAIN A CAUSE OF ASPHYXIA NEONATORUM, AND ITS TREATMENT.

BY

GEO. H. NOBLE, M.D.,
Atlanta, Ga.

THERE has been a great tendency to overlook the cause in the treatment of asphyxia in new-born children, which is due probably to the presumption that it is a delay on the part of the lungs in performing the first inspiratory act. The problem then was how to start it. This was supposed to be solved in the employment of artificial respiration and excitation by reflex action, etc., as they seemed to keep the heart acting until things could right themselves.

The result was a practice, more or less routine, energetically and often imperfectly applied.

It is true the pathology has been studied, but so far it has done but little in directing a remedy to the cause. It is therefore that the influence of two cases I have recently had may be turned in this direction that I desire to report them.

CASE I.-The mother of the first case was a primipara. The 'Barnes: "System Obst."

liquor amnii had escaped eighteen hours before I saw her. The contractions were frequent, forcible, and of long duration. The os was rigid and undilated. One-fourth of a grain of morphia sulphate was administered hypodermically, from the effects of which dilatation went on readily. Labor then continued, with the fetus in the first cranial position, without any very great difficulty.

The fetal heart could not be heard before delivery, which fact, taken in connection with the long contractions, caused a prediction of "suspended animation."

The pulse of the cord was weak, the muscles were flaccid, and the surface was pale. Friction, hot and cold water, flagellation, inflation, artificial respiration, and other means of resuscitation, failed to revive the child, after a trial of forty minutes or more. The surface grew paler, and the umbilical pulse grew weaker and weaker, and finally stopped. The cord was then tied, and the heart auscultated; an occasional beat (one in about six or eight seconds) could be heard. Attempts to revive the child were resumed without success.

It occurred to me that there might be an anemic condition of the brain, and having its relief in view, I put the baby in a perpendicular position, with its head downward. In a few moments it gasped; this added encouragement to my efforts, and I again began artificial respiration. Failing in this, I returned it to the inverted position, in which it made other attempts at respiration. I then brought it to the horizontal position to see if it would continue its efforts to breathe, but it did not. Other methods were again employed, but in vain. Then for a third time it was placed heels uppermost, and a third time it began to breathe; the heart's action increased in frequency, but so soon as she was removed from this position, the respiration ceased, and the interval between the heart-beats grew longer.

By this, I was convinced that the influence of gravity upon the blood was the only favorable thing that I could bring to bear upon the case, so I accordingly wrapped it in a woollen cloth, and directed the nurse to hold its head downwards, alternately turning the face and the occiput to the fire. In about an hour, the circulation and respiration were acting normally, and the baby was crying loudly.

CASE II. The second case was also the child of a primipara. There were no marked deviations from natural labor other than a very great overlapping of the cranial bones. The head was large, and the occiput became very much pointed in moulding. The membranous portion of the posterior fontanelle could not be detected during labor, but the day after measured an inch and onefourth in its greatest diameter.

The child was in the second stage, or pale asphyxia, as the surface was pale, the skin was cold, the sphincters and other muscles were relaxed, and as no reflex action did occur, in this in

stance as in the other, the most and the best of the many methods of revivification were plenarily applied, but without the desired results, and doubtless much valuable time was lost and detriment effected in their employment, as it became necessary to resort to gravitation of blood to the brain to engender the desired end. It came, however, but slowly, for three quarters of an hour had passed before he was breathing well, making in all an hour and a half from the time of his birth.

It was afterwards handed to the nurse, who, in dressing him, placed him in a sitting posture; the result was an expungence of all that I had done, or the secondary asphyxia of Marshall Hall. The case then seemed hopeless, but notwithstanding I fixed him head downwards, with the happy result of again restoring him to life.

that

These cases plainly demonstrate, I think, the want of blood in the brain. In each time, it was allowed to flow away from organ; in the first case, all attempts at respiration ceased; but, to the contrary, efforts at respiration were induced each time the blood was permitted to gravitate to it. And the second case was twice revived in this way.

The nervous centres from a deficiency of blood were unable to recognize and respond to the stimulus that ordinarily would have excited respiration. The cause of which, in the first case, was likely due to the feeble action which in turn was produced by the frequent long contractions of the uterus.

In the second case, it was due to compression of the brain in labor, as the heart's action was good (but afterwards grew feeble), and the pulse full; and as "paralytic" (or "pale") asphyxia is produced by compression and other injuries to the brain and medulla oblongata. This is especially apt to occur in labor with disproportion, under delivery by forceps or by turning.

Syncope has been invoked to explain some of these cases.' The secondary asphyxiation must find its explanation in the inability of the weakened heart to pump the blood to the brain, with the child in the sitting position.

Believing, then, anemia of the brain, or a condition of syncope, to be a pathological factor in some cases of asphyxia neonatorum, I would advise, for its relief, the ready method that I employed in the foregoing cases, viz., the gravitation of blood to the brain.

Doubtless, this is the explanation for the return to life of those babies cast aside as dead; for it is more than possible that Barnes': "System Obst.," p. 631.

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