THE

BRISTOL

fTl>ebtco=(Tbu'uvgical Journal SEPTEMBER,

DELIVERY

FORCEPS

FIFTY

1892.

DURING

THE

LAST

YEARS. BY

Joseph

Griffiths

Swayne,

Consulting Physician Accoucheur Lecturer on Midwifery at

M.D.

Lond.,

Bristol

General Hospital, the Bristol Medical School. to

the

A half-century's

experience in any department of the healing art ought always to be worth recording; but to be ol any real value, such a record should not depend solely on a man's memory, which is necessarily fleeting and fallible, but should be founded upon a series of facts,

each of which he has occurrence.

kept

carefully

Since I first

noted at the time of its

began practice

in

1842,

I have

accurate notes of all my obstetric cases; and I there-

fore venture in

1892 to submit to your notice the experience which I have acquired respecting Forceps Delivery. Before 1842, when I was not yet a qualified practitioner, I attended thirty-five midwifery cases under the superintendence of my father, who was then lecturer on obstetrics 12 Vol. X.

No. 37.

DR-

154

JOSEPH

at the Bristol Medical

GRIFFITHS

School;

but

SWAYNE ON

as

I did not at that time

attended, and as (to look keep proper register the at matter from a student's point of view) I was not "fortunate enough to meet with a forceps case before 1842, I shall make no further allusion to my experience as a student; nor, in relating my experience as a qualified practitioner, shall I refer to those cases in which I had of

a

cases so

"

to use the

forceps simply

to hasten

delivery

on

account

of

complications, dangerous either to mother or child, or both, such as convulsions, hemorrhages before labour, prolapse of the cord, &c. All these cases have special dangers and difficulties of their own, and have no bearing on the use of the forceps in difficult labour per se. It is in cases of this latter kind that the forceps is of such inestimable value. In difficult labour it supplements the powers of Nature when deficient; it helps them to overcome mechanical obstacles to the passage of the child, arising either from want of room in the pelvic canal, or unusual size of the child's head or malpresentation of the same. It is necessary to lay this stress upon the head, because it is the only part to which the forceps is applicable. No man in his senses would dream of applying the forceps over the body to assist a tedious case of breech presentation, for instance. From January 1st, 1842, up to January 1st of the present year, I have met with 220 cases of tedious and difficult labour in which it was necessary to have recourse to the forceps. Out of the whole number of 220 cases, I was the

original

the

beginning

(who had charge of the'end) in rather more remainder, viz. 106, were

attendant to

114, whilst the I was called in to consult with other were

the

original

attendants.

each than cases

from

case

to which

practitioners

It is obvious

viz.

half,

that,

who

if

we

FORCEPS DELIVERY.

155

wish to draw any just conclusions as to the success or otherwise of forceps operations, consultation cases should be

strictly

excluded.

In the

early part

unskilful

they neglected skilful cannot

now,

and

one

cases

that

were

unusually

to

career

bad

practitioners. draw any just

ignorant

much

were

practitioners

are

events,

of my

was

more

mid wives and common

called

frequently moribund,

almost cases

than in

to

or, at all

in the hands of

It is therefore obvious

more

that

we

statistical conclusions from this

solely on those cases which beginning to the end by the same

source, but must base them were

attended from the

practitioner. During the

of this paper it will be convenient years into five periods of ten years

to divide the

course

fifty

as we pass on, any alterations and imin provements midwifery which have taken place in each decade, and which have a special bearing on the subject

each, noticing,

of

striking characteristics of modern midwifery is the more frequent use of the forceps in difficult labour, a change of practice which forceps delivery.

One of the most

my own experience, as well as that of others, proves to have been attended with the best results. It was far

otherwise, however, during the first decade of my practice, from 1842 to 1852. The forceps was then used very rarely, and with extreme caution, I may almost say timidity. This arose in a great measure from the following cause : During the middle of the last century Smellie, the greatest English accoucheur of that period, greatly

improved

the

forceps,

profession,

rose

and

frequently

the natural result of this

much success;

instrument

and used it

and with

was

that the

in favour with the medical

very highly resorted to much too

was

12

?

often,

and not

156

DR.

GRIFFITHS SWAYNE ON

JOSEPH

seldom with disastrous results. these results when

we

obstetrical education at that reaction

period.

the instrument

against

Nor

consider the

arose

can we

wonder at

imperfect Hence

a

state

of

powerful

towards the end of

the last century, and was started by such obstetric physicians as Dr. W. Hunter, Dr.

distinguished Osborne, and

Dr. Denman.

inculcated

implicit the

All these

reliance of

practice

men

powerfully

expectant.

The

Ramsbotham

an

the efforts of Nature, until at last

midwifery

became in the

The effect of this recoil of the

scarcely passed century.

on

away,

in the middle of the present passage, which I quote from Dr.

even

following (whose

highest degree pendulum had

work

then the favourite text-

was

shows very well the prevalent dread of the long " forceps : I must not close my remarks without coinciding

book), in

opinion with Professor Davis, that the instrument, although very powerful and valuable, is at the same time very dangerous in its use; that it should not be taken in hand except by those who have acquired some proficiency in operative midwifery; and that it is to be had recourse to, more as an experimental measure for superseding the necessity of destroying the child, than as one of the common resources

It

was

and

art."

1

perform

a

forceps operation

in

1842.

The

arrested rather

high up in the pelvic cavity; I could not make the blades of the forceps lock

was

as

our

under the influence of such doctrines, that I

first had to head

of

I sent for my father, who soon effected delivery. explained to me that my failure arose rather from

properly, He

than any other cause. By repressing the head little with his left hand, he succeeded in reaching the

timidity a

anterior

ear

and

passing 1

the blade of the short

Obstetric Medicine and

Surgery.

forceps

FORCEPS

DELIVERY.

157

it. By this it is evident that my father acted in strict observance of Denman's twelfth aphorism on the

over

use

of the

should must, can

forceps, which always be applied

therefore,

be felt."

that time it

be

too

follows:

as

over

the

ears

"

The

forceps

of the child ; it

apply them before an ear an excellent practical rule; but at implicitly obeyed. At the present

improper

This is was

is

to

the contrary, as I shall show by-and-by, it is too much neglected; for it is an undoubted fact that the ear

time,

on

of the child is the most

sure

and certain

guide

to the

proper application of the forceps. And a proper application of the forceps to the head is more than half the battle in

using

it with

success.

