WQl. E46cL I860 ■ ^- -*• i—, &, x y \ —i *' X./ L|J/\ siV •>. \ rA^~^ . / ___ V* /f Tl^J^+^ti (tiS-e^J'KjLv 2-c-Y DESCRIPTION OF A 'NEW MIDWIFERY FORCEPS, SLIDING PIVOT TO PREVENT COMPRESSION OF THE F(ETAL HEAD, (WITH CASES.) T. ; Jl .' ^ *Sh;„„. ' BY GEORGE T. ELLIOT, Jr., M.D. ^ wa IS&O DESCRIPTION OF A NEW MIDWIFERY FORCEPS, HAVING A SLIDING PIVOT TO PREVENT COMPRESSION OF THE F(ETAL HEAD, (with cases.) y BY GEORGE T. ELLIOT, Jr., M.D., PHYSICIAN TO BKLLEVUE HOSPITAL; THE NURSERY AND CHILD'S HOSPITAL J AND THE LYING-IN ASYLUM ; CORRESPONDING MEMBER OF THE EDIN- BURGH OBSTETRICAL SOCIETY ; FORMERLY SIX MONTHS INTERNE OF THE DUBLIN LYING-IN HOSPITAL, AND TWO YEARS RESI- DENT PHYSICIAN OF THE N. Y. LYING-IN ASYLUM. •«*■ Thk man who offers a new Obstetric Forceps to the profession, must be prepared to prove that he has not done so hastily, and that he can present reasons which are at least satisfactory to his own mind; while there is nothing so comforting to a large number of professional men as the frank confession that nothing on the score of originality is claimed. I believe that the essential elements of the midwifery forceps, for all time, were discovered by the well-known accoucheurs whose names have become identified with the instrument; but that its benefits have been greatly extended by improved cutlery, and its adaptation to increased uses with diminished risk. Nor do I believe that the ultimatum in this direction has yet been reached. Moreover, the various modifications in the history of the instrument are unknown to the mass of the profession, while many of them are unattainable; and the choice of physicians is further limited by the fact that eminent men so modify prac- tice in their respective cities, as to give yon certain kinds of instruments, well made in one city, and the reverse in another; 2 Elliot on Xar M< ImUry Forceps. hence an instrument may be introduced with advantage in one ei;v. while it would be superfluous in another. Ae;en. there are gentlemen who would desire to procure, or cause to be made, an instrument that they had seen serviceable in the hands of a friend or instructor, and have a right to the opportunity of satisfying their wishes. Ami instrument makers furnish better instruments when the professional man, responsi- ble for the model, can personally supervise them. Nor, in my judgment, can the need of an Obstetrician bo satisfied with one instrument, let it be made never so nicely; for the greater the degree of perfection, which it attains in one direction, the stronger the necessity that it lack some elements of perfection in another. And the most that can be expected of an instrument is, that it successfully meets very numerous indications. I believe— 1. That the principal use of the forceps, in the immense majority of cases, is that of a tractor alone; and that com- pression is always in some degree injurious, and to be avoided if possible. •_'. That this traction can bo applied, and should be applied, by competent men, in well selected cases, even though, the head bo float above the brim as to be only capable of being" steadied by the hand, introduced above the pelvic brim; and that thus the class of forceps, known as short forceps, would not in these cases meet the full requirements of the art. 3. That this traction can be applied, and should be applied by competent men, in well selected cases, through an os uteri, as yet barely dilated sufficiently to admit the blades separately, and that dejivery may subsequently be effected by dilating, or lacerating, or incising the os and cervix uteri; and that in many of these cases, the neglect of this procedure entails loss of foetal life, demands the perforator, or perils the mother's life. by delay, based on ignorance of the full capabilities of the instrument. 4. I believe in the existence of a large class of cases, in which a light and slender forceps can simplify delivery by altering the position of the head—a procedure inoperative and injurious, when performed with instruments of large pelvic curve—while its neglect frequently demands the perforator, or makes the difference between a safe operation, or one of the greatest risk, to one or both of the lives at stake. 5. That a forceps, capable of fulfilling all these requisitions, must, of necessity, be well adapted to those simpler cases, to which some men would limit their use, rendering them in the words of Dewees, '; scarcely subservient to the art." Thus the forceps now presented is made as light as is con- Elliot on New Midwifery Forceps. 3 Whole length of forceps....................... .16* inches. AtoB...!.........•..........2l| inches, face of forceps. c u D ..........2J " back of E " F.' '.'.'.'.'.'.'.'.'...............6* " G " H....................... i " I " J......................4* K«L.......................If L " M.......................6* ' N " 0........................f p >r sent for me, on account of non-advance of the head, anxious expression of patient's countenance, ami dry tongue, and because he could not satisfy himself that the fatal heart continued audi- ble. 1 saw her at 11a.m. Head pressing against bony outlet. P"-t. font, to right acetab. Vagina cool; perineum rigid. F rpcrolf rcr.— liose Swift was delivered by these forceps, in IJellevue Hospital, on account of arrest of the head, probably from exaggerated^ Ilex ion. The particulars of the case are published in the New York Journal of Medicink for July last. In applying the instrument, it occurred, from the position of. the head, that the points of the blades reached the temples, just above the zygoma-, and the handles, of course, not comino- together, the pivot was adjusted to obviate risk from pressure. The e/ris—Room sinotdarly obtained f>r forc-> -Child dtad—Mother did \i\V.