cosmoline; over this a light compress. This simple dressing should be held in place by a broad abdominal bandage drawn tightly and securely around the body, leaving the drainage tube free. The patient should be kept perfectly quiet, in a horizontal position, until such time as the progress of her case would warrant a change. Talking, visits from friends, or any excitement calculated to disturb the patient, should be strictly prohibited. The diet should be light, simple and nutritious; avoiding fresh or salt meats, fish, eggs, sour food, boiled dough and coffee.

INFANT MORTALITY DUE TO PARTURITION.

BY O. B. GAUSE, M.D.

It is a well established maxim in obstetrics that when there is a live child in the womb at the beginning of labor, it is the duty of the accoucheur to present it to the mother alive at the close of labor, provided he can do so without jeopardizing the safety of the mother.

The chairman of the bureau has assigned to me the consideration of infant mortality during parturition and the measures to be used by the accoucheur to so conduct the labor as to save the imperiled child and fulfill the requirements of the above maxim.

Let it be understood that what may be said in this paper by way of preventive measures is subject to the proviso attached to the maxim.

The safety of the child may be endangered by many causes and conditions; the following enumeration may be considered as embracing the most prominent:

Convulsions, uncontrollable flooding (placenta prævia), malformation of maternal pelvis, inordinate size of foetus, malformation of fœtus, prolapsus of the cord, mal-presentation or position, protracted labor, or unforeseen accidents and complications (rupture of the womb or of the cord.)

Convulsions, unavoidable flooding and rupture of the womb will be considered as special perils to the mother, and are therefore excluded from this paper.

Our first point is, that the child is not imperiled during the first stage of labor; hence all measures for the safety of the child have to do with the second stage, except in exceedingly rare cases of premature loss of the waters before labor begins.

Our second point relates to the malformation of the maternal pelvis, in which the smallest available diameter is not less than 3

inches. The loss of the child is unavoidable at term-to prevent it, labor should be induced as soon after the completion of seven months gestation as possible. Of the several methods suggested for inducing premature labor, I have found the douche, either of cold or hot water, or both alternately, the most satisfactory.

Our third point relates to cases of inordinate foetal development. Size will in this case give us tedious labor, requiring the aid of art to deliver and cause the sacrifice of the child in behalf of the mother. Here as well as in malformations of the foetus are conditions which often render all efforts to save the child nugatory, and must make up a part of the list of unavoidable losses during parturition.

Our fourth point relates to such accidents as are unforeseenrupture of the cord or rupture of the womb. The measures to be used may be stated, comprehensively, to be, prompt delivery by manual or instrument means.

Our subject is now reduced to three conditions of peril to the fœtus during labor, viz. : protracted labor, prolapsus of the cord, and mal-presentation or position.

1st. Protracted Labor. In determining the question of the condition of the child in a case of tedious labor we are to consider the stage of labor, the amount of amniotic fluid lost, and the degree of mobility of the fœtus in the pelvic canal, rather than the duration of the labor. In a given case the welfare of the child may require the resources of art in an hour or two after the beginning of the second stage of labor, while in another case it may be several hours before the condition of the child will either require or justify any special interference. Having determined that the child is suffering, delivery should be effected as speedily as possible. To wait until signs of maternal exhaustion supervene is to needlessly sacrifice the offspring. I have seen not a few cases where, by the aid of forceps, a labor has been terminated in a few minutes, by the delivery of a dead child, whereas, if the same means had been used a few hours before, the result would have been a live child. My investigations into the history of such labors have convinced me that there were abundant evidences that the child was in peril, in time to have saved it. Tyler Smith says, "The accoucheur should

be an observant spectator of the operations of nature, thoroughly cognizant of what these operations are, and capable of appreciating at once the slightest departure from their normal course."

2d. Prolapsus of the Cord. This complication of parturition is the most fatal to the child of any that can occur. The statistics give us a fatality of 50 per cent. By itself considered, it does not embarrass the labor or endanger the parturient woman in the least. Yet this condition, so fatal to the child, and so harmless to the mother, is not unfrequently transformed into a peril to the mother by heroic efforts to save the child. In the management of these cases the accoucheur should act with great deliberation and from a clear conception of what he wants to do and the means at his disposal to accomplish it. If he is persuaded that the prolapsed cord can be replaced by direct manipulation, then let all his energies be directed to that end; if he is persuaded that it cannot be replaced, then don't attempt it; if he feel sure that version will enable him to deliver the child promptly and lessen the peril from funis compression, then proceed at once to execute that maneuver; if he is fully satisfied that he can protect the cord in one of the notches on either side of the sacral promontory while he applies the forceps and delivers the head, then that becomes the proper measure. The point I wish to make is this: first decide what to do, with the conviction that it can be done, and then go about it as though it and it alone remains to you. By trying first one plan and then another and another, the sufferings of the woman are increased an hundred fold without a corresponding hope of saving the child. If the prolapsion occurs before the engagement of the presenting part in the superior strait, placing the woman in the elbow and knee position and keeping her there for a lengthened period, and aiding by very delicate and careful manipulation, the prolapsed loop may be made to re-enter the womb. The contractions will force the presenting part into the strait against gravitation while the cord is held in place by gravitation. If the presenting part has engaged in the brim and a loop of the cord has fallen into the vagina, the postural treatment will be of little avail. In such a case the cord must be kept in the vagina and the delivery effected as promptly as possible. In vertex presentation, in the occi-pubic

position, the loop of the cord may be carried above the occiput by sweeping it around the head with the finger. This maneuver is sometimes facilitated by the elbow and knee position. Prolapsus of the cord may sometimes form only a part of a case, as in transverse positions, in which case the art resources may be directed primarily to the correction of the presentation, in doing which the prolapsion may be corrected.

3d. Mal-presentations and Positions. Whatever constitutes a bar to spontaneous delivery necessarily puts in peril the life of the child. It is not the purpose of this paper to individualize every condition which may arise to hinder spontaneous labor and point out just what to do to extricate the child from its impending fate. We shall content ourselves with indicating in a general way the procedure made necessary in the course of some of the more common mal-presentations and positions, i. e. presentations and positions which are likely to require the resources of art to save the child, by reason of unusual delay. It may be laid down as a maxim, that when the presentation is by either extremity of the child, the resources of nature will be equal to the safe accomplishment of the labor. The failure to recognize this in the past has given rise to the oft-repeated charge of " meddlesome midwifery." The point we wish to press is, that interference is not to be predicated on the presentation or position, (provided it be either cephalic or podalic), but upon indications which arise in the progress of the labor, giving unmistakable evidence of special danger to the child. It was Dr. Hunter who said, "When I first began practice, I followed the old doctrines in breech presentation, although I did not like them, but yet dared not broach new ones till I got myself a little on in life; at this time I lost the child in almost all the breech cases; but since I have left these cases to nature, I always succeed."

It is an unquestionable fact that in face presentations and in podalic presentations, conditions arise requiring the aid of art more frequently than in vertex presentations, and consequently these presentations are more frequently marked by infant mortality. Assuming then the possibility of aid being required in a given case, it is of the utmost importance to seize the most favorable moment. Efficient and sufficient aid does not always mean the delivery of