And here in limine I

beg to differ entirely from those practitioners who, text-books, advise that the forceps should be applied solely with relation to the pelvis and without regard to the child's head, and who say that it is no matter how the head is seized so long as it is seized. I grant that, in using the long forceps, we often act in this way; but, then, we do so from necessity rather than from choice, because the prominent sacrum or other pelvic deformity, which is generally present in such cases, obliges us to introduce the instrument in that part of the pelvis where we can find most room for it. But still, even then it is best, if we can, to apply the forceps so as to grasp the transverse diameter of the head. This, I need hardly say, is the most favourable manner in which we can grasp it ; in fact, I believe it to be the only manner which is thoroughly compatible with the safety must

in their

of both mother and child.

When the

forceps

has been

applied in the best way, the blades of the instrument correspond to a line drawn from the vertex to the chin of the

child,

a

diameter

a

little in front of the

longest

or

158

DR.

JOSEPH

GRIFFITHS

occipitomental diameter,

and

SWAYNE

ON

usually corresponding

to

the axis of the

pelvic cavity. The extremities of the ought half-way between the angles of the jaw and the point of the chin, and the fenestrse should enclose, in their widest part, the ears, and in their narrowest part, near the shanks, the parietal protuberances. The blades will then press on the angles of the and the malar and frontal bones in front and the jaws, mastoid processes behind, all of which are parts well adapted to bear pressure without injury. When, on the contrary, the forceps is applied obliquely?one blade, for instance, resting on the side of the forehead, and the other on the occiput?it is found to be difficult, or almost impossible, to lock the instrument; and if it does not slip off at once, which is most likely, the head is grasped very unevenly, so that one edge of each blade presses deeply into the scalp, or flesh of the face, whilst the other projects from the head, and makes most injurious blades

to reach about

pressure mother.

on

the

vaginal

with

If,

extractive force

the

walls

and

instrument

soft so

parts of the much

applied,

compressing power be applied, the face of the child may be deeply marked, the eyes or the much

nose

or

injured,

ulceration

integuments

and

frontal bone

produced,

case.

even

and

exfoliation of as

In another instance

I

myself

paralysis

sloughing a portion

of the of the

witnessed in of the

portio

one

dura

resulted from the pressure of the point of the instrument If the blades be applied upon the nerve behind the jaw.

especially if one be passed too far, and the project beyond the angle of the jaw, it may compress

unevenly, end

and

loop of cord (if, as is often the neck), and thus cause the a

met

with

several undoubted

the case, it be coiled round death of the child. instances

I have

of death thus

FORCEPS

DELIVERY.

159

occasioned.

Consequences nearly as disastrous may arise from the pressure of unevenly applied forceps on the soft parts of the mother, such as sloughing of the vagina, crushing of the sacral nerves, and lacerations of the perineum. As to the blade of the duced not

or

the

first, we

this is can

generally reach I

think,

as

which should be intro-

matter which

a

reach the

pelvic brim,

forceps

depends upon whether When the head is below

ear.

in the

majority

the anterior

ear

of

; and

that the older accoucheurs

it

is, we can there is no question, are right when they cases

recommend that the anterior blade should be first introduced and

position

adjusted

of the

to

the ear,

posterior blade,

so as to govern the which is to be introduced

There

is, however, by no means a general agreement point; some authorities, on the contrary, recommending that the posterior blade, being the easiest to introduce, should be passed first. With this recommendation I can by no means concur when the case is one for which the short forceps is suitable; but it is quite a different matter when the head is arrested at the brim, and no ear can be reached. In such a case no instrument but a pair of long forceps with a lateral curve after it.

on

this

should be used.

We have then

a more

difficult state of

things to encounter, and delivery becomes an operation involving much anxiety and requiring much skill. We lose

our

sure

the

and certain in

guide, the ear, haphazard

and have to

apply way by the forceps fontanelles. of the sutures and guidance Moreover, we have to apply it so that the concavity of its lateral curve is turned towards the front of the pelvis, or the instrument will not follow the curve of the pelvic canal. The forceps will then have to be adjusted rather with relation a

more

l6o

DR.

to the

JOSEPH

be situated somewhat

pelvis;

Each blade will

than to the child's head.

pelvis but

SWAYNE ON

GRIFFITHS

then

even

the child's head

obliquely

towards each side of the

should try, if possible, to seize its short diameter. When such a we

by things present, it may be advisable to introduce the posterior blade first, as recommended by Dr. Barnes and many other good authorities. When we recollect how short and inefficient the long forceps used by our grandfathers were, we cannot wonder that they should have felt very shy of performing this high operation ; and that when they failed, as they too often did, they felt themselves obliged to have recourse to the state of

is

horrible alternative of nental

craniotomy. the

authorities, especially

All the best Conti-

French,

were

then much

ahead of the British in this respect, simply because they devoted more attention to the subject, and used longer and

more

efficient instruments.

The number of

forceps operations performed by

me

during the first decade of my practice is sufficient proof of the disinclination to use the forceps (and especially the the

long forceps),

forceps

in

which

only

was

seven

then

cases

so

prevalent.

I used

of difficult labour in

a

deliveries between the years 1842 and 1852. The mothers all did well; but one child had been dead

total of for

some

about

by

308

the

a

hours before

month after.

forceps

case was

birth,

before birth.

Denman's short

this instrument

consequently

a

and another died of

The head

was

The

straight

much

forceps one.

pyaemia

compressed

used in every The blades of

approached too near together, and it had great compressing power. I am sorry to

say that during this decade I had to resort to craniotomy in two cases, which I feel convinced might now have been

successfully delivered by

the

long forceps.

In both there

FORCEPS

l6l

DELIVERY.

of the

conjugate diameter of the pelvic brim, and the head consequently would not enter the pelvic cavity; no ear could be felt after many hours of extreme suffering, and the patients had both become so exhausted that my father, who consulted with me each time, thought that craniotomy was the only alternative. On looking at the kind of long forceps that he then used, which was Ramsbotham's, and which is deficient both in length and in lateral curve, I believe that his judgment was right. During the course of this decade, just before the middle of the present century, two most important

was

slight narrowing

discoveries

were

made

which

conferred

inestimable

I mean the discovery of benefits upon the human race. the about anaesthetics, year 1846, by two American dentists, Jackson and Morton, and the discovery of the infectious nature of

puerperal fever,

in

1847, by

Semmel-

weiss of Vienna. Sir

James Simpson did real good service to obstetric time, by making great improvements in the long and short forceps, and by publishing a series of papers on turning as a substitute for the long forceps. The long forceps he contrived is an especially good one. It is at least an inch longer than Ramsbotham's, measuring clinches, and combines the excellencies of Levret's lock and Naegele's handles. It is still a good deal used, although most practitioners, like myself, have abandoned it for Dr. Barnes's, which is about an inch longer, and a still better instrument. Simpson's short forceps is only gf inches in length; it is straight, like Denman's, and the blades are similar, but wider apart; it has also shanks between the blades and the lock, and this allows it to be used when the head is high in the pelvic cavity. The handles, however, are very short, but still allow one to use quite a

science about this

162

DR.