—Tane Holland,'21, second child. In labor in Iiellovuu from Feb. l>th, 2 a.m., to Feb. ll'ih, 2.45 a.m. Drs. F. A. Burrall and N. Barrows. Child still-born, weighed T^lbs. Two years since she was confined with an eight months child, "cross birth," lived threo weeks. Now at full term. Feb. ISth. While preparing for bed, membranes ruptured with- out previous pain. Came immediately into lying-in wards, when the left foot was distinguished high up, back of fetus to left acetabulum. Dr. Elliot summoned, and arrived at 1 a.m., Feb. Huh, just as the knee had reached the vulva. 1.40 a.m. Pains being very severe, chloroform given moderately, and in a few minutes the body of the child passed. After the hips had pas-ed naturally into the world, a loop of cord was brought down which could not be felt to pulsate. Motions of the child but an instant before had given signs of life, and showed its danger. Arms being delivered, and the head re- fusing to yield to traction or the customary manipulations in these cases, Df. Elliot passed the first blade of his forceps promptly to its position, but the large head of the child so pressed against the right pelvic brim, as not to afford any space for the second, and all hope of saving the child soon ilea. The perforator was sent for, and while making considerable effort to force a dull instrument through the occipital bone, Dr. E. felt the head to rise sufficiently on the right side to allow the passage of the second blade, when dropping the perforator, lie applied his forceps, and delivered with difficulty. The uterus not being promptly followed down, hemorrhage fol- lowed to an extent which demanded sharp treatment. Did subsequently perfectly well. Child still-born, weighing 7£lbs. Remarks.—On some future occasion 1 shall have something to say of the dangers to foetal life in pelvic presentations, and the necessity of being always ready to apply forceps when manipulation fails; and I may here introduce a case in point, as tfte instrument used possusst.d the same blades as thos, here described. Case 8.-—Forceps in brce<-h pr< sentaiion—Rotation "backwards of chin.—A patient of mine, with an under-sized antero-poste- rior diameter of brim, had been delivered by me of a living child (whose parietal bone was marked by the promontory) with forceps. Falling in labor again, she sent for me, and 1 took my friend Dr. J. W. S. Gouley with me. Wo found a large dead male child, with the shoulders born, and hanging by the head, the chin having caught over the linea ileo-pectinea, a 'ittie to the right of the eminentia ileo-pectinea. Apply in "■ Elliot on New Midwifery Forceps. 11 the forceps, I rotated the chin backwards, when, depressing it, I delivered with a promptness which would probably have saved the child's life, had they sent for me earlier. Case 9.—Deformity of antero-posterior diameter of brim— Forceps— Yersion—Perforation—Recovery of mother.—Mary O'Connell, 33, third, Bellevue, Drs. Andrews and Maury. Labor commenced May 15th, 10 p.m., L.O.A. Terminated May 16th, 11.15 p.m. Child still-born, girl, 91bs. Patient short stature, apparently well formed; married ten years; first child delivered naturally, and living, though some- what before the full time. Four years later delivered, after a tedious labor, of a still-born child. Mary was one of these un- satisfactory patients from whom one can with difficulty learn anything, and when the answer is obtained, one has to suspect that almost as much as the previous uncertainty. However, at 7 p.m., 16th, Dr. Andrews, on carefully examining the patient, appreciated the presentation and position, and rupture of mem- branes, and detected a diminution of the antero-posterior of brim to somewhat less three inches. He sent for me. I agreed with him entirely; believed it impossible for the child to pass, ' and anticipated very hard work. Sent for my colleague, Dr. Barker, who recognized the deformity, which was probably due to exostosis, and agreed perfectly in our views of the ope- rative procedure, viz., forceps first, and if they failed, version. Pulse 70; condition of patient excellent. Anterior lip, how- ever, down before the head and cedematous, though readily replaceable. At 10 p.m., then, things being in this condition, no advance having been made, the head above the brim dip- ping the arc of parietal bone formed by the plane of the brim alone into the superior strait of the true pelvis, I applied my forceps, which were promptly adjusted and locked. I then made traction wTith all the strength which my arms afford, sitting at one time on the floor, and pulling in the direction of the superior strait with all my might. During one of these efforts I felt them slip slightly, and instantly stopping, read- justed them, and continued until all were satisfied that traction was of no avail. , I then withdrew the forceps, and passing my left hand within the uterus brought down the right foot. This was not sufficient, as the other caught above the pubis, and was brought down with some difficulty. The hips being delivered, the cord was found to pulsate feebly. The arms were readily brought down, but no manipulation would suffice with the head, which having necessarily turned with the sagittal suture parallel to the transverse diameter of the pelvis, happened so to close the rio-ht side as to forbid all hope of introducing the second blade 1'2 Elliot on New Mdwifery Forceps. of any forceps. The cord now ceased to pulsate. Being