house, that he ran sixty yards, that he spoke a few words, and struggled for an hour before he died.

ECLECTIC DEPARTMENT.

"Carpere et colligere."

ART. I.—MANAGEMENT OF THE OBSTETRICAL FORCEPS. By C. C. P. CLARK, M. D., Oswego, N. Y. Trans. New York State Medical Society, 1871.

In the fast-growing and ambitious cities of the West it may often be noticed that more attention is given to laying out and grading new streets, than to keeping in good condition the old thoroughfares of daily business. In these last, masses of refuse will be seen to hide a dilapidated pavement, while far out on the city's verge the surveyor and the paver are busy.

In our own art, if I mistake not, there is in like manner, an eager pursuit of novelties, to the harmful neglect of principles and methods that are of daily application. I shall offer in this article some reasons for thinking that the rules and modes of using the obstetrical forceps have suffered this neglect, and I shall make some suggestions for their improvement.

Notwithstanding the indisputable fact that only a few experienced obstetricians acquire such dexterity and confidence in the use of the forceps as to resort to it freely, it may still be truly said that the whole armory of our art furnishes few instruments that are so useful in saving life and in lessening suffering. I think it furnishes none that are so capable of serving these ends. It fails of doing all it might do, because of the real or supposed difficulties and dangers that attend its use. Many an obstetrician, skilled and ready in everything else, is afraid of the forceps. Distrusting his own dexterity and fearful of possible evils, he rarely or never resorts to this instrument. To the neophyte it is a terror.

I think the consciousness of my young readers and the recollection of their elders will give consent when I say that no operation in instrumental therapeutics is more dreaded by the novice than the delivery of a parturient by the forceps. I, for one, shall never forget the anxiety, the agitation, the sinking of the heart, the fear of failure, and, worse still, of the exhibition of incompetency, that preceded, nor the blind groping with the blades and the vain attempt to remember and apply the precepts of the books, that attended my early trials with this instrument. Such repelling and unmanning terrors, and such fruitless efforts, be it observed, are doubly unfortunate, when, as in this operation, the crisis to be met is one that occurs to every practitioner, one that he must often meet alone, and one whose peculiar urgency is greatly augmented by the impatience, the anxiety, and the expectation of friends, and by the suffering and often the danger of the patient herself.

In my own case I cannot be wrong in attributing these early fears and perplexities to faulty instruction. My purpose in this article is to show that these terrors do not legitimately arise from the character of the operation itself, nor are these difficulties inherent in it; but that they result from the erroneous way in which the subject is taught in books and in schools. I undertake to show that, in many of its most essential particulars, that teaching is defective and erroneous in substance, and in manner unnecessarily complex and obscure. A total want of uniformity in the rules laid down by different authors adds to the perplexity of the pupil.

In place of these obscure, complex, impracticable and discordant instructions, I undertake to give a set of rules that shall be simple and intelligible, that shall be applicable to all cases, and that shall thus rob the operation of its terrors, and make its practice, for obstetricians of ordinary intelligence and dexterity, easy and certain.

The points that I propose to touch upon are:

1. The danger that attends the use of the forceps.

2. The exigencies that call for the forceps.

3. The best kind of forceps.

4. The position of the patient. 5. The law of application.

6. The manner of introduction. 7. Locking.

8. Slipping.

9. Compression of the head.

10. Management in extraction.

On all of these points I shall venture to differ more or less widely from the received authorities, and I shall discuss only the particular matters in regard to which I thus differ from them.

1st. Dangerousness of the Forceps.—Is the delivery of a parturient woman by the forceps attended with any considerable degree of danger to her? The general tone of our teachers and text-books replies in the affirmative to this question. I shall never forget the earnestness with which that excellent and conscietious instructor, the late Professor C. R. Gilman, used to impress upon the minds of his pupils the terrible dangers that attend the use of all midwifery instruments. It was his custom, in closing his lecture, to fling them from him with a somewhat theatrical show of terror and aversion, and to warn us in the most impressive manner of the fearful responsibility that accompanies their use. An innocent pupil was almost led to think that, in certain bad cases of labor, it was pretty much an even thing between letting the woman die a natural death and twisting her womb off with the forceps, or letting her bowels out with the perforator.