JOSEPH

GRIFFITHS

SWAYNE

sufficient amount of extractive power.

instrument, has been used by I still continue to the

of

use

only

use

one

me a

a

handy times, and

very

great many

If, however, I were limited to forceps in every case, I should unit.

choose Barnes's, for it

doubtedly just entering

head is

It is

ON

can

be used both when the

the upper strait and when it is quite cavity, although I prefer in the latter

low in the

pelvic straight instrument, like Simpson's short forceps. About the year 1856, I discarded Denman's forceps and adopted Simpson's short forceps, which I found to

case a

be much child.

more

Perhaps

insensibly labour, able.

to

and safer both for mother and

satisfactory,

use

in consequence of this I was led almost the forceps more frequently in difficult

and with results that seemed to I find that in

five times.

1856

All these

this kind of short

were

forceps

me

I used this

very favourless than

forceps labours, for which peculiarly well adapted. My no

tedious first

is

record of the first two decades will show very well how gradually I came to appreciate more and more the safety and

efficiency

of this instrument.

used the

From

times; forceps times, just four times previous decade. In these, my first

only

I used it 28

I shall have

by-and-by

recorded, in

total of

a

1842 to 1852 I 1852 to 1862

but from

seven

the number of the two

decades,

which

compare with my last two, I In cases, 35 forceps deliveries.

to

672

29 of these I was called in consultation, whereas in six only was I the original attendant. Twenty-eight were primiparas, and only seven multipart. This shows, what would naturally be expected, that it is in first labours that this

forceps is so especially useful. forceps than Simpson's

short

delivered with the instruments used

In

fact,

long forceps Dr. Davis's,

were

I

employ

no

other

the present time. I only three times. The

at

Dr.

Clark's,

and Sir

FORCEPS

James Simpson's long forceps,

and the results

able to both mother and child. found to be

passed proved

far the

163

DELIVERY.

were

The last-named

favour-

forceps

I

but before many years had by I substituted for it that of Dr. Barnes, which

best;

to be still better.

leaving this decade, it would be a great omission neglected to record a most important event which took place on the 16th of December, 1858; viz., the Inaugural Meeting of the Obstetrical Society of London, under the presidency of Dr. Rigby. This was the first beginning of a Society which has since done more than any other in this kingdom for the promotion of obstetrical science. It began well by a valuable paper by my friend Dr. Tyler Smith (who was once a pupil at our Bristol School), in which the author pointed out that too frequent craniotomy Before

if I

had hitherto been the for this "

twice

operation as

often

as

opprobrium

had been

of British

in France and four times

and to

this sad

midwifery;

in this

performed

state

as

country

often

as

of

in he

things Germany;" advocated, first and foremost, the more general application of the forceps, especially the long forceps. Dr. was followed soon afterwards Smith's by a paper Tyler very complete and practical one by Mr. P. Harper on "A More Frequent Use of the Forceps as a Means of Lessening both Maternal and Foetal Mortality." The Society which commenced so auspiciously has since done excellent work in claiming for the forceps its proper place in

midwifery, and

of infant life.

gynaecology

has

cure

consequently effected

It has also conferred

on

a

great

saving

the science of

benefits but little inferior to those I have

mentioned in obstetrics. With

regard to to 1872,

the third

just decade,

which are interthe ten years from 1862 and the last two decades, mediate between the first two

viz.,

dr.

164

JOSEPH

GRIFFITHS

SWAYNE

ON

remark, except that they show a of the forceps with correspondgradually increasing ingly favourable results. There were 72 forceps cases in there is not much to

use

total of 495 deliveries. In 45 of these I was the consultant and in 27 the original attendant, thus showing a

a

comparison with the cases predominated ; 19 multiparous cases. Two

increase of the latter in

gradual

former class. for there

As

usual,

first labour

53 of these and mothers died and six children, but all these were consulta-

tion

were

delivery, and happened a scarlatina, to the six

whilst

place six days after caused by uterine phlebitis; the other days after delivery, and arose from

One maternal death took

cases.

was

few

which also attacked the husband.

children,

one

in the five

With

had been dead for

others death

clearly

some

regard hours;

resulted

from

compression of the head during birth, and in one case evidently from pressure by the forceps on the cord, which happened to be round the neck. My statistics during the next decade (from 1872 to 1882) show 67 forceps cases instead of 72 as in the previous decade ; but as the total number of cases of all kinds is larger, the percentage of forceps cases is consequently smaller from 1872 to 1882. This arises from the circumstance I

was

the

that

original

in this

decade the

attendant

greatly

cases

in which

outnumbered the

instance, in a total of 609 labours attended by me, there were 67 cases of forceps delivery, of which I was in 49 the original attendant, and in 18 only the consultant. Primiparse, as usual, predominated, there being 50 of them to 17 multipart. There was no maternal death, but 12 infants died, half of them in con-

consultation

sultation

cases.

For

cases.

During

this

decade,

in the year

1875,

I must

announce

FORCEPS

a

from the old safe rule of Denman in his

departure

Aphorisms, that finished before innovation

165

DELIVERY.

"the first stage of labour must be perfectly think of applying the forceps." This

we

old established rule of

on an

to the courage and skill of Dr.

practice

Johnston,

was

due

Master of the

published by him in 1875, in his annual report of that hospital. In certain cases where the child's head is arrested by slight disproportion at the brim of the pelvis, the membranes will often rupture early, before the os uteri is fully dilated. Under

Hospital, Dublin,

Rotunda

and

was

such circumstances, the labour will often be rendered exceedingly tedious, simply because the head will not descend upon the os uteri, so as to complete the dilatation. In such cases, he introduced the forceps within an cs uteri that would

brought it down effect delivery. by him,

which

just

admit

the head and

very gradually, so as to dilate the os and Several cases of this kind were related attended with most favourable results

were

both to mother and child. I had

an

I

called in to

was

it, grasped

opportunity a

of

Soon after

testing

similar

this

case

of

reading

his

report,

practice myself. difficulty by another

new

long been arrested at the and the os uteri, as correctly as I could measure it with three fingers, was not more than 3 inches in diameter. I used Simpson's long forceps, and after a good deal of time and patience effected delivery safely, both as regards mother and child. Before three years had passed, I happened to meet with three similar cases, in which the diameters of the os were respectively 3 inches, 2w inches, and not more than th'e diameter of a crown piece; and

practitioner. pelvic brim,

the results one case

but had

The head had

were as

favourable

as

in the first instance.