by this time pretty well fatigued. Dr. Barker endeavored to bring the head through, but it was too firmly we'dged to pass. I then introduced the perforator midway between the occipital pro- tuberance, and the mastoid process, and rattled Churchill's crotchet freely about within the cranial cavity. I then tried to introduce Dr. Thomas's ingeniously contrived craniotomy forceps, but although the blades are only the breadth of the middle finger, there was absolutely no chance for the second blade. Having then hooked the crotchet firmly over the occi- pital bone, Dr. Barker and I relieved each other in our tractions. He made two efforts, and in my third, the head finally passed, one hour and fifteen minutes after the commencement of the operation. The woman recovered perfectly, although there was puer- peral fever at the time in the house,- justifying thus what I sincerely believe to have been excellent practice, viz. in com- mencing the operation before the patient was exhausted by fruitless effort, and reflecting great credit on Dr. Andrews for discovering and appreciating the pelvic deformity when he did, instead of simply satisfying himself that there was a head pre- sentation in a woman who had born a living child. Case 10.— Convulsion*—Albuminuria—Absolutely unyield- ing os and cervix — Douche — Incision —Jorceps—St ill-bom child—Mother died. The following case is in the icords of my friend Dr. Samuel Rotton: " Catherine II----, aged 26; primip. I was called upon to attend this patient at the solicitation of Dr. James Hyslop, as he had a previous engagement in another part of the city. The patient had for the previous month or six weeks complained to her friends of swelling of the hands and arms, and of the whole of the upper part of the body, and also a puffiness of the eyelids which made it unpleasant to move them ; the urine was scanty and at times highly colored. She asked no advice, as 6he was assured by her friends that it was nothing unusual. She had during the afternoon walked to her sister's, a distance of more than two miles. Shortly after arriv- ing, she was troubled with labor pains, and through the even- ing, as they increased in severity, slight convulsions accompanied each pain. When I first saw her at 1 a.m., the convulsions were so severe that she did not recover her consciousness after- wards. I found the os slightly dilated, but not more than suf- ficient to pass with difficulty two fingers, and quite undilatable The bladder was distended, and I drew off with the catheter about 'J.0 ounces of dark bloody urine. I put her immediately Elliot on New Midwifery Forceps. 13 under the influence of chloroform, and kept up its effect until 4 o'clock p.m., during which time she had but one convulsive paroxysm which occurred while my attention was drawn from her for a 6hort time, so that she passed from under the influence of the chloroform; but during this whole time, with every pain, there was a threatened convulsion which was subdued only by the chloroform. I administered nauseating emetics, and abstracted blood in the hope of procuring dilatation; but at the expiration of 12 hours, the os was as undilatable as at first. I could not at any time hear the foetal heart, but thought that several times I heard the placental soufflet. About 3 p.m., she seemed to be sinking fast, the pulse sank rapidly to 18, and the respiration to 7 in the minute; I again bled her, and the pulse returned to 90, and the breathing became more frequent and less labored. " I had sent for medical assistance, and Dr. Gouley now ar- rived; we injected about three gallons of warm water against the os in hopes of dilating it so as to apply forceps ; but it remained as rigid as a board. After partially dividing the os on one side, one blade of a pair of rather heavy forceps belonging to Dr. Hyslop was introduced, but it was impossible for either of us to introduce the other blade, and if even the fingers were passed up some distance by the side of the blade, the contrac- tions were so violent as to cause the operator great pain by the compression of the fingers against the iron. We found that with these forceps it would be impossible to deliver, so we sent for Dr. George T. Elliot. With difficulty, Dr. Elliot's forceps, which were much lighter and of very superior shape, were in- troduced by him, and the delivery accomplished only after dividing the os on both sides. " The child was dead. A warm injection was administered, the bloody urine again drawn off, an active purgative given, and cups applied freely over the kidneys; but the patient did not rally, and died about midnight. The friends would not allow a post-mortem." [This was probably as well marked an illustration of an ab- solutely rigid os and cervix as could be presented.—E.] Case 11.—Arrest in inferior strait—Forceps by Dr. F. W. Lambert.—Sarah Kodgers; single; aged 23; 1st L. O. A.— From Aug. 2d, 10 a.m. to Aug. 3d, 9 a.m. Bellevue Hos- pital. . . The head was detained for seven hours in the inferior strait before fairly reaching the outlet. Perineum very rigid. Dr. Lambert, the House-Physician in charge, sent for me to see the case at 4 a.m., Aug. 3d. lie attributed non-advance to con- traction of outlet. The pubic arch admitted two fingers par- 14 Elliot on .X'W Midwifery Forceps. allel to each other beneath the pubis : the point of ossification between the rami of the right pubis and ischium was certainly too convex. Advised delay, ami left subsequent operative inter- ference to the discretion'of Dr. Lambert. He waited four hours, and then applying these forceps, delivered a living male child weighing S lbs. without lacerating the^ perineum, although there was very great risk of doing so. Pivot placed in first hole. No traces of blades. Aug. 8//i, r.M. Both do- ing well. Q/s, jo.