On looking over authors I find that these terrors are by no means peculiar to Professor Gilman. Cazeaux warns us of "lesions of the cervix and perforations of the vagina." He says: "There can be no doubt that the use of the forceps increases the danger of delivery." Churchill speaks of "laceration of the vaginal parietes, bruising the os uteri," etc., etc. Blundell says: "In violent hands the long forceps is a tremendous instrument. Force kills the child, bruises the soft parts,

occasions mortification, breaks open the neck of the bladder, crushes the nerves," etc. etc. So much is he afraid of wounding the soft parts that he advises us always to count the pulse between the pains, to see whether we are killing our patient!

It was reserved for Dr. G. S. Bedford to reach the acme of terrorism, and to stir the imagination of his hearers and his readers with the most fearful pictures of ruin wrought by the forceps.

"The use of the forceps," he says, "is too often a scene of harrowing agony to the patient." He speaks of "fractured bones" and "disparted symphyses"; of "vesico-vaginal fistula," of "occlusion of the vaginal walls and the meatus urinarius," etc., etc., as common results after forceps delivery.

He pretends to support these statements by cases, but the reader who carefully examines these cases will see that they really give his representations no countenance. In the case, for example, which he gives on page 570, the history that he narrates in no way warrants him in attributing the calamitous result to the use of the forceps. It was probably due to the length-three days—and the severity of the labor, and would in all likelihood have been different if the forceps had been used in time. It was probably "masterly inactivity," and not the forceps, that did the damage. I believe that similar criticism will apply to almost all of the cases that are given in books to illustrate the dangers of the forceps; the premises will not warrant the conclusion, and, indeed, the history is generally too imperfect to warrant any conclusion. To me, with some observation and experience of my own, these terrible representations seem ridiculous and absurd. I affirm that the forceps is not in any material degree a dangerous instrument to the mother. In my own practice and observation I have but once seen death follow a delivery by the forceps. In that case the fatal flooding was clearly due to exhaustion and uterine atonicity from too long delay of delivery; the application of the forceps and the extraction of the child were quick, easy, and painless. I have seen some discreditable fooling, and a little cruelty with the

forceps, but I have never seen a case in which there was reason to attribute any injury of the parturient to its employment. When skillfully used it is not only harmless, but painless. I never attended a patient whom I delivered with this instrument without her asking for it again. The forceps is, indeed, a peculiarly innocent instrument. With its curved form and rounded edges it is almost incapable of mischief. It cannot cut, or puncture, or tear, or scrape. Neither can it bruise the soft parts without the most stupid and reckless violence. As for its being pushed through the vaginal or uterine walls, it would be difficult or impossible to do it intentionally. Injury to the bony parts of the pelvis is equally out of the question.

The proportion of women that die after the use of the forceps is no evidence of its dangerousness; as well might we in the same way argue that bleeding, or opium, or any other treatment is dangerous in puerperal convulsions. Statistics are therefore of no value. It is obviously impossible to distinguish between the deaths that are caused by the forceps-if it is claimed that any are so caused-and those that result from the conditions that called for them, or from other causes. The forceps is seldom resorted to save in protracted and difficult cases, and in these a considerable mortality is to be expected from causes entirely independent of the instrument.

I will not deny that, if the operator, following the instructions of the books, endeavors, obstinately and uncompromisingly, to introduce the long, double-curved forceps into the upper part of the pelvis, with its pelvic curve twisted from accordance with the anatomy of the passage thereto, he may injuriously bruise the maternal parts; nor will I deny that a similar or even greater evil may result if he imitate Dr. Elliott (viz., his Obstetrical Clinique, passim), and wantonly and absurdly use such force as to "break" or "bend" a blade, "endanger the integrity of his instrument," "lay out his whole strength with braced feet," etc., etc. What I do claim is that, if he use ordinary anatomical knowledge, mechanical skill, and common sense, the obstetrician cannot harm his patient with the forceps,