As to Obstetrical Forceps.

EDITOR MEDICAL WORLD:-Doctor Middleton's article in the November number is responsible for this communication, and it is written only with a hope that it may do some good.

I commenced the practice of medicine thirtyfour years ago, in March 1856, and have always had a good practice. I have had, though, only little over three times as many labor cases in thirty-four years, as Doctor Middleton has had in five years. The latter has used the forceps in forty-five cases out of two hundred, and I have used them three times in seven hundred cases.

Dr. Middleton has never had a case of labor requiring the use of forceps. He says he never saw a case demanding instrumental interference more than the one he reported, and I am sure there was no necessity for them in that case. A primiparous woman twenty-two hours in delivering a ten pound boy, with no complications, does not demand the use of forceps, and the old Doctor was right in objecting to their

use.

I do not agree with you, either, Mr. Editor. I do not think the old Doctor showed any want of courtesy, or was unprofessional at all. The only point I wish to make is that many young doctors, either from having been improperly taught, from a want of patience, or from a want of a knowledge of their duty, resort to the use of the obstetrical forceps when there is no necessity for it. The advice I hope to convey by this communication is, that Dr. Middleton and many other good young doctors like him, may be induced to lay aside the obstetrical forceps, and use them only when the necessity

arises. Do not ridicule the idea "Let nature take her course." The physician who loses

J. C. H. JONES, M.D.

Forceps.

EDITOR MEDICAL WORLD:--Allow me to express my opinion as regards Dr. Middleton's letter in November issue of your bright journal. I agree with him that the forceps, in experienced hands and under proper aseptic application, is more advisable than to wait for several hours, after the head has reached the position he describes. I have seen, in a large obstetric practice, continued pressure on soft parts produce more gangrene of tissues, perimetritis, endometritis and septicemias, from allowing nature to take its course for a number of hours, than from any other cause. Where the os is easily dilatable I never fear the forceps.

I have frequently found change of position to produce rapid dilatation and descent of head. How do three hundred forceps deliveries in ten years strike you?

DR. B. M. FELDMAN. 84 Rivington St., New York, N. Y.

Obstetrical Forceps.

EDITOR MEDICAL WORLD:--In the November WORLD is an article as to the obstetrical forceps, by Dr. Middleton. It illustrates a position in which, sooner or later, most young physicians find themselves. Here we have two physicians-one the older, older in years, rich in experience, and content with methods that have served him well, and, perhaps, has some contempt for one younger, with less gray hair and less experience. The younger one, enthusiastically working hard to relieve suffering and pain by all modern methods, and he does so in all cases where he can; but here they call a halt-"Let nature take her course. While we agree with the editor that forty-five instrumental cases in five years is anything but conservative, there are conditions which need the earnest and careful considerations of both old and young, and for the subject of such thought we shall have to go no further than an article in the same journal by Dr. Ira Harris, of Syria. You have here examples of quick and easy labor, or very hard ones, the latter, no doubt, due to either deformity or malposition. Here things are carried on as nature intended-every pain accomplishes something. What is the reason? One reason, no doubt, is the fact that different classes do not intermarry, and they all possess the same general characteristics, so that the head of the child is

adapted to the pelvis of the mother, and, unless there exists some abnormal condition, all goes well. So it is in old countries where caste or clan keep them together. It is not impossible that the Mosaic laws have reference to this in Deut., viii: 3.

In this country how many women are fit to give birth to the children they carry? We have no restrictions, and the tides of immigration from all countries break up the line of race distinctions. This is a fact more apparent to the young than the old, but is only one of many factors in difficult midwifery. Comparative anatomy would teach us that, as the mental development increases, the, size of the head also increases, and relatively, the size of the pelvis decreases. Is this the history of the past or rather the deductions of modern investigation ?

To sit and wait for birth to take place under the circumstances cited by Dr. Middleton is not doing as well as the old midwives of Syria, and deserves less credit and the remuneration should not be more. The case reminds me of the remarks of a physician after a surgical operation, where modern dressings were to be used. "Leave it open," he said. "Let nature take her course. Don't a dog lick his wounds?" I answered, "Yes, doctor, but an educated physician is supposed to know more than a dog.'

Here is a delicate woman, suffering the agonies of which no man knows, for five hours, after being in a condition to be relieved. As the editor has said, it is well to wait for the pains to mould the head, and it is true in so much as they do mould and accomplish something each time; but when this is only accomplished after hours of agony and persistent vomiting, showing that there are unnatural and unusual difficulties, all these unnatural struggles bring on remote troubles that are far worse than the helping out, at last, with the forceps.

Some will suggest various drugs to produce contraction, but, while anything yet remains in the uterus, it is, at least, an uncertain method.