—Contracted pelvic bri/n—Arrest—Jorceps—(Jiild still-born—Mother recovered— Yesico-raginal fistula.—March 28th, l^oS.—Mrs. Barnett, aged 32, fell in labor with her second child, under the care of Dr. O'Rorko. 6 a.m. lie found the membranes ruptured, and that she had been in labor ten hours. Os fully dilatable. Presentation cranial, and above the brim; foetal heart beating; mother's condition good. Twelve horn's after this, at Dr. O'Koike's request, I saw the patient with him. Dr. Iviernan was also present. Mother's condition good; abdomen a little tender on pressure. Foetal heart and uterine souffle distinctly heard at the same site, viz.: just below the umbilicus on the left side. Pains growing weaker. Outlet well formed. Ant.-post. diam. of brim seemed a little over three inches. Head not engaged in brim. Sagittal suture transverse. Fontanclles not clearly to bo dis- tinguished. Pelvis shallow. It was decided to apply forceps, because of pelvic contraction, non advance, and suspicions fact that the first child was still-born. Chloroform by Dr. O'liorke. Forceps applied over the oblique diameter, extend- ing from left orbit. Having exerted all my strength to no purpose. Dr. O'Borke relieved me, and advanced the head ; as rotation commenced, the forceps slipped somewhat; when hav- ing re-applied them, I resumed my tractions with all my force, and withdrew the head. The child gasped when born, but could not be revived. Perineum lacerated. Placenta came away well. March 29th.—Pulse 120; pain over uterus. Blister 6x8 and mercurial ointment; with opium internally. The traction made by the forceps in this case was very great, and Dr. O'Rorke expressed his surprise that the instrument could bear it. She recovered well, but complained of water dribbling from her if she stands, or lays on either side. When she lies quietly on her back there is no flow, and she can retain her water all night. I made an examination, which, however, was not very thorough, as I desired to send her to Bellevue, where she could have better opportunities for treatment; and inclined to the Elliot on New Midwifery Forceps. 15 opinion that the case was one of incontinence. My colleague, Dr. Taylor, has made two thorough explorations, and has dis- covered, on the last occasion, a small opening to the left of the vesical termination of the urethra, in which a small probe can pass. The result of treatment shall be reported hereafter. The fistula is in a site where there was no pressure either from the head or forceps, and I cannot understand how it occurred. It is the first result of the kind which has ever followed any midwifery case in my practice, operative or non- operative. Cases 13, 14, 15, 16.—In answer to a note which I addressed to Dr. B. F. Barker, inquiring what experience he had had with these forceps, he replied: " I have used your forceps in four cases, and they have - excellently answered my purpose. '• The first case was a primipara; presentation, right occipito- iliac posterior, the head descending into the cavity, and the occiput rotating backwards. After waiting some time, I became satisfied that delivery would not be accomplished by the natural efforts. With your forceps I rotated the occiput under the symphysis, and completed the delivery with great ease. " In the second case, also that of a primipara, the forceps were used on account of a narrow vulva, and a rigid perineum, the uterus having become exhausted from the protracted labor. The head was at the lower strait. " In the third case, the forceps were applied while the head was at the superior strait, immediate delivery being rendered necessary by convulsions. " In the fourth case, the head was delivered by the forceps after the body had been delivered by turning. " All of the children are now alive, and the mothers made a good convalescence." Case 13 affords an interesting example of what should always be at least attempted, and tempts me to record a case of great interest to me, and having a direct bearing _on the subjects of this article, as illustrative of successful rotation with Dr. Simp- son's forceps in a difficult class of cases. Case 17.—Face presentation—Rotation of chin to pubis with forceps.—Mary Jones, aged 19; first; Bellevue. Dr. C. Haasse, house-physician. In labor from Nov. 10th, 1857,11 p.m.—12th, 6.40. Child, girl, weighing 8£ lbs. Both did well. First seen Nov. 11th, at 2 a.m., by Dr. Haasse. Os just admitted the fino-er. Membranes broke at 4 a.m. Os then dilated to the size of half a dollar. Pains good, but little progress till 9 a.m., when they ceased. Morphine then enabled her to sleep, from 10.a.m. till 3 p.m. Dr. Haasse then made out face presentation. Caput 6uccedaneum on right frontal protuberance. Chin di- 1C Elliot on New Midwifery Fxtreept. reeled nearly back to right sacro iliac-syndmndrosis. 5A cm. No perceptible progress! Dr. Elliot delivered a living child with Simpson's forceps, rotating first the chin to the pubis. Iyinaiks.—I have seen but "three cases of face presentation which required interference; one with Dr. I. E. Taylor, in which he turned ; and Case IS.—Locked face presentation—J ore, ps—P* erf orator.— One to which I was called in consultation, and to which I also invited Drs. Metcalfe and Charles I). Smith. The patient was a primipara—the presentation had not been recog- nized, and the eye had been pushed out by repeated examina- tions, and hung from the denuded orbit. * No fcetal heart. I applied two different pairs of forceps, and neither Dr. Metcalfe nor myself could move the head; when I perforated through the orbit, and the mother made an excellent recovery. r.rv, 19.