CLINICAL LECTURES.

"Ex principiis nascitur probabilitas: ox factis, vero veritas."

ART. I.-MANUAL PRESSURE APPLIED THROUGH THE RECTUM AS A SUBSTITUTE FOR THE FORCEPS IN BREECH PRESENTATION. By John E. WALKER, M. D., Greensboro', Ga.

I was

Case 1st.-Mrs. S., primipara, aged twenty-four. called May 27, 1867, and found her in labor; pains regular and at' intervals of twenty minutes, gradually growing shorter as the labor progressed. After three hours the membranes were ruptured, and I was to determine certainly the position, which I found to be the breech. In such presentations I had met with average good success, and of course felt no great amount of anxiety. The labor progressed favorably until the entire body was born. I used the common means to prevent pressure on the funis, drew down the chin, carrying the body in the curve of Carus, and making as much traction as I could with safety to the child. The pains were vigorous, but they made no impression; the soft parts became rigid and grasped the head firmly, and would not allow it to descend. My forceps were at some distance off, and no time could be spared in this emergency. The thought occurred that if I could raach the crown and press it downwards I could complete the delivery at once. I thought I might do this per rectum. I had the patient placed on her right side; holding the child with my left hand, I introduced the index and middle fingers of my right hand into the anus without difficulty; placed them on the child's head, when by firm pressure thereon, assisted by the efforts of the mother, I had the satisfaction of completing the delivery in a very few seconds, and presenting to the young parents a large, and healthy boy.

Case 2d.-Mrs. V., primipara, aged seventeen years, taken in labor about noon, October 13, 1869. I was summoned about 5 o'clock; found everything in as favorable condition as I could wish, but after the membranes ruptured I discovered that the breech presented-the child was large and strong, the mother vigorous and cheerful. I gave notice that at a certain signal I wished her turned on her right side, for reasons which I would explain at the proper time. When the shoulders had been expelled I had her turned as directed. I carried the body in the curve of Carus, brought down the chin by the usual method, but the expulsive efforts were powerless to relieve the head. I introduced the index and middle fingers of right hand into the anus, which lay stretched across the child's face like a valvular opening. I was thus able to reach the crown, upon which I bore down with considerable force, directing the mother to use such efforts as she could to aid in the expulsion, and had the satisfaction to complete the delivery in less than ten seconds, the child crying out vigorously.

Case 3d.-Mrs. J., multipara., aged forty-two years, at or about the completion of her eighth month was suddenly seized with labor, the membranes rupturing without previous symptoms, while she was standing beside the breakfast table. I was summoned at once, and was at her bedside in a very few minutes; learned that she had felt no motions for a month; they had never been vigorous. There was a peculiar fetor arising from the liquor amnii. An examination disclosed the fact that the breech presented; the labor progressed slowly but regularly. Allowed chloroform in moderate quantities. When the body and shoulders were born the head was disposed to linger, as the child was dead (the cuticle being stripped off a great portion of the body, etc.) I made considerable traction in the axis of the inferior strait, but to no effect. This lady had hæmorrhoids, but notwithstanding I introduced my fingers, as in the two first cases, into the rectum; then pressing firmly on the crown of the head, I completed the delivery in a very few seconds. She recovered without a bad symptom.

Case 4th.-Mrs. B., aged thirty-five, has borne several children; is suffering from phthisis pulmonalis. December 13, 1869, was taken with alarming uterine hæmorrhage at or about the twenty-seventh week of her pregnancy. I was called, and reached her in two hours; found her very much exhausted; the hæmorrhage had somewhat abated, but she was evidently in labor. This progressed irregularly for several hours; she took cordials; ultimately the membranes ruptured, and I was able to discover that the breech presented; as the case progressed the hæmorrhage ceased. After a reasonable time the body of the child was born. The woman being on her left side, I attempted to use my left hand, but failing, I desired the patient (assisted by female attendants) to turn on her right side. I then introduced two fingers of the right hand, as in the three other cases, and delivered the head in a very short time, the child being alive, and lived thirty hours.

