If we observe that the uterine contractions are becoming more feeble, that the pulse is more rapid with a corresponding decrease of tension, that the head does not press forward and recede with each succeeding pain, that there is a tendency to increase of pallor, a diminution of vaginal secretion and general symptoms of fatigue and inability to muscular exertion, then we have an accumulation of forerunning exhaustive symptoms, which call for the use of the obstetrical forceps, and at this point, by way of parenthesis, I desire to say that no obstetrician can say how long a woman should be in hard labor before the forceps are indicated. It is positively not a matter, of time, but one of conditions. A woman who is strong and vigorous with good circulatory tension and a well balanced nervous system may withstand hard labor for six, ten or twelve hours, without showing signs of exhaustion, while another less vigorous, may show exhaustive symptoms in a few hours; so let your judgment rest upon the ocnditions rather than the length of the labor.

2d. When haste is required, as in eclampsia, or in placenta previa, when engagement has taken place, or when sudden death of the mother has occurred, and the child is to be saved, or in concealed hemorrhage, rupture of the uterus, strangulated hernia, or dangerous symptoms of the fetus, such as violent motion, rapidity of fetal heart sounds, passage of meconium, etc.

3d. Deficient uterine contraction. There are times when by rest under narcotics or anesthesia, or by stimulating by means of quinine, massage, etc., we are unable to produce sufficient contraction for the delivery of the child, and nothing, remains but instrumental delivery Again, forceps are indicated in a breech presentation in the delivery of an after-coming head, provided such delivery is attended with difficulty.

Now there are certain contraindications to the use of forceps; they should not be applied to the hydrocephalic head, nor the decomposed head, for they will certainly fail to hold, and even if they do, the end gained is not equal to the risk to the mother. They should not be applied to the perforated head, as it can better be handled with a cephalotribe.

Forceps should not be applied if the os is not dilated to three-fourths of its full size, and not then if the os is undilatable. The forceps should not be applied when there is a mechanical obstruction, such as fibroids or carcinoma, for the friability of the cervix in these cases will greatly endanger the patient. Forceps should not be applied to the fetal head when the conjugate diameter is below three inches.

Again, the forceps should not be applied until the amniotic sack is ruptured, and last, but not least, the forceps should not be applied until the head has engaged at the brin'.

Had I not witnessed time and again the manner in which this instrument is misapplied and used, I would feel it a duty to ask your forgiveness for presenting the technique of this operation, therefore hoping I may assist some one to become more skillful, I will present the modus operandi of this obstetrical manipulation. 1st. The patient, the instrument and the physician should be prepared. The hair should be clipped from the labia majora and from the mons eneris if long. The vagina, external genatalia, lower abdomen, inner thighs and perineo-rectal region

should be scrubbed with green soap followed by bichloride 1-4000, and this by sterile water.

The bladder should be catheterized. The forceps should be boiled in bicarbonate of soda solution for ten minutes and dipped in lysol solution as a lubricant.

The physician should cleanse his hands as carefully as in a laparotomy. The patient should be placed across the bed, or if a long and difficult operation is anticipated, a table is preferable. Experience has taught me that these extreme precautions are necessary, and I can truthfully say that in the delivery of 1100 children in a period of fifteen years, with 81 forcep deliveries, I have not had a case of infection, either sapremic or septicemic in character. During 400 births previous to 1891, I had four deaths, and I am confident now that none of these should have died had the germ theory been promulgated sooner.

Your patient should be anesthetized. I prefer chloroform if delivery is likely to be effected in a short time, and ether if longer. One assistant should hold each limb, and I should prefer to have the feet some six or eight inches higher than the bed or buttocks. Now is the time for you to introduce finger or hand, if necessary, and make an exact diagnosis as to the location of the fontanelles and the direction of the sagittal suture. When possible or practical apply the forceps on the opposite side from sagittal suture. It may not be practical in the high application, and in this case they can be applied to the sides of the pelvis, and as soon as the head has reached the center of the pelvis, remove and reapply to sides of head, as you will less likely do damage to the child.