—Prohipxe of funis—Dr. Thomas'* plan—Forceps -Li ring child— Mother did well.—Joanna Burke, aged 24; 1st; Bellevue. Drs. II. F. Andrews and R. B. Maury. May 9th, W»s, 10 p.m. Os size of a dime, membranes to be felt durng a pain. 4.45 a.m. Membranes had ruptured; water gone; several loops of funis without the os uteri, and pulsating strong- ly. Dr. Andrews faithfully tried to reposit the cord bv 1)7-. Thomas's plan (vide vol.iv.p. 241, N. V. J. ofMkd.), but wi'thout success ; patient unruly. The woman was kept in Dr. Thomas's position for more than an hour; I was then sent for, and the patient placed on her back, and chloroformed to stop risk from uterine contraction. Went instantly, and arrived a few minutes before six. Directed Dr. Lambert to spring on the bed and hold the woman's hips in the exact position recommended, detailing another gentleman to watch the respiration, as she was luly under the influence of chloroform ; and by introducing my whole hand in the vagina, succeeded in repositing the scarcely pulsating funis within the uterus, to such an extent that the two furc-hngers, buried within the uterus, could barely touch it. But when the next pain came on, it drove the funis up the reversed superior strait, so as to fill the vagina to the *ulya. There was no time to lose; and having the woman rapidly placed on her back, I delivered her with all haste possible. The head had barely completed the movements ot descent, and was yet in the superior strait; and my forceps were thrown over one oblique diameter, and the child de- livered almost as rapidly as I can write this description The pivot was not regarded much and the child was marked over the lip with one blade, a result which could have readilv be,,, avoided. ,f I had adjusted it accuratelv before n.ak;'.,, lu ' rrae-1(,,s. But I had waited so long for the hope of succe- h, the manoeuvre described, that I did not dare delav one instant Elliot on New Midwifery Forceps. 17 The child was asphyxiated, but was restored to life. It died on the fourth day, from inanition, with which I think that the sore lip had something to do. Remarks.—I have since had an opportunity of repeating this manoeuvre, in a case where there was originally presentation of edge of placenta, hand and foot, which became complicated with prolapsed funis. Case 20.—Placenta prcevia—Presentation of foot and hand —I* relapse of funis—Adherent placenta—Hemorrhage—Child born alive—Mother did not recover.—Consultation with Dr. Eustace Trenor; report condensed from his notes. Mrs. Kane, aged 30, has suffered for several years from bad health and bad habits, and has on three occasions flooded seriously after mis- carriages. Last March, when six mouths gone, she was much excited in endeavoring to procure bail for her husband, who had been arrested for disorderly conduct. On the next day she had a moderate attack of hemorrhage, controlled by Dr. Trenor. Two subsequent attacks were controlled by Dr. E. Hoffman. June 2d.—She was awakened during the night by labor pains, followed by liquor amnii, when the pains ceased, and she flowed profusely. Dr. Trenor saw her in about three hours, and found her rather pale, with a quick and somewhat feeble pulse of about 88, complaining of weakness, and some- what restless. Os uteri pretty high up, dilated to about the size of half a dollar, rigid, thick, and filled with a clot. At Dr. T.'s request, I saw her at 7 p.m., when the pulse was 83, moderately strong ; lips somewhat blanched ; expression pretty good; no dizziness or dimness of vision ; voice strong; abdo- men flaccid; long axis of uterus transverse; foetal heart in right lumbar region ; no clots in vagina; no flow of blood ; an old foetid clot, weighing about 3ij- lying within the os. No cen- tral implantation of placenta, and no placenta felt at that time. Os uteri dilated to the diameter of 1£ in., and not in any way dilatable. Two fingers passed within detected either an olecra- non process, or an os calcis. It seemed to me most likely the former. The tips of either fingers or toes could also just be touched. I thought them most likely the fingers. 11 p.m.—Saw the patient again with Dr. Trenor and Dr. Maury. Pulse 78 ; moderately strong. Expression better. No hemorrhage. Os as before. Presenting parts not reached more readily, but a flap of the stringy placenta now recognized hang- ing to the os on the right side. , . T June 3d.—Has vomited once or twice during the night, and then slept quietly. No hemorrhage. Condition rather better. Slight pains commencing. Os uteri softer. At noon, Dr. T. os <■ 2 18 Elliot on New Midwifery For reps. found that dilatation was slowly progre-ing under the e'lu- ence of moderate uterine contractions. Ordered ^j. ol. nc, as the bowels had not been moved since May 30th. At about 4 p.m. Dr. Trenor called on me, and stat.d that a h->P of the cord was now presenting at the os uteri and jo't«iting. Wentimmediatelv and placed the woman most accurately in the position recommended by Dr. Thomas, and introducing mv left hand entirely within the vagina, returned the loop so deeply within the uterus that it could just be touched by my two forefingers buried within it. I thus retained it during two pains, my fingers, in the direction given to the superior strait, p'>inting"downwards and towards the bed. In the interval that followed the second uterine contraction, I withdrew my fingers, and