I failed to deliver with recourse to

Barnes's with

In

Simpson's long forceps, perfect

success.

The

166

DR.

JOSEPH

GRIFFITHS

SWAYNE

ON

in the second case, and also in the third, in which I made no further trial of Simpson's instrument. Although it was a better long forceps than

thing happened

same

of its

predecessors, it is in every way, except perhaps in the handles, inferior to Dr. Barnes's, which I had just then begun to use. As regards the use of the forceps before the os uteri is fully dilated, it is an operation that needs all the cautionary words which most

Dr.

McClintock used when it

requires great patience,

might

care, and

It

first described.

circumspection,

and

lead to most serious results in unskilful hands.

would not dozen

was

have

myself

two

attempted

it if I had

only

had

I a

forceps my previous experience. No one, in the present day, would venture to deny the great benefits resulting to the mother from a timely resort to the forceps in tedious and difficult labour; but as regards the child the prospect is not altogether so couleur de rose. In 1878 I read a paper at the Annual Meeting of the British Medical Association, in Bath, on "The Effects of Forceps Delivery on the Infant;" and I stated that my own experience led me to agree with a conclusion of Dr. Galabin's, which he formed after most careful and patient investigation; viz., that It has not been shown that the majority, or any considerable proportion, of the or

cases as

"

stillbirths which

by by

a a

now occur

saved

in Britain would be

resort to the

timely timely use of more

that would

the

forceps." long forceps many

formerly

have

been

preventable

It is true that infants

are now

destroyed by

craniotomy ; yet it is no less true that in some other cases the forceps is a source of danger to the child by its increasing the previous pressure on the head during a hard labour ; and I gave four cases of my own in which the death of the child was clearly due to a cause which,

FORCEPS

far

as

the

I

as

others: I

has not hitherto been mentioned

know,

mean

167

DELIVERY.

the

of the umbilical cord

compression

The cord of the

by by

all

know, is very often round its neck ; and in the cases mentioned, I actually observed, when I delivered the head, that a loop of the cord had been and was actually being compressed by the forceps against the angle or ramus of the jaw. Here, then, we have a source of danger to the child, arising simply from the use of the forceps, and which cannot be guarded against by any ordinary amount of

forceps.

child,

as we

I have since met with other similar cases; and the subject may still be said to be sub judice, I hope at

skill. as

some

It

future time to refer to them

only remains

for

now to

me

more

in detail.

give briefly

the statistics

of my forceps deliveries during the last decade. From From 1882 to 1892 there were 47 forceps cases in 243 deliveries. The most remarkable feature is that the cases in which I

was

the

double those in which I 15. One mother sultant ; and five

attendant

original was

were

consultant,

32, which

died, but in a case where infants, in four of which

I

or

nearly only

were

was a con-

cases

I

was

consultant. I must

now

frequency with

give

a

few

which the

figures

to show the increased

forceps has

been used in the last

decades, as compared with the first two. From 1842 to 1862, there were 35 forceps cases in a total of 672 deliveries, i.e. nearly 1 in 18; whilst from 1872 to 1892 there were 114 forceps cases in a total of 852 deliveries, or about 1 in 7^. Again, in the first two decades the 35

two

forceps

cases

consisted of 28

the number of the former latter.

decades,

being

This difference is not for the 114

forceps

and 7 multiparae; four times that of the

primiparae so

cases

marked in the last two in this

period

were

made

168

DR.

up of 82

ON

GRIFFITHS SWAYNE

JOSEPH

32 multipart. These numbers very with those given by Dr. Johnston in his

primiparse and

nearly correspond report of the Dublin remarks

Rotunda

"There 113 advisable to deliver with the :

were

primiparse,

where

forceps,

we

and

83

1875,

for he

considered it of these

were

There is another

than two-thirds."

or more

for

Hospital

cases

difference between the first two and the last two decades which I must

From

explain presently.

1842

to

1862,1

was

forceps cases, and the original attendant in 7 only ; whereas from 1872 to 1892, I was the consultant in 33 cases only and the original attendant in 81. It will

the consultant in 28

be observed from this that the

consulting forceps

cases

the last two decades exceeded those of the first

only;

whereas the

cases

in which I

the

was

attendant exceeded those of the first two

by

no

by

in

five

original less than

This proves how thoroughly one's mind had become impressed, in the course of years, with the great advantages of a more frequent use of the forceps. Before 74.

saying anything

speak

of

praise

of

more

praise

of the

it;

forceps, I wish to be alleged in dis-

two things that may and first to call attention to the maternal and

one or

infantile

mortality.

attended

by

The whole number of

in 50 years is 114 in which I

me

groups; viz., ?in this group 106 in which I

no

mother

was

deaths of mothers; cases, I will not be

of

in

220. was

died;

forceps

cases

This consists of two the

and

original a

attendant

second group of were four

the consultant?in this there

but,

as

I said before of consultation

responsible died six

for their issue.

The first

after her confinement,

these, primipara, days septicaemia; the second, a multipara, from uterine phlebitis; the third, a primipara, from scarlatina, which also attacked her husband; and the fourth, a primipara, from uraemia, which came on after delivery. When we from

a

169

FORCEPS DELIVERY.

add these two groups together, in 224 forceps cases, which is bad average when collected from other quarters. cases; not

a

Churchill's Manual of

1855

he

have

we

exactly

only

death in

one

compared

four deaths

56

with statistics

In the edition of Dr.

gives

statistics of

forceps

mortality obtained from 34 authorities, both British and " foreign, and the total result is, that in 1,284 forceps cases 76

mothers

cases

Now,

283

lost,

were

children

about

or

were

born

1

in

dead,

16^-; or

and in

1,262

in

4!."1

about

these statistics of Dr. Churchill's

1

were

collected

about 40 years ago, at a time when accoucheurs used the forceps with great reluctance, and put off using it as long as

possible; whereas nearly all my cases were attended time, when the more frequent use of the forceps

since that

had become in the

general,

and before bad

labour,

The smaller maternal accounted for.

mortality

is

and when it

as

was

employed

symptoms began

mortality

in the latter

earlier

to appear.

cases

is thus

In Dr. Churchill's statistics the infantile

great

as

1

in

remarked

4f.