2d. Do not make haste or become excited, as you are doing a simple mechanical act, and a proper diagnosis of position and presentation will enable you to apply without difficulty. First take the lower blade in left hand and hold at right angle to your forearm. Introduce your right set of fingers within the cervix. Not one finger, nor two fingers, but as many fingers as your forcep blade is wide, and guide the blade to the side of the bead. If it is in the high operation, it may be necessary to introduce the whole hand as a guide. By pressing the handle downward and toward the center, it will readily slip around the head. Make a similar manipulation with the upper blade. If properly applied they will readily lock. This application must always be made in the intermission of a pain. Tentative traction should be made to determine if the forceps will

hold.

As to the use and application of the forcep in breech presentation, it is usually unnecessary. By the time dilatation of the cervix is complete, the breech is sufficiently low to hook the fingers in the thigh, and make enough traction for delivery. However, in a comparatively small pelvis with both feet up, the blades may be applied to the greater trochanter and a reasonable degree of force used without risk to child.

Now as to the abuse of this valuable instrument. There may be a number of abuses to which the obstetrical forcep is subjected, and for many reasons. Partly I may say from inability to properly diagnose the existing condition, and partly from greed on the part of the physician. At times the physician will attempt to use the instrument when positively contraindicated. For instance, an application on a hydrocephalic head

1

will result in slipping, and perhaps great injury to the maternal structures. Again, a man who is unable to properly estimate the size of pelvis may attempt to drag a normal child through a pelvis less than three inches, thus subjecting the mother to great traumatism and destroying child by using extreme traction and compression. 3d. It is an abuse of the instrument and in opposition to its purpose to attempt to use it as a dilator, as the fingers are more effectual, and there is less danger of severe tear and damage to uterus. 4th. We abuse the very intent of this instrument when we use more compression than the given amount of traction requires, and in this manner destroy the child or inflict permanent cerebral injury. 5th. The unskilled application by those who have had much experience is an abuse which we cannot pass lightly by. Physicians in haste or in ignorance of a proper understanding of the shape of the birth canal and the contour of head make grave errors in their adjustment. They attempt to place the wrong blade first, they do not use the hand to guide; they frequently use too much force in its introduction, and are not careful to adjust lock, therefore do not apply to opposite sides of head. 6th. It is abusing a good article when we apply a straight pair of forceps in the high operation without having attached to said forceps some form of axis traction device.

And now from an ethical standpoint, one of the greatest abuses of this instrument is its unnecessary use. We have the life and health of two individuals in our hands, and yet for our mere convenience we are sometimes tempted to use them when unnecessary. We do so for the purpose of saving time, or ending a tiresome and tedious wait. The conscientious physician should not assume such a responsibility.

8th. And again, from a pecuniary view the instrument is used and abused, and many a mother is subjected to a forcep delivery for the purpose of increasing the fee. This procedure smacks of graft and a greed for notoriety and gain, and should meet with the condemnation of all ethical and honest practitioners.

Remember, brother, that your duty as an obstetrician is somewhat a sacred one, and that you should no more allow yourself to apply the forcep except as indicated, than the surgeon should operate upon a normal appendix for the sake of a fee. Let your indications be clear cut, and do not subject your patients to the unnecessary risk unless the condition requires it.

A CASE OF COMPLETE INVERSION OF THE UTERUS.-Dr. J. Seymour Emans on being called to a patient who had rceently been delivered of a child, found the uterus inverted in the vagina. He suggested the reduction of the organ under ether. Sixteen days after the confinement he performed the operation. The patient was kept in bed ten days. Her temperature did not at any time rise above 99 deg. Two weeks after the operation the patient was feeling perfectly well and the uterus was in good condition. Complete inversion of the uterus arises but once in about 200,000 cases of confinement.-Med. Rec.

My desire and aim have been to utter nothing but the truth. I have no love for error in any form or in any field of knowledge.-Hiram Christopher

The Medical Herald.