found, to my regret, that the next pain drove the cord up the inclined plane of the superior strait into the vagina. A repetition of this manoeuvre was attended with a similar result. Not deeming it prudent to delay longer, but maintaining the woman in the same position, 1 turned my attention to the os u'eri, which I now found dilatable enough to admit my hand sufficiently far to recognize, first, a hand, which I dropped, and t1.,on a foot, on which I drew (the woman all the while in the seme position), until Iliad drawn the thigh into the world, when I turned the patient on her back, and rapidly completed delivery. The child gasped, breathed, had a good color, and gave every sign of reviving, and then disappointed my carefully-founded h> •] •" by dying, in spite of every effort used for restoring life. 1 had no i^ost mortem, but have seen children die suddenly in this way, just after a natural labor, in which there had apparently nothing untoward occurred. The liver seemed, however, in this case, to be noticeably large. The uterus, meanwhile, had firmly contracted around the placenta, 5ij- of Canavan's fluid extract of ergot having been given immediately after the birth of the child, but Dr. Trenor called my attention to the fact that blood was flowing in a con- tinued stream from the vagina. On introducing my hand into the uterus, I regretted to find that the placenta was every- where adherent, except at the flap alluded to, and removed it with some trouble, being obliged to leave some pieces which could not be detached without bringing the uterine wall with them. The flooding diminished, and the uterus contracted, but not firmly. 3iij- of ergot and brandy given. Her expression, behavior, and pulse were now such as to threaten instant death. Dr. Trenor went, at my request, for Dr. Van Buren, to trans- fuse the patient. It was, however, nearly two hours before Dr. V. B. arrived, and by this time the hemorrhage had been con- tro.Icd. Elliot on New Midwifery Forceps. 19 During all this time her head was thrown down, arms and legs held up, ice over the fundus, while I carefully grasped the uterus with one hand, which at the same time compressed the aorta through the yielding abdominal walls; and with the other, with the aid of ice in the vagina, irritated the cervix, in the hope of reflex action, and thus, with the aid of ergot, brandy, chafing, and hot cloths, after an hour and a half hard work, rallied the patient, whose pulse had twice disappeared from her wrist. I have seen a number of bad cases of flooding, but never saw one so near death recover, except a woman with placenta prsevia, in the Hotel Dieu, in Paris, whom Nelaton successfully transfused, though she afterwards died from metro-peritonitis. The pulse shortly rallied after vomiting, and at 8.30 was 120, very feeble, and the patient restless, sighing, and tossing about, with a very feeble and exhausted expression. My mind inclined to the propriety of transfusing her then, but it was concluded not to do so. June 5th, 10.30 a.m.—Since the last note, Dr. Trenor has carefully fed the patient on beef tea, brandy and opium, and she has rallied. Ergot kept in readiness, quinine and sulph. acid given, and a blister has been applied over abdomen, to anticipate metro-peritonitis. June 6th, 4 a.m.—Dr. Trenor wTas sent for in haste, as the patient had been flowing freely since 1.30 a.m. By the time he had reached the house, the patient had taken |jss. tine. ergot. A sheet and three smaller cloths were covered with blood, and there was a great deal in the bed. The patient was blanched, almost pulseless, and too feeble to speak above a whisper. On examination, the vagina was found filled with a large clot, and the uterus with another, both of which were removed. The uterus was flabby and enlarged, gss. more of the tine, ergot, with irritation of the cervix by the fingers, brought about a lazy uterine contraction. Brandy was given freely, and the uterus compressed by the hand ; but the hemor- rhage persisting, Dr. T. plugged the vagina with strips of oiled linen, and finally brought about firm contraction, which was insured by the hand for three hours, when the binder was re- applied. During these three hours Dr. T. had kept the head down and the arms and legs in the air, and had given brandy somewhat freely. The pulse, at the wrist, was now but just perceptible, and sensation in the legs almost gone. She com- plained of darkness, her lips were blue, and the skin of the upper lip and towards the alas of the nose acquired a dusky hue After the application of the binder, brandy and beef tea were given, and she gradually rallied, sleeping at first, and •jn Elliot on New 1/. twifry Firccj*. afterwards becoming restless throwing herself on her side, and from one side of the bed to tho n't her. suddenly. 10 a.m. V dse 124. Has vomited five or six times and taken J gr. of opium. 2.45 p.m. Suddenly attacked'with a violent tit of vomiting, throwing oil' in all*about a quart of fluid—at first tho nourishment which she had been taking, and then matter of a dark greenish hue, with greenish and very dark ilocculent mat- ter in it, and without odor. In about fifteen minutes a violent chill came on, lasting some fifteen minutes, when some re- action came on. June 7th, 11 a.m.—Tampon removed from vagina. During the night had several hard chills, one of them apparently excited by swallowing 5ss. of Labarracquc's Solution, given by her mother-in-law (who also stupidly threw away the placenta). Stomach very irritable; takes very little. Some attacks of faintness. Coughs, with pain in the ovarian regions. Pulse 124. 