Thus I have given four cases -three within a few weeks of each other-in all of which this method, for which I claim originality, has fulfilled my desire. I may state that in each of these cases the face looked towards the sacrum, but I can see no reason why it may not be applied when the position is reversed. In adopting this practice care ought to be taken that the nails are closely pared, so that injury may not be done to the bowel. I am satisfied that this practice will supersede the use of forceps, and is far less dangerous to mother and child. With it I do not expect to lose a single child nor injure a single woman.

I have examined a number of authors, and find no one has practiced it; and therefore I shall claim priority in the discovery until some one proves his claim to be better than mine.

NOTE. Since writing this report several months have elapsed, and during this time I have found the following passage in Hodges' Obstetrics, page,

200:

"This is the critical moment as regards the life of the child; delay now is very dangerous, not because the cord is greatly

compressed, but because the functions of the placenta have almost universally ceased; the uterus, empty of the child, has contracted sufficiently, in ordinary cases, to detach the placenta, and of course to destroy its functions. The danger is much greater in primiparous patients, where the perineum is rigid; and in all cases where, from the size of the child's head or other cause, any delay is experienced. Our practice, therefore, in such cases has been when the face is upon the perineum to pass one or two fingers into the rectum, which will enable us very efficiently to increase the flexion of the head, and at the same time to diminish the liability to injury of the perineum. We feel very confident that, by these simple manœuvres of carrying the body of the child in front of the pubis, and by pressure from the rectum, a rapid delivery can be very universally facilitated in perfect accordance with Nature's laws; the chin of the child being thus brought to the centre of the orifice of the vagina, and the cervico-bregmatic circumference parallel to its plane." He writes in another place as follows (see p. 99):

"Should there, however, be any great delay at this juncture, still further assistance may be rendered by traction upon the body of the child by the practitioner or his assistants directly upward—that is, with the neck parallel to the symphysis pubis. A moment's consideration will exemplify the great mechanical efficiency of traction thus established at this juncture when the face is on the perineum, the top of the head on the rectum, supported by the fingers of the practitioner. Traction thus made acts through the medium of the neck on the whole head, and draws against the symphysis pubis. The base of the occiput is, however, immovable, and hence all such traction must have the effect of determining the anterior part of the head nearer the chest of the child; in other words, to augment flexion and to assist the bearing-down efforts of the mother in propelling the head. In this way we, in the language of the mechanician, use the head as a lever of the third kind, the fulcrum being at the base of the occiput, the power acting through the spine, while the resistance is at the forehead."

ART. I.-PROCEEDINGS OF THE LOUISVILLE OBSTETRICAL SOCIETY AT ITS MEETING December 13, 1870. [Reported by the Secretary, Dr. MORTON.]

Dr. Newman exhibited to the Society a very ingenious instrument designed by Dr. David Cummins, of this city, for making wire sutures in the operation for vesico-vaginal fistula, and made by Charriere, of Paris, under his immediate instructions. Dr. Newman had just used the instrument with complete satisfaction. The use of the canula-needle in this operation is not new; the modifications, however, made by Dr. Cummins on the instrument generally used constitute a greater improvement upon that than it was upon the ordinary surgeon's needle with forceps. Indeed this instrument, with its case of needles of every desirable curve, is complete, and the operation for vesico-vaginal fistula, which before had been so tedious, is now not only a very simple but a very easy feat in surgery.

The instrument is used after the following manner: The end of the silver wire is inserted in the perforated handle (the perforation being slightly greater in diameter than that of the wire ordinarily used in the operation for which the instrument is designed) and pushed forward with the thumb and finger until it passes the toothed wheel seen in the cut, where the tube through which the wire passes becomes an open groove, so that the little wheel, which is held up by a spring, may be pressed down upon it by the thumb.