It

is, however, as I the forceps effects

before, still uncertain whether any great saving of infant life. In my 220 cases 32 children were lost, which is a mortality of 1 in 7; but I have no space now to go into the causes of such mortality. The most usual was pressure, either from the long labour, the use of the forceps, or both. Another objection that has been made to the use of the forceps is that it increases the frequency of perineal laceration. This I emphatically deny. It does not in skilful hands, but it does in the hands of the

clumsy and ignorant, and under such circumI was once a powerful weapon for evil.

stances becomes called in the

by a practitioner of this description. perineum torn completely through into the 1

Churchill's Miclwifery, p. 339. 13

Vol. X.

No. 37.

I found rectum,

DR.

170

although

GRIFFITHS SWAYNE ON

JOSEPH

the head

still

was

pelvis. thought, firmly,

got hold of the head, as he making strong traction, but in the

accident.

Such

accident may ensue also, if when the pelvic outlet the operator goes on extracting

if it

of

allowing plenty

to

overcome

perineum. stance,

was

when

an

as

were

and

direction,

a

wrong off the head, and hence the

forceps suddenly slipped

head is at the

He had

in the

high

at the

brim;

or

of time for

with the

if, in a primipara, instead dilatation, he endeavours

forceps

I do not think it

the resistance of

advisable,

a

rigid

under such circum-

it grasps the head the last it is very any traction, but for

to remove the

forceps, unless obliquely; for just at

awkwardly or useful sometimes, not for making gently guiding the head forwards beneath the pubic arch. Occipito-posterior presentations are very likely to require the forceps, and also to cause perineal laceration, especially if, as the head descends, the occiput does not come round to the front as it usually does, but, on the contrary, turns

backwards into the hollow of the sacrum, and remains in that untoward position until it is expelled. There were

220,

as a

many as 35 number much

occipito-posterior positions in the beyond the usual average of such

cases.

I have not

kept

an

exact account of the number of

perineal lacerations which occurred in my forceps cases, but I have a strong impression that it is very little above that which often

occurs

in first

labours without

the

forceps.

The worst instance of ruptured perineum which I have met with in any of my cases, with or without the was one in which the tear went through the forceps, fibres of the external the it

sphincter ani,

recto-vaginal septum.

happened,

It

and healed well

as

but did not involve

stitched up at the time others did; and I never

was

FORCEPS DELIVERY.

had

a case

of laceration

quent surgical side of the

having given question, which

it has been

do full than

justice

bad that it

required

a

subse-

operation.

And now, as

so

171

painted,

a

sketch of the unfavourable

shows that it is not

so

I turn to the favourable

to which would

require

more

black

side,

to

vivid colours

I possess.

It appears from my statistics of the cases that they consisted of 164 primiparsb

220

forceps

and

56 multiparas;

first labours

as

i.e. very nearly three times as many were of others. This corresponds

there

very closely with the experience of others, and shows that first labours, especially, are those in which the is of such invaluable service.

forceps

whatever

that,

and

longer amount

of

has arisen

dangerous.

as a

general rule,

There is

no

doubt

first labours last much

incomparably greater suffering than others, and hence probably the popular notion that they must be more are

attended with

Such

formerly before forceps was so

a

an

notion may have been well founded

anaesthetics

very seldom correct in the present

were

used,

employed,

and when the but it is

by

no

On the contrary, all my own experience goes to prove that first labours are less dangerous than others. Most accoucheurs of experimeans

day.

will, I think, agree with Dr. Churchill, that a prolonged first stage, which we so often get in primiparae, is not per se dangerous; but few will, I think, be disposed to deny that it may indirectly become a source of danger, and that the pain, the loss of sleep, and want of rest attending a prolonged first stage, which has lasted perhaps for several days, may lead to a flagging of the ence

vital powers in the second : and this is the reason, I think, why we so often notice that the progress of the child's head in first labours becomes 13

*

more

and

more

DR.

172 slow while

GRIFFITHS

JOSEPH

the

traversing

SWAYNE ON

pelvic canal,

until at last it

stationary as it approaches the pelvic outlet, forceps is required to complete the labour. There doubt, I think, that fifty or sixty years ago, when

becomes and the is

no

obstetric practitioners this state of

things

first labours.

Much

were so

did

implicitly

greatly

century, dangerous rule

use

increase the this the

more so was

the close of the last that

reluctant to

when

men

the

forceps, dangers of

case

towards

obeyed

of Denman's:

"

more

that the

head of the child should have rested six hours upon the perineum after the cessation of labour pains before the

forceps

are

used."

day the more frequent and skilful quite abolished the dangers of a prolonged second stage thus occasioned, so that we are justified in considering that the second stage of labour is more dangerous to a primipara than it is to a not multipara. My own statistics give abundant proof that the safety But in the present use of the forceps has

primipara is not risked by this modern mode of practice. Although the general symptoms may be quite

of

a

favourable,

I

never

allow the head to be arrested in the

pelvic cavity

for

the

That this

forceps.

more

than two hours without

practice

is

applying the result

justified by began practice, labours, in which I was

will be evident when I state that since I in

I have attended 311 first original attendant from the beginning to the end of the

1842,

the

labour;

employed the forceps in 79 of these in four?and that there has not been

that I

i.e. about

one

cases? a

single

maternal death in the 311 cases. The forceps, when used in this way, undoubtedly contributes to the safety of the

patient by shortening the labour, and thus saving her not only from a great amount of pain, but what is of much

FORCEPS

more

evil,

DELIVERY.

173

consequence?a great deal of exhaustion. The first doubt, can be removed by chloroform, but the

no

latter would be increased

by it. But the mere abolition pain by thus shortening the labour great is quite enough to justify the use of the forceps. No one who has practised midwifery before the days of chloroform, as I have done, and has witnessed the inexpressible anguish and agony which women had to

of

amount of

a

endure labour

during

the

prolonged

(although, perhaps,

which he

was

or cease to

afraid to

thank

God,

use "

too

ordered the love of

spring lens, an

pelf,

of action and the

on

men," which

besetting

that it should in the

inestimable benefit

soon), will

who alone

wills and affections of sinful so

second stage of a first an instrument

he had at hand

end,

can

ever

forget it, unruly

order the

that He should have was

both the main-

sin of the Chamber-

after many years, confer

the human

race.

Since the earlier part of this paper was printed, I have found that I should have given the number of

forceps

cases

Therefore the instead of 114. for 81 read 79.

in the last decade

as 46 instead of 47. of the last two decades will be 113 On page 168, line 11, for 33 read 34, and

cases

A summary of the forceps cases referred to in the foregoing paper is given in tabular form on the following pages.

CASES

FORCEPS

from

1842

to

174

OF

EPITOME

1892.

