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noticed, going on during these intervals. The rest, also, which this change in the manipulations allows to the operator, is a matter of some moment, where inflation has to be carried on for any length of time.
In order to satisfy myself as to the comparative efficiency of these procedures, in introducing air into the lungs, I next day got the permission of the friends to make a few experiments on the body of the child. I first tried the effect of compressing the nares and blowing into the child's mouth, after the chest had been compressed, as previously described. When this was done, even though the muscles of the chest had become rigid, the full inflation of the lungs became obvious, and the sound produced by inflation, as in using a hare's lungs, could be distinctly heard. I then fised into the trachea a short tin tube attached to a long gutta percha tube, which latter had connected with its other extremity a bent glass tube, partly filled with water. The motion of the water, in this little apparatus, showed, with great delicacy and precision, the effect of movements impressed on the ribs or sternum, and the following are the results obtained : 1st, the largest amount of air forced from, and again taken into, the lungs, was found to be produced by pressing the ribs laterally, as I did before inflating the lungs of this child ; 2d, pressure on the lower third of the sternum had a less, though still a decided effect on the air contained in the lungs; and my impression, after making this experiment is, that the much greater number of movements that can, in this way, be given to the chest, make it, per se, nearly, if not altogether, as powerful a means as the first for introducing fresh air into the lungs; 3d, forcing upwards the diaphragm, by making pressure on the abdomen, produced on the water in the tube little or no effect.
I have mentioned that, at the end of three hours, the pulsation of the heart was vigorous, and that the respiratory motions could be noticed to extend to the upper part of the thorax. I then began to use inflation less frequently; and, as the position of the child on the front of the bed was somewhat inconvenient, I thought I might venture to remove it to a table near the fire, on which were placed warm pillows and flannel. Almost immediately upon making this alteration, I noticed that the respiration became less distinct; and in a short time the change was so decided as to compel me to replace the child in its former position ; after which, both the heart and chest began shortly to move nearly as before. Perhaps the cause of this unfavourable change may have been that, in the new position, the air did not get access to the lungs so easily as formerly, although I did not observe any very decided difference in this respect; but there was also another circumstance which I suspect might exercise some influence in producing the unfavourable change. While the child lay on the bed, the head and upper part of the body occupied a slightly dependent position; whereas, on the table, the whole body was placed horizontally. Might it not be, that, in the former position, the arterialized blood found its way more easily to the nervous centres, and thus preserved a greater amount of sensibility? Whatever may have been the cause, the fact referred to shows how slight are the alterations, under such circumstances, which may produce important differences in the result. In this respect, I recollect, many years ago, while assisting Dr G. C. Holland in performing experiments on artificial respiration in rabbits, in connection with his work on “ Animal and Organic Life," being struck with the fact, that even such a slight circumstance as occasionally altering the position of the animal, had some effect on the experiment. If, for example, while the lungs were being infiated, the action of the heart became weak, the posterior extremities had merely to be elevated to cause the heart to be immediately, for a time, stimulated into vigorous action. At the commencement of operations, in the case I have been relating, I kept this observation in mind, and perhaps the alterations of position which were at that time frequently made, assisted in keeping up the then faint action of the heart.
It is hardly necessary to say that, before beginning the inflation of the lungs, I introduced my finger into the pharynx for the purpose of clearing away any mucus which might be lodging at the top of the windpipe; and also, that the inflation itself was performed very gently, in order to avoid the risk of rupturing the air tubes. I may remark, however, that the introduction of the finger into the pharynx may have some effect in rousing the dormant sensibility in such cases, as we are by this means acting upon parts peculiarly susceptible of being powerfully stimulated. To increase this stimulus, and also in the hope that a small portion might find its way into the stomach, or be absorbed, I occasionally, during the continuance of inflation, dipped my finger into spirits, and rapidly passed it down to the top of the æsophagus.