An old gentleman said to me the other day, "Doctor, why is it that families have only one or two children nowadays?" I think the answer is in the above.

"Oh, Mother Eve, wouldst that thou hadst not had an appetite for fruit !"' Oberlin, Ohio.

W. C. BUNCE, M. D.

Saw Palmetto.-Obstetrical Forceps. EDITOR MEDICAL WORLD.-As there is quite a call for information in regard to the use of saw palmetto, I will give my experience in

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in twenty-four hours. A year ago last July I had a short respite of a month or so, and thought I had succeeded in overcoming the difficulty, but it was only partial and temporary, and I had to resort to the catheter again. had been using rectal suppositories of ergotine, iodoform and belladonna, various internal remedies-staphisagria, carbonate of lithia, etc.-and locally ointment of lanolin, cocaine and U. D. M." of the Century Chemical Co., St. Louis, applied to the catheter. During last winter I continued using these remedies, with partial relief, and in March last commenced using the saw palmetto, when I began to improve and, by the first of May was so much better that I omitted the use of the catheter, and have not used it since until about the first of this month-over six months respite-the longest in over four years.

I was so well that I became negligent in the use of the remedies, and so suffered myself to become constipated and lithemic, causing cystic irritation and spasm at the neck of the bladder, requiring the catheter a few times.

A few doses of maltine with cascara sagrada for the bowels, carbonate of lithia and pichi for acid urine and irritation of the bladder, and resumption of the saw palmetto for the prostate gland soon corrected all the unpleasant symptoms, and now all is right again. I find it necessary to keep the bowels regular as possible to avoid pressure from gas or impacted feces on the gland and neck of the bladder, also to be somewhat careful of diet, to prevent lithemic symptoms. Although the cystic trouble was relieved by the former remedies, I am satisfied that the gland remained congested and inflamed till I began the use of the saw palmetto and since then has materially lessened in size and is relieved of its tenderness and inflammation.

I do not expect an entire cure at my ageseventy-seven last month-but if the remedy continues to act as favorably as for the last six months I shall be very thankful and a very happy man. I have never used it in the cases Dr. Styles mentions in November number, but had good results in a case of bronchial catarrh, but shall use it in other cases if occasion requires.

As to the obstetrical forceps, I am in hearty accord with the "old doctor" in Dr. Middleton's case, page 428, in letting "nature take its course when everything is all right." The

vomiting, of course, was somewhat troublesome, but only reflex, and helped to relax the parts. After the os was the size of a silver dollar, small and oft-repeated doses of ergot and cimicifuga would have increased the pains, and he would soon have discovered the "bulging of the membranes so beautifully described by Playfair," and even if vomiting continued enough would remain in the stomach to absorb and act on the uterus-in fact, the small dose I would give could not be rejected, say ergot f. ext., dr. j; tinct. cimicifuga, dr. ij; in sweetened water, oz. j; a teaspoonful every ten or fifteen minutes.

To illustrate, I will cite only one among many similar cases I have had to deal with. Some four years ago I was called at 2 o'clock in the morning in consultation with a young physician. After introduction to the family we retired to the porch, and he gave me a history of the case and his opinion; said it was a primipara, been in labor forty-eight hours, was completely exhausted. He had given dram doses of fluid extract of ergot, but it was immediately vomited. It was a face presentation, and we must apply the forceps, as she had no strength left.

I told him I would examine and see what was best to be done. I found the patient a robust and well-developed Italian, both she and the family badly discouraged and worn out, pains feeble and no effort to bear down, the os thoroughly dilated, and a beautiful "bulging of the membranes," which the young doctor mistook for a face presentation, and through them I could feel the vertex, first position, all right.

I informed the Doctor of his error and advised small doses of ergot and cimicifuga, but he said she could not retain it, as he had tried repeatedly, without success, though, if I could propose anything to help her he would submit to my judgment.

I made a mixture, as described above, and gave a teaspoonful, and another in ten minutes, when she retched a little, but brought nothing up, but the pains increased in strength and frequency, and after two more doses I ruptured the membranes, and then she had enough to do with the pains, without bothering with the stomach. A few more doses at longer intervals brought the head down on the perineum, which relaxed kindly, and the child was safely delivered about five in the morning (three hours after my arrival), without the forceps, nature having taken its course, with a little help from small doses of ergot.