POSITIONS OF HEAD :?

1842

Mult.

Dr.

1844

Prim.

Mr. Croft

1846

do.

Mr. Cleave

1848

do.

Mr. S. H.

1849

do.

Dr.

Swayne

1849

Mult.

Mr.

Taylor (pupil)

1851

Dr.

1853

Prim, aet. 40 Prim.

1854

Mult.

Dr.

1854

Prim,

Dr. Lancaster

Swayne (pupil)

Consultant.

Bartley

Result to Mother.

Result to Child.

Did well

Lived

do.

do.

used.

OLA

Dr.

Swayne

do.

Denman's short do.

do.

do.

do.

do.

Stillborn

do.

do.

do.

do.

Lived

None

ORA

do.

do.

Mr. Swayne and Dr. Swayne Dr. Swayne

OLA

do.

do.

Phlegmasia dolens, slight legs. Right parietal bone bulged

ORA

Davis's short Denman's short do.

do.

do.

None.

OLA

do.

do.

Stillborn

None

do.

do.

do.

Lived

Dr.

do.

do.

do.

do.

Slight perineal

do.

ORA

do.

do.

do.

Simpson's None.

do.

Swayne

&c.

Complications, Sequela,

Swayne

sen.

Swayne

Forceps

Mr.

Swayne

Mr. Leonard,

Position

of Head.

dr.

A ttendant.

Multipara,

Forehead to left acetabulum FLA) Occipito-posterior do. FRA j" Do. right positions.

None.

Child die? after the month from pyaemia. Child had been dead some hours. None.

Child

attack in both in

Some

was putrid. hemorrhage. Ergot ineffectual.

by

pressure.

post-partum

laceration.

set.

1855

32 Prim.

1855

do.

Mr.

Cooper (pupil)

do.

FRA

do.

do.

do.

do.

Mr.

Mayor,

do.

OLA

do.

do.

Died

Mr.

Biggs (pupil)

do.

ORA

do.

do.

Lived

7

8

9

1855

Mrs.

Baily (midwife)

sen.

uterine tractor failed.

Child died after two hours from pressure.

set.

1856

41 Prim.

6

Ergot given

JOSEPH

Original

Date.

3. 4.

GRIFFITHS

Primibara

Do.

acetabulum, OLA do. ORA right

SWAYNE

2.

to left

ON

Ordinary?1. Occiput

with little effect. 10

10

9

1856

do.

Dr. Brookman

do.

Dr.

1856

Ashley (pupil)

Sway tie

Dr.

Swayne do.

None

Did well

Lived

do.

Denman's short do.

do.

Stillborn

do.

Simpson's

do.

Died

OLA

set.

short do.

None.

Ergot ineffectual; Rigid

os

third

male

uteri. V.S. to 16 oz. child died. Blood

day

1857

30 Prim, set. 30 Mult.

1857

do.

1857

Prim.

Mr. Board

(pupil)

do.

do.

do.

Died

Stillborn

1857

do.

Mr. S. H.

Swayne

do.

FLA

do.

Did well

do.

1858

do.

Mr. Wilson, sen.

do.

OLA

do.

do.

Lived

1858

do.

Mr. Crichton

do.

do.

do.

do.

do.

None.

1858

do.

Mr. Macdonald

do.

do.

do.

do.

do.

None.

do.

Mr. Sawer

do.

do.

do.

do.

do.

None.

do.

do.

Clark's

do.

do.

Head arrested at brim.

OLA

long Simpson's

1856

1859

do.

None

do.

None

do.

Dr.

do.

Mr.

Hodges

Swayne

do.

10

lbs.

Os lacerated.

On

child, weight

under dura mater.

Child died from pressure.

do.

do.

do.

do.

Lived

None.

do.

do.

do.

None. The mother died of puerperal fever after six days. Child died from compression of cord, which was round the neck. An occipital presentation.

ast.

1859 1859 1859

40 Prim. Prim, set. 40 Prim.

Mr. Dr.

Wilson, jun. Swayne

None

do.

do.

None.

do.

do.

Perineum lacerated as far as

None

FRA

short do.

Mr. Macdonald

Dr.

OLA

do.

do.

do.

None.

None

FLA

do.

do.

do.

None. None.

do.

1860

do.

i860

Mult.

Dr.

i860

Prim.

Mr. Wine

(pupil)

Dr.

Swayne

OLA

do.

do.

do.

i860

Prim.

Mr. Wine

(pupil)

Dr.

Swayne

ORA

Simpson's

do.

Lived

i860

do.

Mr. Sawer

do.

Stillborn

Swayne

Swayne

Dr. Swayne and Mr. Goodeve

OLA

short do.

Post-partum hemorrhage Perineum lacerated to

DELIVERY. FORCEPS

Prim.

sphincter ani.

from inertia uteri.

sphincter

ani.

175

Mr.

1856

1861

Mult.

Mr. Lansdown

1862

Prim.

1862

do.

Dr.

1862

do.

Mr. Corbould

1862

do. aet. 38 Prim.

1862

Dr.

Swayne do.

Mr. Baretti

Position

of Head. ORA OLA

Forceps used.

{Rams-

Result to Mother.

botham's Did well

long Simpson's

Result to Child.

Lived

Complications, Sequela, &c,

None.

do.

do.

Slight perineal

FRA

short do.

do.

do.

None.

do.

do.

do.

do.

None.

do.

ORA

do.

do.

do.

None.

Mr. Macdonald

do.

OLA

do.

do.

do.

Swayne

Mr. S. H.

None Dr.

Swayne

Swayne

ij6

Consultant.

laceration. DR.

A ttendant.

18C2

do.

Mr. Parker

do.

do.

do.

do.

do.

Piece of exfoliated bone came away from child's head. None.

1862

do.

Mr. Macdonald

do.

do.

do.

do.

do.

None.

1862

do.

Mr. T. E. Clark

do.

do.

do.

do.

do.

Prominent sacrum.

1862

Mult.

None

do.

do.

do.

do.

None.

1862

do.

do.

None

do.

do.

do.

do.

None.

1862

Mr. Sawer

Dr.

do.

do.

do.

do.

None.

do.

do.

Died

do.

Mother died on the ninth

1863

Prim, set. 40 Prim, set. 30 Prim.

do.

She died from

1863

do.

Some

1863

do.

1863

do.

Mr. Hamilton

do.

1863

do.

Mr. Macdonald

do.

1863

Swayne

Mr.

Sheppard

Swayne do.

weighed ioflbs.

phlebitis.

Dr. Marshall

do.

do.

do.

do.