The posterior extremities presented in this case, which can certainly be classed as but one degree removed from “ still-born.” The single case which, out of 467, was “ still-born," had a similar presentation. These, therefore, have been, in my practice, the cases in which the greatest danger to life occurred. In both instances I used every means in my power to effect the delivery rapidly ; but still more time was lost than could have been desired. Perhaps, also, the amount of traction necessary, even with the finger in the mouth, may have injured the spinal cord. Where considerable force is required, the main strain must fall upon the spinal column, and I have seen paralysis of one arm for some months produced by it, where the child survived. It has struck me that considerable assistance in making traction might be derived from the use of the “ lever,” passed along the face of the child, and operating on the vertex; only, that in making such a use of it, the handle would require to be somewhat more bent than in the usual forms of this instrument. I shall certainly try what assistance can be derived from it in the first suitable case that occurs to me,
Although not immediately connected with the subject of this paper, it may be interesting for me, in concluding it, to refer very
shortly to the startling statement which I have made at its com- mencement, that I have now delivered 416 cases in succession, in every one of which (where not previously dead) the child was born alive; and that only one child was still born” out of my last 467. Some of these children lived for only a short time, from being somewhat premature, from malformation, or from other causes, but they were all“ born alive.” If I am not very much mistaken, this is “a great fact” in obstetric science, and ought certainly to make those practitioners pause who have hitherto been contenting themselves with a mode of practice which has yielded a mortality of one in twenty, or even one in forty. Having explained in detail, as already stated, in the 22d No. of the British and Foreign Medico-Chirurgical Review, the practice which I have pursued in order to procure this result, I shall at present content myself with saying, that its chief feature consists in shortening the second half of the labour process. This I have done mainly by a more frequent use of the forceps than has hitherto been practised, the numbers delivered by them, in the 300 cases already published, having been not quite 1 in 7. In the whole 467 cases the numbers remain nearly the same, so that I have delivered successively 66 times with the forceps without the loss of a single child; while, from a statement published in the 20th No. of the British and Foreign Medico-Chirurgical Review, it appears that in 78,892 midwifery cases, the mortality when the forceps were used, in the hands of British, French, and German practitioners, was nearly 1 in 4. This discrepancy in the results is easily explained, when we notice that, while I have had to use the forceps in nearly every seventh case, other parties referred to have employed them only once in every 200, 300, or 700 cases, probably trusting instead of them, except in extreme cases, to nature and the secale cornutum. As a natural consequence, in a large proportion of these extreme cases, in which the forceps were used, the children were “still-born," not because instrumental interference materially increased the hazard to the child, but because it was already dead, or in articulo, before this was resorted to. In a lingering labour I hold it to be the part of a good practitioner, never, if possible, to allow his case to become 6 extreme;" and this, I have endeavoured to show, a correct knowledge of the mechanism of labour will, to a large extent, enable us to accomplish.
The maternal mortality in the 467 cases, I may mention, was four, or about 1 in 117, and one of these could not properly be attributed to the labour process, as the patient was in the last stage of phthisis, and almost in articulo, when premature labour came on, and death followed within an hour or two.
The two questions in obstetrics, “In an average healthy population, how often will the forceps require to be used in order to
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secure the smallest amount of infantile mortality ?” and “What ought that mortality to be over the whole, in a well conducted practice ?” are of vast importance to the accoucheur, and to the general practitioner. I have given my experience on the subject, and although it may probably appear to some who have been accustomed to trust, in a great measure, to the efforts of nature for the accomplishment of labour, that one in seven or eight is an amount of interference with the forceps unusual and uncalled for, I can say most conscientiously that I am not aware, among the cases reported, of a single instance in which they could with safety to mother and child have been dispensed with. In the last two years of my practice particularly, during which I have now had the advantage of a pretty ample experience, I may say that I have been extremely anxious to limit their application as much as prudence would allow, and yet I find that I have still been compelled to resort to their use in about the same ratio, with the gratifying result, however, both as to mothers and children, that has already been noticed.