4 p.m. Pulse 140. Kesp. 30. Abdomen more tympanitic, and tenderness spreading upwards laterally. Micturition causes severe pain in the hypogastric region. The skin is covered with a cold perspiration, and dusky, livid spots are appearing on the thorax anteriorly. Ordered, every three hours, 5j. of a solution of the sulphate of morphia, gr. iiiss. r,iv. of water. June 8th, lo p.m.—Under tho intluence of morphia. Pu- pils contracted ; patient quiet and sleepy. Spots disappearing from thorax. Pain less acute, but more extensive. Pulse 116, stronger and fuller than yesterday. Respiration 36. Con- tinue morphia, and ol. tereb. gtt. x. every second hour, and an enema containing ol. tereb. 3ij- and §j. ol. ric. in emulsion. 5 p. m.—A little more restless. Pulse 134; respiration 38; subsultus tendinum. Has had one dark green fluid evacuation resembling the matter vomited two days ago. Abdomen softer and less tympanitic, but not less painful. Lochia have almost ceased; tongue becoming dry and brown with disposition to crack. Face very anxious. Lies on her side with knees drawn up. 9th, 11 a.m.—Pulse 120 ; respiration 58. 7 p.m.—Died. No post mortem allowed. Remarks.—Although this case has no direct connection with the subject of this article, yet I think that its interest would warrant its introduction into any article on midwifery. But it is published here on account of the interesting parallelism between the results of the same manipulation for reducing the prolapsed funis; and because I desire to say that notwithstand- ing the failure of the manoeuvre proposed by Dr. Thomas in these two cases, I am convinced that by its aid we can better, and more readily, retain the funis in utero than by any other means with Elliot on New Midwifery Forceps. 21 which I am familiar, and we are always well entitled to hope that the funis may slip behind some presenting part sufficiently large to retain it, and thus be restored to its original and natu- ral position in the majority of cases. I shall certainly employ it hereafter whenever the condition of facts is such as to pre- vent me from delivering with great rapidity, either manually or with forceps. But from these two cases we cansee that the position proposed and careful reposition of the funis, are not of themselves sufficient to prevent the funis being driven up hill by uterine contraction, unless sheltered by a presenting part of sufficient volume. Case 21.—Deformed pelvis—Breech presentation—Perfora- tor—Convulsions—Recovery. Remarks.—This, like the complicated case of labor that I saw with Dr. Trenor, has no bearing on the forceps presented, but serves as an additional example of the growing frequency of the pelvic deformities imported into this country by the lowest of our foreign population. Things have changed greatly since the days of Dewees. A graduate of Bellevue Hospital now runs a fair chance of seeing as many deformed pelves during his eigh- teen months connection with the Hospital as that distinguished man acknowledges to have met with during his career; and thus the practice of obstetrics is being modified by this among other causes. ^rrs.----? a primipara, aged 25, short in stature, but with no apparent deformity, came to full term, and fell in labor on the night of the 12th under the care of my friend, Dr. H. S. Hewit. At 11 p. m. the membranes had ruptured and the wa- ters escaped. Foetal heart beating; breech presentation recog- nized ; pains slight. Sent for me 9 a.m., 13th. Found os fully dilatable; sacrum of child directed to left sacro-iliac synchon- drosis Fcetal heart very audible, with summum of intensity above and to left of umbilicus; maternal passages and pulse o-ood Pains had been strengthened by ergot. Recognized ge- neral pelvic deformity; pubic arch good, but rami of ischia too close. Entire brim under size with apparently 2f ot antero- posterior diameter and promontory sharp. The pains continued good all day, as did the foetal heart and the mother's condition. The child's scrotum was distended and forced down. Its sphincter ani contracted around the finger. In the evening, after watching the patient for twelve hours, I advised an operation, and stated that the difficulty would be so great that 1 should require another assistant, as Dr. Hewit wa! to take charge of the chloroform Dr. Metcalfe then be- came associated with us, and I proceeded with a blunt hook to brino- down both thighs, and then both arms, which was accom- «'- la.Li.T on Xi.c Midirifery F< weeps. pli-hed without fracture. Tiie ho.id came to tho brim with the chin to the left ilium, and no manual efforts were of any avail : nor v.-as there any space for forceps. I then introduced the blunt hook into the mouth, the child being dead, and pressing the crotchet against the occiput, worked till I fractured the jaw at the junction of the left ascending ramus, without any ellect. Then introduced the perforator behind the mastoid process <»f the right side, and made ineffectual efforts with the crotchet. At this stage, there was room for ono blade of the cephalotribe in front of the left sacro-iliac synchondrosis, and 1 introduced it in the hope that some lucky move would make room for tho other; but it was impossible. Accordingly I re-introduced tho perforator and crotchet, and pulled till 1 was temporarily used up, though the head had now begun to descend. Dr. Metcalfe succeeded me, and with strong effort withdrew the head. Placenta followed immediately, and uterus contracted well. No hemorrhage. Some symptoms of metritis, which subse- quently presented themselves, yielded to a blister dressed with mercurial ointment, and the exhibition of morphia and the veratrum viride. The patient had convulsions of a mild character on the fol- lowing Tuesday night, in which the tongue was not bitten ; and again on Wednesday night, Dr. Hewit being summoned sud- denly to her, witnessed a recurrence of the phenomena apparent- ly from fright. Urine drawn with the catheter, and examined by Dr. G'uh v, gave evidence of a slight amount of albumen with casts of the uriniferous tubes, and blood corpuscles. 