Dr. M. and many others may quibble at the small dose, but I cannot deny the evidence of my own experience in their efficiency, and the

case above cited proves that they are tolerated and act better than the large dose. I am not prejudiced against the use of forceps in complicated cases, or even in natural labor, when the small doses and nature fail to relieve. I think the Doctor rather hasty in proposing to deliver in five minutes," but sympathize with him in having to wait "five long hours" while the old Doctor encouraged the patient and and let "nature take her course" in "moulding the fetal head and dilating the maternal parts," as the editor well observes. During the past year I have had two cases where I used the forceps, but previous to that have not required them for many years. believe in the "binder" if the lady feels the want of a support, but my experience of over fifty years has proved it to be of little value. I go after the placenta as soon as the nurse takes the child, but I had a case the 17th of September, when it did not respond to the usual manipulations, su had to introduce my hand, and found it adherent to the fundus of the uterus, and I gently separated, and brought it away all right. Recovery was slightly delayed by unhealthy discharge, but was easily corrected and recovery complete. Lathrop, Cal. H. KNAPP, M. D.

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Saw Palmetto for Sexual Debility. EDITOR MEDICAL WORLD: .Dr. F. S. Style's experience with sabal serrulata (November number, page 416) is the same as mine. I have used it several times in impotence, combined with nux vomica, tinct. cactus grandiflora, phosphoric acid, etc., according to each case. I used the saw palmetto on a big, strong-built man, with small testicles. He was about to get married, but, having no erections, he called at my office. After three months, using saw palmetto in different combinations, his testicles were properly developed. He married, and his wife has borne one child (female) one year after marriage.

St. Clair, Mich. DR. HERMAN RIETZE.

"I THINK there are only two things," said Coleridge, which can justify a surgeon in performing the Cæsarean operation; first, that he should possess infallible knowledge of his art; and, secondly, that he should be infallibly certain that he himself is infallible."

For one dollar you get the Official Formula of American Hospitals. One single formula, the "Pectoralis E.," of the Germantown Hospital, is alone worth the price of the book.

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Extra-Uterine Pregnancy.

EDITOR MEDICAL WORLD:-The following case of extra-uterine pregnancy may be of interest to the readers of THE WORLD.

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About o'clock A. M., Sept. 16th, Mrs. W. was seized with violent pain in the hypogastric region, followed by great prostration. I was summoned in haste, and found her still in pain, face pale, surface cold, pulse feeble and irregular. On inquiry I learned that she had had weekly, for five or six weeks, slight uterine hemmorrhage, lasting but one day. She had not felt as well as usual, yet had suffered no pain, except the evening before, when it was relieved by hot applications. I made a hagy digital examination, and found the os natural and no hemorrhage. She fainted several times, and once lay in that condition some time. There was nausea and vomiting. The pain was relieved, or nearly so, by fifteen drops of deodorized tincture of opium. After four hours of rubbing and the use of hot applications, together with stimulants, she began to rally and grow warm.

In the afternoon of the first day the temperature began to rise and the abdomen became ympanitic. The temperature reached 102° F. In about seven or eight days the temperature fell to 99.5°, with a favorable prognosis. October 3d, she was again vomiting, with temperature 102° and increase of tenderness of abdomen. October 18th, temperature became normal, and October 24th she was bolstered up in bed. On the fourth day, with very slight hemorrhage, she passed from the uterus a six or eight weeks' fetus.

I think this must have been a case of interstitial pregnancy. There must have been rupture of the fallopian tube, allowing the escape of blood into the abdominal cavity; yet, how could the fetus pass off the way it did unless it was interstitial, or partially so? There was no external hemorrhage except two or three drops at the time the fetus passed away. Two physicians agreed with me in diagnosis of extrauterine pregnancy.

Mrs. W. is the mother of four children, the youngest being about eighteen months old. She has always had good health. All she now complains of is a sore place and a drawing in the left groin.

The treatment consisted in the use of stimulants, digitalis and ergot hypodermically, and the treatment of pelvic inflammation, salines, quinine and opium to relieve pain. At one time the operation of laparotomy was seriously thought of.

Two Singular Cases of Obstetrics. EDITOR MEDICAL WORLD:-In March of this year I was sent for hurriedly to consult with Dr. O., who had the case in charge, in behalf of a woman undergoing the throes of unsuccessful labor, which she had been engaged in for two or three days. I found her very much exhausted and exceedingly nervous. After a thorough examination I found the arm presenting and the body of the child apparently horizontal across the abdomen, above the upper strait of the pelvis, and immovable. After vain efforts to change position of the child and endeavor to get either the head or feet to present, I had to desist, as she was sinking rapidly, and resort to some other plan to save her life, if possible. Right here I wish to say that I had extracted two children before from her that could not be born natu

rally-one by craniotomy, and the other I had to dissect out, a piece at a time, while she was under the influence of chloroform. The first time she was unconscious from the effects of convulsions. She recovered from both labors nicely and had other children in the meantime without more than the usual trouble. Under these circumstances I again resorted to dissection, and had removed the arm at the shoulder, when I found that she was

sinking so fast that it would not be safe to give her any more chloroform, so she died in about an hour from that time. The child was apparently very large, as the others had been that I removed, one of them weighing fifteen pounds. I was not allowed to make a post-mortem. Now, the question arises, what was the immediate cause of death? As I had used a great deal more of the anesthetic before than I did this time, and she was under labor equally as long, if not longer, and made good recoveries both times, I ascribe her sudden collapse to internal hemorrhage, as there was very little external bleeding. Am I right, or can some of your correspondents give a better cause? If so, let us hear from them.