As a rather interesting corollary, in several respects, to the foregoing remarks, I may add, by way of postscript, the history of the following case, which has occurred since they were written :-On April 7th, at 9 p.m., I was called to Mrs J., in labour for the fourth time, the three former having been uncommonly easy. She informed me that for two days labour pains had been occurring occasionally, but that they had become frequent and pretty severe for the last three or four hours. On examination, I found that the os uteri dilated to rather more than the size of a half-crown piece, could easily be reached with the finger, but the presenting part of the head (the left parietal bone, though of this at the time I could not be very certain) could barely be felt, there being an interval of an inch and half, or two inches, between the head and the os uteri. For an hour and a half, or so, the membranes at each pain were partially pushed down into this elongated portion of the uterus, the os uteri becoming at the sametime somewhat more dilated. Thinking to bring the head closer to the os uteri, and hence to assist in its dilatation, I ruptured the membranes; but I found, after doing this, that the head and uterus still continued to maintain nearly the same relation to each other, though the head could shortly afterwards be touched more easily than before. Things remained in nearly the same condition till about one a.m. on the 8th, when the pains almost entirely subsided. I remained in the house till eight a.m., and then left, having given directions to let me know when the labour returned with any vigour. I was not called again until April 9th, at half-past two p.m., when I found that pains had been occurring at considerable intervals during all the time I had been absent, until within the last two or three hours, during which they had been frequent and brisk. On examination, I now found that the head could be reached by the finger with ease, and that the
elongated uterus, well dilated, which formerly felt thin and tense, was swollen and soft, and was still more elongated than formerly, reaching, in fact, close down to the os externum. For the next two hours, the head and uterus advanced very slowly together, until at about half-past four p.m. one ear could be felt a little above the symphysis pubis, and to the right side of it, the face of the child being towards the left acetabuleum, while the anterior lip of the os uteri overlapped the os externum, and touched its posterior or perineal portion. After waiting for nearly an hour without any further advance of the head having taken place, it became clear that this protracted case (already very unfavourable as to position, from the head having to perform three-eighths of a revolution, before the face could get into the hollow of the sacrum) would shortly become fatal to the child and hazardous to the mother, from detention, if not also from impaction, unless the swollen uterus could be got over the head. After making vigorous efforts to effect this, I found that, in the present position of the head, it was impossible to do so, and I therefore lost no time in applying the forceps, in order that the head might be forced down upon the elongated uterus, and greater advantage given in pushing the latter upwards. My usual rule in applying the blades of the forceps (Zeigler's) is, to fix the first over that ear which is the easier come at. On this occasion, however, as I have frequently before experienced, when the head is high in the pelvis, the application of the first blade over the ear next the pubis, prevented the introduction of the second blade, as the latter could not be thrown sufficiently backwards to slip over the promontory of the sacrum. I therefore withdrew the anterior blade, and fixed the posterior one first, making the ear next the pubis my guide in doing so. The anterior blade was then easily fixed. Having got a firm hold of the head, I exerted a considerable amount of traction (turning the face at the same time into the hollow of the sacrum) before much impression was made. After some time, however, a sensible advance had taken place, the now elongated head pressing slightly on the perinæum. I then withdrew the instruments, and some vigorous pains coming on shortly afterwards, I pushed the uterus over the head with ease, and the child was born in a few minutes afterwards, at near six p.m., having a very short umbilical cord tightly twisted round its neck. This last circumstance, which, at an early stage of the labour, I suspected to exist, I may remark, was doubtless the chief primary cause of the detention of the head, and secondarily, of the elongation and swelling of the uterus, which necessitated the application of the forceps within its swollen neck and lower portion; and I may also remark, that I think it extremely probable from the appearance of the placenta, as well as from the discharge of some clots of blood during the latter part of the labour, that a portion of the placenta had been detached before the child could be born.
When born, the child was completely asphyxiated, and I had