conservative and antiseptic surgery. A quarter of a century ago, when we knew comparatively little of the necessity for absolute cleanliness of wounds, and the aseptic technique of to-day, his leg in all probability would have been amputated, and if he had survived at all in spite of flies, maggots, the then so-called laudable pus, gangrene and septic poisoning, his life would at least have been spent minus a leg. This patient was under my constant observation for nearly four months, after which time his experienced mother (in the use of antiseptic dressings) attended him, under my supervision and direction, until final recovery, a period of nearly a year from date of injury.

My professional brethren in cities, where they have access to well-equipped hospitals and trained nurses, doubtless will very readily perceive and appreciate, at least, some of the difficulties which their country brethren in the profession have to contend with and surmount, and far away, too, from modern appliances and the much-needed advice and cooperation of skilful surgeons.

ASPHYXIA NEONATORUM; PROGNOSIS AND TREATMENT.

BY C. H. RICHARDSON, M.D., MONTEZUMA, GA.

I hope I will be pardoned for bringing before this Association a subject which is almost as old as the profession itself, but one of great importance to the human race; and when we are brought face to face with statistics, showing the appalling death-rate due to "still-births," it behooves uz to inquire the causes more minutely, and use every scientific method by which we may reduce this death-rate, realizing the fact that every infant saved is another human soul added to swell our population. Is it not as important to save a life that has just been ushered into the world as to save one in middle life or old age? Is not the responsibility the same? A conscientious physician will make no distinction, where the mother's life is not involved or jeop

ardized.

In a general practice of sixteen years, coming in contact with various abnormal and difficult obstetric cases, and having it fall to my lot to have born at numerous times, under my care, infants to all appearances hopelessly dead, and to some mothers who are anxious to have a living child, has caused the writer, and would cause others under similar circumstances, to use his best endeavors to overcome this difficult problem.

For ordinary purposes, as we generally meet them in practice, we will class asphyxia under two different forms: First: Asphyxia apoplectic, or congestive form. Second: Asphyxia simplex, or anemic form.

It is the first form which we more often encounter, for it is this variety that we meet in prolonged labors, or pressure upon the cord either around the fetal neck, or pressure on the cord by the fetus, or from the too free use of ergot in the first and second stages of labor, or prolonged breech presentations. The latter has more often been the cause of asphyxia, in my cases, than all others combined.

We meet the anemic form in those cases of partial separation of the placenta from whatever cause; also from feebleness of the child, which may be due to the feeble health of the mother. High temperature of the mother during pregnancy from any acute disease often causes the feeble condition of the infant at birth. When partial separation of the placenta occurs previous to the birth of the fetus, there is scarcely any hope of resuscitation, as the blood supply is cut off from the fetus in utero.

In the apoplectic or congestive form we should never abandon it, and while there may appear to be no hope of resuscitation, no effort at respiration being made on the part of the infant, no heart-sounds, if any, very feeble, yet life can be and is often brought around if judicious and timely efforts are made on the part of the accoucheur; except in hopeless cases of miningeal hemorrhage, which, if occurs, cannot be diagnosed at the time from the simple congestive form, as the symptoms are one and the same.

A few illustrative cases will indicate clearly the different forms of asphyxia which we generally have to contend with:

Mrs. A. was taken in labor on the evening of October 2d, 1889. I was told on arrival that she was having a considerable flow or hemorrhage, but very little pains of labor; and in conversation, found out that on that day she had fallen down her doorsteps. In a short time labor pains began, but not severe; as the pains grew stronger, and as the head came down, hemorrhage began to grow less. She continued thus during that night and a part of the next forenoon; when almost exhausted I delivered her with for ceps; immediately upon the delivery there was a severe hemorrhage, which was controlled by kneeding the uterus and extracting the partially separated placenta. I then gave my attention to the fetus, and after exhausting my own and every other known method, gave up the job, as in all probability the fetus had been dead for several hours in. the uterus.

I was called to Mrs. B. on the evening of May 3d, 1892; upon arrival I found the amniotic fluid had drained away, and diagnosed a breech presentation; labor was slow and tedious, as the case was one of a primipara. After several hours of hard and laborious pains the fetus was expelled apparently dead; but was resuscitated after laboring with it for about forty minutes, and is living to-day, a healthy and robust child, going to school.

Was called on the morning of January 10th, 1899, to see Mrs. C., a multipara, who had had previously three children born alive, but only lived a short time; also three miscarriage. Father and mother were therefore anxious for a living child. Labor pains were few and far between; in a short time I diagnosed a breech presentation; labor continued on slowly all day; as evening drew near, the pains began to grow stronger and much severer. I anticipated a still-born child; and as the breech was delivered, and nothing but the head left to be expelled, I urged the mother to use her best endeavors, knowing that delay at this period would be fatal to the child; but it seems when labor progresses thus far, in these cases, that nature fails to do her part; nature becomes exhausted, and not having sufficient expulsive power, she fails. So, we assist nature by first pushing the body of the fetus down between the limbs of the mother, so as to bring the occiput under the pubes; then raising the infant up, so as to bring the chin down, and at the same time putting one finger in the mouth of the infant, it was expelled; born, as I had anticipated, apparently dead, but was resuscitated by strenuous efforts continued for about fifty minutes.

As to the treatment: We will find different types and degrees of asphyxia, as I have stated. Some cases are easily resuscitated by a gentle slap with a cold hand upon the spine, or by puffs of air blown into the mouth of the infant, or by plunging the infant into hot water; but it is of that severer form where the infant is born pale with flaccid limbs, or born purple with blue lips, no sign whatever of respiratory effort, and no pulsation in the cord; it is this form which I desire to speak of the treatment, as it is this form that requires our most urgent and immediate action and skillful treatment. Inflation of the lungs, either by mouth to mouth method, or by means of the laryngeal tube, has been of little service in my hands. I have derived no benefit from either, for the simple reason that in mouth to mouth method we more often blow into the stomach than into the lungs. As to the introduction of atubeintothe larynx in a fetus, it is no easy matter; moreover, time is precious, and we have no time to make unsuccessful efforts. Neither have I derived any benefit or been successful with the plan of inducing respiration by traction upon the tongue, as advocated by a certain writer; but the plan which has been more successful in my hands than all others is a modified form of the Schultze and Dew methods combined. I order two vessels, one of hot and one of cold water, placed upon the bed, and immediately upon the birth of the infant I place the infant, alternately, in the hot and cold water. This of itself produces a shock to the spinal accessory nerves which is transmitted to the medulla, the center of respira