Mr.

do.

do.

do.

Did well

do.

do.

do.

do.

do.

do.

Slight perineal

OLA

do.

do.

do.

None.

do.

do.

do.

do.

None.

Lang

do.

occipital

Conjugate?3

inches.

SWAYNE

Dr.

Child

JOSEPH

Original

or

GRIFFITHS

Primipara Multipara,

malignant

day

scarlet fever.

post-partum hemorrhage. laceration.

10

from uterine

ON

Date.

1863

Prim, jet. 36 Prim.

i863

I

Mr. Sawer

Dr.

Swayne

FLA

Simpson's Did well

9

Lived

Sheppard

do.

OLA

short do.

Mr. Hamilton

do.

OLA

do.

do.

Lived

Mr.

do.

Stillborn

10 None. Child died from pressure on was round the neck. None.

cord, which

Mr. Macdonald

do.

do.

do.

do.

do.

None.

1864

do. set. 28 Prim.

Mr. S. H.

do.

FLA

do.

do.

do.

1864

Mult.

Dr.

None

ORA

do.

do.

do.

post-partum hemorrhage; controlled by ergot and pressure. Inertia of uterus. Ergot ineffectual.

1864

Prim.

Mr. Macdonald

Dr.

OLA

do.

do.

do.

Adherent

1864

do.

Mr. S. H.

do.

do.

do.

do.

do.

1864

do.

Mr. Hutchins

do.

FLA

do.

do.

Died

1864

do.

Dr.

OLA

do.

do.

Lived

1864

do.

Mr. Baretti

Dr.

do.

do.

do.

Stillborn

1864

do.

Dr.

None

ORA

do.

do.

Lived

1865

Mult.

do.

None

FRA

do.

do.

do.

two sutures; united well. after Soon birth child died from pressure on head. Pedunculated tumour attached to fundus uteri. Child died from head pressure during labour. Large cephalhsematoma of child's head. Cured by puncture. None.

1865

do.

Mr. Sawer

Dr.

OLA

do.

do.

do.

None.

1865

Prim.

Dr.

None

do.

do.

do.

do.

Some vesical irritation afterwards.

1865

do.

do.

None

do.

do.

do.

do.

None.

1865

do.

do.

None

do.

do.

do.

do.

None.

1865

do.

do.

None

do.

do.

do.

do.

None.

1865

do.

Mr. C. Leonard

Dr.

do.

do.

do.

Lived

None.

1865

do.

Mr. S. H.

do.

do.

do.

do.

None.

1863

Swayne

Svvayne

Swayne

Swayne

Swayne

Swayne

Swayne

Swayne

None

Swayne

Swayne

Swayne do.

(with hand)

Some

placenta,

with

hemorrhage.

Slight perineal laceration;

FORCEPS

Mult.

8

DELIVERY.

i863

7

177

6

A ttendant.

1866

Prim.

Dr.

Consultant.

used.

Result to Mother.

Result to Child.

Simpson's

Did well

Lived

do.

Stillborn

Swayne

None

Lodge

Dr.

Swayne

None

do.

do.

do.

Lived

OLA

short do.

178

Forceps

Position

of Head.

Complications, Sequela,

&c.

None. Child died

apparently from pressure of

1867

do.

1867

do.

1867

Mult.

do.

None

do.

do.

do.

do.

Adherent

1867

do.

None

do.

do.

do.

do.

None.

1867

Prim, ast. 40 Prim.

Mr. T. E. Clark

Dr.

do.

do.

do.

do.

None.

1867

Mult.

Mr. Norton

do.

ORA

do.

do.

Stillborn

1868

Prim.

Mr. S. H.

do.

OLA

do.

Lived

None.

1868

Mult.

do.

do.

do.

do.

do.

None.

do.

do.

None.

do.

do.

Perineal laceration as far as sphincter. Two sutures. Healed well. Placenta retained by hour-glass contraction and adhesion. Perineum lacerated nearly to sphincter. Two sutures. Healed well.

1868

Mult.

Dr.

Swayne

Swayne

Swayne

None

1868

Prim.

1868

Mult.

Dr. Marshall

Dr.

Prim.

Dr.

None

Mult.

Mr. Cross

Dr.

1869

Prim.

Dr.

1869

do.

1869

Mult.

1869

do.

Swayne

Swayne

Mr. T. E. Clark Mr. Colthurst

do.

head.

OLA do.

None

-

do. r Ramsbotham's

-j

I Long

Simpson's short do.

None.

placenta

Ergot given

do.

do.

do.

OLA

do.

do.

do.

do.

do.

do.

do.

Ergot ineffectual.

None

do.

do.

do.

do.

None.

Dr.

do.

do.

do.

do.

None.

FRA

do.

do.

do.

Occiput

Swayne

Swayne do.

peeled

turned

to the front

traction.

Prim.

Dr.

Swayne

34

None

ORA

do.

do.

do.

56789

Perineum

off

by hand.

without success.

ORA

Swayne

was

JOSEPH

Dr.

Swayne

GRIFFITHS

Mr.

slightly lacerated. 10

DR.

Original

oy

during

ex-

Healed well.

SWAYNE

Primipara Multipara.

ON

^

Date,

18G9

do.

Dr.

do.

Mr. Rossiter

18G9

Swayne

Swayne

1869

do.

Dr.

1869

do.

Mr. Coe

1870

do.

1870

Mult,

1870

do.

1870

Swayne

Dr.

Swayne

Swayne

None Dr.

Simpson's

Swayne

Did well

Lived

Perineal laceration nearly to sphincter. Three sutures. Healed well. None.

short do.

do.

do.

FRA

do.

do.

Stillborn

ORA

do.

do.

Lived

do.

do.

do.

do.

do.

None Dr.

ORA

10

Died from head pressure.

Arm

wanting.

Placenta retained by hour-glass contraction. Perineum

slightly

lacerated.

Sutures.

Healed well. FRA

do.

do.

do.

None.

None

ORA

do.

do.

do.

Hour-glass

do.

None

do.

do.

do.

do.

contraction. Placenta wholly adherent. Placental adhesion and hemorrhage.

Prim.

do.

None

FLA

do.

do.

do.

None.

1870

Mult,

do.

None

OLA

do.

do.

do.

None.

1871

do.

Mr. Cross

Dr.

FRA

do.

do.

do.

do.

d?" Died

Mr. S. H. Dr.

Swayne

1871

do.

Dr.

1871

do.

Mr. Smith

1871

Prim,

1871

do.

1871

do.

Swayne

Swayne

Swayne

Dr.