Last Saturday night, November 23d, 1890, I was sent for in great haste to see a patient having spasms, the messenger said, and was likely to die before I got there, as the party lived at least ten miles off. So, hastening to the place, where I arrived about midnight, I found a young robust woman, about sixteen years old, in labor. She had been since Thursday withonly a midwife in attendance, and was completely unconscious of anything around her and not likely to live long without relief. So I proceeded at once to make an examination, when I found the head presenting in the upper strait of the pelvis, and consequently presumed

I would have an easy time extracting the child with the forceps. But I was very much disappointed, as I could not budge it an inch after straining every nerve and muscle of my strength for some time, with the little bearing down exercised on her part. After this futile attempt I again introduced my hand to ascertain the cause of the trouble, and found the neck grasped as in a vice by the mouth of the womb, and the body of the child high up in the abdomen, and I was unable to get even my fingers past the neck of the child. I will here remark that the patient had a very contracted pelvis, although a large woman for her age. Now the question arose, could anything be done to relieve her, outside of a Cesarian operation? She was too much exhausted for that, even had I been prepared to perform it. So I concluded that she must die, and, to make a long story short, she died about 8 o'clock Sunday evening. She was still having convulsions about every half hour until 8 o'clock Sunday morning, when I began to use morphine pretty freely, and she had no more from that time until she died. Could the child have been removed before the convul. sions came on? and were they the cause of the contraction of the.womb around the neck of the child, or can we have hour-glass contraction before the child is born? are questions I would like to have answered by the medical fraternity. K. TAYLOR, M. D.

SLAMESVILLE, W. Va.

[These are, truly, melancholy cases, and, were not such cases so rare, they would be enough to cause the stoutest heart to dread ever to approach the obstetrical bedside again. Death never seems so awful as when it enters the birth-chamber, carrying away, as it does, both the beloved martyr to maternity and the unborn hope of future years.

In the first case it seems that about all was done that could have been done. Either temporary ill-health or organic weakness developed by previous obstetrical strains had reduced the woman's truly wonderful powers of resistance. Death might have been caused by internal hemorrhage or by the organic weakness and prostration rendering her unable to stand the anesthetic.

The second case illustrated the dangers attending the employment of midwives, and also the evils of procrastination. Evidently the Doctor should have been called much earlier in the case. However, being in the case, relaxing medicines should have been used to relieve the uterine spasm and the general convulsions as well. Gelseminum, pilocarpus, lobelia, veratrum viride, chloral and inhalations

of chloroform are all in the line of theindications here. Quinine would also have been of some aid.- ED.]

A Simple Means of Assistance to the Perineum During Labor.

EDITOR MEDICAL WORLD.-Every physician during his attendance upon a case of labor experiences, in the last part of the second stage, a certain amount of anxiety, especially if he encounters a rigid perineum, with a tremendous increase in the frequency, duration and propeling character of the pains.

As the head touches and distends the vulva and perineum, the anus is expanded, fecal material is forced out, and the perineum is stretched as thin as parchment, and it seems as if this last portal must inevitably give way. It is then that we cannot know too much that will enable us to assist and support this structure. It might be well to state at this time, in a few words, the principal methods of support to a perineum in this condition.

1. Ask the woman to refrain as much as possible from bearing down, withhold the progress of the head by the finger and relax the parts by hooking a finger into the rectum and drawing forward.--Goodell.

2. Another method is by placing the palm over the anus so that the distended perineum rests between the thumb and fingers; then lift or push the perineum upward and forward toward the pubes.-Playfair.

3. With the patient on the left side, standing behind her, the first two fingers of the right hand may be applied to the occiput and the thumb in the rectum, hold the head completely under control and force it out between the pains. Fasbender.

As to the above methods in the care of the perineum, every physician can testify to their utility, and, while I fully realize that, in most cases, they will be all that is necessary, yet I will mention a simple, but by no means an unimportant, thing in securing the rapid relaxation of the perineum.

As the occiput comes in contact and distends the perineum, I use applications of hot water to the vulva with napkins, the water hot as the hand can bear, and often repeated. I have seen many times a rigid and troublesome perineum melt, as it were, before my eyes. Not only does it materially assist in the distension of the parts, but it affords great relief to your patient from her terrible suffering at this time, and you also let her and the nurse know you are trying your best to assist and to comfort her, and for which she will forever be grateful.