26th.—Has done well. Premature labor advised hereafter. Case --.—Contraction of antero-posterior diameter of brim _/«;//r.y).v— Version—J^erforator.—This was a case, to which Dr. MeLcod, the present resident physician of the Lying- iu Asylum, was called in consultation, Dr. Powers being in atteudance. Dr. McLeod being now (Aug. 9th) out of town, I cannot present all the points of the case, nor its sub- sequent result. The deformity was such, that the finger readily enough reached the promontory, when passed along the plane, extend- ing to the lower part of the pubis. Her'first child had been force-delivered, still-born; she was now at term; and after a tedious labor, Dr. .McLeod had applied forceps, the head not being engaged within the brim, and had failed to advance it lie then performed version, a difficult task in this case, with a large male child to contend with, and had brought away the trunk without injury, but could not advance theliead by any traction. Failing entirely with the hand, and the child bcin«- dead, with the chin to the right ilium, he introduced the Elliot on New Midwifery Forceps. 23 crotchet in the right orbit, and made strong traction, until the orbit and malar bone yielded before the instrument to the alveolar process. He then requested me to see the case. She was under the influence of chloroform, administered by Dr. Powers. The woman's condition was good, and I tried manual efforts, as I often have in these cases, until I have felt and heard the bones of the neck crack, and without avail. With the permission of the gentlemen, I applied my forceps, and hung on it awhile to no purpose. In this case the blades could be readily introduced; so capricious are these cases, some of the diversities of which are illustrated in this article ; and there being nothing left in the right orbit to pull on, I proceeded to introduce the perforator, designed by M. le Dr. Blot, of Paris, which I like better than any perforator which I ever used. My reason for not using it at once, was chiefly the position of the head. It was so high up, and so locked, that there re- mained but the choice of two places for perforation. One through the mouth, with the risk of its slipping through the hole made by the crotchet, and the other through the occipital bone, between the protuberance and the mastoid process, and here the entrance of the point could not be guarded, and the axes of the head had to serve as guides. Having opened the head and evacuated the brain, Churchill's crotchet did the rest, the base of the occipital bone giving a capital purchase in these cases. Sept. 20th.—Patient recovered perfectly. Chloroform.—Perhaps it will be as well to mention here, in reference to chloroform, that I always use it in private midwifery practice when desired, and always offer its advantages; and have never performed but one midwifery operation without it, and then in deference to the wishes of a senior physician ; and that neither in these cases, nor in the very numerous ones in which I have given it for my surgical friends, in the severest operations, have I ever had cause for regret or alarm. On one occasion, there was a little boy at the Asylum, thirteen days old, with a congenital oblique inguinal hernia, which had been always reducible, and was now so no longer. Failing with the taxis, I requested Dr. John C. Cheesman to see it, and he manipu- lated the parts carefully, and without success. I then proposed to give chloroform. He stated his preferences for ether, but allowed me to do as I chose. Having brought the child under chloroform, I held him up by the heels, when Dr. Cheesman reduced the hernia instantly." In the afternoon, on my way back from the truss maker's, I met Dr. Murray, of the army, told him of the case, and asked him to visit it with me. We found the hernia down, and not caring to try too much taxis under the circumstances, I gave chloroform again, and with '-■* Elliot on New Midwifery Forceps. the same result. Radical cure was then cllbctcd with tli'- truss, i :..s must have been nearly five years ago. Case 23.—Jorceps vhen the head floated above the brim — > fctyto mot he rand child.—Before closing this article, which has spun itself out to an inordinate length, I would like to mention a ( a-e, happening some two years since, which now occurs to me, illustrative of the second point made, regarding the application of the forceps. Unfortunately tho notes are not in my posses- sion, but it becoming, in the opinion of Dr. I. E. Taylor and myself, desirable to deliver a woman in Bellevue, in whom tho child's head floated above tho pelvic brim, I proceeded to turn in the presence of Dr. Taylor, and tho house staff. Of those present, I remember at thi> moment Drs. John 0. Draper and Boiling A. Pope. Having introduced my left hand entirely above the pelvic brim, I found that the wrist accidentally steadied the head by pressure on the chin. Calling for Dv. Simpson's forceps, without removing my hand, I delivered a living child. Mother did well. 43 West 32d street. s/rh\y / \ *% L/S.-I V%^ y\ k.. \. *rX/flin\y NATIONAL LIBRARY OF MEDICINE nlm omMoil? b