[Discussion of Current Topics invited in this department. The Editors assume no responsibility for the views expressed by correspondents.]

THE FORTY-NINTH ANNUAL MEETING OF THE MISSOURI STATE MEDICAL ASSOCIATION AT JEFFERSON CITY.

The capital of the State of Missouri is almost an ideal place of meeting. With a fair amount of hotel facilities, and an unlimited number of private lodging houses, Jefferson City offers ample accommodations. The capitol building with its senate chamber and house of representatives, both connected with a number of committee rooms, furnish excellent meeting places. The only objection is the proximity of the house of representatives to the railroad yards, and the whistling of the locomotives becomes rather annoying at times.

The first day was devoted to the meeting of the judicial council and the house of delegates and the report of committees. The second day was devoted to the reading of papers before the medical and surgical sections. The division of the work of the State society into sections has proven successful. A section devoted to specialists of diseases of the eye, ear, nose and throat is advisable. The opportunity of the large number of specialists from all parts of the State to meet in annual convention, and at the same time and place of the state meeting would induce a large attendance.

At 6 o'clock most of the members ate supper at the state prison to the music of the prison orchestra. The novelty proved charming.

Ths evening of the second day was spent in listening to three addresses, each one, of considerable duration. Addresses of long duration in quick succession are so fearfully alike. The repetition of common platitudes about the development and history of medicine and surgery are tiresome. One oration at a time, please, without attempting to cover the entire field of human knowledge.

Between 9 and II o'clock Governor and Mrs. Joseph W. Folk gave a reception at the Mansion to the members of the State Medical Society, which was well attended and every one seemed to enjoy meeting the genial Governor of the State of Missouri.

The third morning was devoted to a short meeting of the house of delegates and the election of president for the ensuing year. Much valuable time was entirely wasted and the election of president should be held after ⚫ the retiring president's address, on the evening of the second day. Politics consumed all morning, so neither section of the society had any opportunity of meeting.

Á story is in circulation, invented in a spirit of frivolous waggery, to the effect that once upon a time the devil, having undertaken an excursion throughout the earth for alleged purposes of investigation, met with all sorts of adventures and mishaps; but that the culmination of all was not reached until he met a political machine, where he lost his tail.

Certainly, the State society is without a "machine !" for of what use? the honorable positions to be given out each year, must come unsolicited, spontaneously, without a struggle, "Act well you part, there all the honor lies." Does not the constitution of the society forbid even the mention of a political campaign? The unanimous verdict of recommendation of a county society would be of no avail against the small coterie of "get there regardless" who have the interest of the association so much at heart, as to banish the thought of forcing any minority candidate upon the association. Wonderful influence of two or three men in a truly democratic association. Recently the primary object of the profession has been to fight the abuses existing not only outside, but practiced inside the regular fold. Do not hide your light under a bushel. The large majority of the members have no axes to grind, no goods to advertise, no grudges to settle. They would always go right for the best interest of the society, but a certain campaign had to be made. It required many explanations, self-accusations, a small number of "mild" contradictions, wire pulling, oratory, and the comic and the tragic in a vaudeville act.

Why should the spirit of mortal be proud? Organizations are necessary and useful, particularly when they stand for morals or ethics, and an attempt to suppress the free expression of the members by a clique, machine or ring, stamps them as enemies of orderly progress.

The constitution of the State association wants by "a full and frank interchange of views to secure such intelligent unity and harmony in every phase of their labor as will elevate and make effective the opinions of the profession in all scientific, legislative, public health, material and social affairs, to the end that the profession may receive that respect and support within its own ranks and from the community to which its honorable history and great achievement entitle it" etc.

The society must purge itself, from too much "machine," and must stand for what is best among its individual members, before it assumes the unspeakable presumption of the above quotation.

The County society is the unit of our present organization, and the State and American Associations are only made up of county societies, therefore it necessarily follows, that the voice of the county society is supreme (with apologies to the bureaucracy.) "Vox populi, vox machina." Το