Swayne

I long Simpson's

\

do.

Lived

\

/

Patient had

do.

do.

do.

do.

do.

do.

do.

do.

do.

None.

do.

do.

do.

do.

do.

None.

None

OLA

do.

do.

do.

None.

Dr.

ORA

Barnes's

do.

Lived

None.

FLA

do.

do.

Dead

Rigid

Mr.

Mayor

Dr.

do.

Mr.

Ring

1871

do.

Mr. C. Reade

1872

Mult.

Dr.

1872

Mult.

Mr. Ellis

1872

Prim.

Dr.

Swayne

?j

{

do.

None

Swayne

do.

do. rRamsbotham's

short do.

Swayne

Dr.

ORA

None

None. Twins. Second child died a few hours after birth ; it was expelled naturally.

do.

Swayne

Swayne

.Mr.S.H.

Swayne

prominent

sacrum.

DELIVERY. FORCEPS

Prim,

0

Forceps pressure produce temporary paralysis of face. Some hemorrhage postpartum; restrained by pressure and ergot.

os.

dented

Narrow pelvis. Forehead of child inby forceps. Adherent placenta.

179

Mr. S. H.

i86g

8

Mult,

1872

do.

1872

do.

1872

Prim,

1873

do.

1873

do.

1873

do.

Dr.

Swayne

Mr. Corbould Dr.

Swayne

None Dr.

Swayne

None

Forceps used.

Result to Mother.

Result to Child.

Simpson's

Complications, Sequela,

Did well

Lived

OLA

short Barnes's

do.

Stillborn

do.

do.

do.

Lived

Simpson's

do.

do.

She had

FRA

Hour-glass placenta.

contraction

Membranes

punctured

&c.

and adhesion of

Child died from pressure on head. for

hydramnios.

Mr. Corbould

Dr.

Dr.

None

FLA

short do.

do.

do.

None.

do.

None

OLA

do.

do.

do.

do.

None

do.

do.

do.

do.

Perineum torn nearly to sphincter. One stitch. Healed well. Perineum torn to sphincter. Two stitches. Healed well. Twins. First, breech. Second, head?

Swayne

Swayne

ORA

1873

do.

do.

None

do.

do.

do.

do. do.

1873

Mult.

do.

None

ORA

Barnes's

do.

do.

None.

1873

Prim.

do.

None

do.

Simpson's

do.

do.

None.

1873

Mult.

Simpson's long Simpson's

do.

Stillborn

J

pleurisy during

her recovery.

forceps.

short.

Prim,

1873

do.

1874

Mr. Talbot Dr.

Swayne

Mr. S. H.

Swayne

Dr.

Swayne

do.

do.

Lived

FLA

short do.

do.

do.

None

OLA

do.

do.

do.

do.

do.

do.

None Dr.

Swayne

do.

34. Prim.

Dr.

Swayne

Cord round the neck

compressed by

Post-partum hemorrhage stopped by ergot, turpentine and pressure. Hour-glass contraction and adhesion of placenta. Two Perineum lacerated to sphincter.

1874

do.

do.

None

FRA

1874

do.

do.

None

OLA

do.

do.

do.

Healed well. laceration. Healed well. None.

None

do.

do.

do.

do.

Perineum lacerated.

do.

1874

do.

sutures.

Slight perineal

One suture.

Two sutures.

Healed

well. do.

do.

for-

ceps.

ast.

1874

1875

l8o

Position

of Head.

DR.

1872

Consultant.

None

ORA

do.

do.

do.

Partial inversio uteri.

\ 8

9

10

Easily

reduced.

JOSEPH

Attendant.

GRIFFITHS

Original

or

Multipara.

SWAYNE

Printipara

ON

Date.

1875

Prim.

1875

Mult.

i875

do.

1875

Prim.

1875

Mr. Parker

Dr.

Swayne

OLA

8

7

Simpson's Did

well

9

10

Lived

Placenta retained by irregular contraction.

None

FRA

short do.

None

ORA

do,

do.

do.

Hour-glass contraction. Adherent placenta.

Mr. Ruddock

Dr.

OLA

do.

do.

do.

Laceration of perineum. Healed well.

do.

Mr.

James

None

do.

do.

do.

None.

1875

Mult.

Dr.

Swayne

None

do.

Simpson's long Barnes's

do.

do.

None.

1876

Prim.

None

do.

Simpson's

1876

do.

1876 1876

Swayne do.

do.

None.

do.

do.

Perineum torn through external sphincter. Four sutures. Healed well. Perineum lacerated to sphincter. Two sutures. Healed well. Os uteri size of crown piece when forceps was used. Lacerated perineum. Healed well.

OLA

do.

do.

do.

do.

None

FRA

Barnes's

do.

do.

do.

None

do.

do.

do.

Stillborn

Swayne

Child appeared to have been dead

hours,

36

None

FLA

do.

do.

Lived

Mayor

Dr.

ORA

do.

do.

do.

Swayne

None

OLA

Simpson's

do.

do.

do.

do.

do.

do.

do.

Prim.

1876

Mult.

Mr.

1877

Prim.

Dr.

1877

do.

do.

None

ORA

short Barnes's

1877

do.

None

FLA

Simpson's

1877

do. set. 37 Mult.

18 77

do.

t

do.

Swayne

None

OLA

short Barnes's

sutures.

do.

None

Dr.

Two

do.

ORA

1876

18 77

None.

None

do. set.

do.

short do.

do.

Prim, set. 36. Prim.

Swayne

do.

do.

Stillborn

some

skin had peeled. Perineum torn to sphincter. Two sutures. Healed well. None. as

Perineum lacerated to sphincter. Two sutures. Healed well. Phlegmasia dolens a fortnight after delivery. Good recovery. Adherent placenta. Removed by hand.

Very prominent

sacrum.

Child had been

dead some hours.

do. do.

do. Dr.

Imlay

Dr. Lawrence

None Dr.

Swayne do.

FLA OLA do.

do.

do.

Lived

Barnes's

do.

Stillborn

do.

do.

Lived

None. Child died from prolapsed cord

compression of slightly against forehead. Adherent placenta removed by hand.

l8l

1876

Dr.

DELIVERY. FORCEPS

6

A ttendant.

1878 1878

Prim.

Dr.

Swayne

Simpson's

None

FLA

Barnes's

Dr. Challacombe

Dr.

OLA

Dr.

None

Swayne

do.

182

Result to Child.

do.

Complications, Sequela,

&-c.

Large cephal-

Child died convulsed on third day. hematoma from pressure.

Did well,

Died

do.

Lived

do.

do.

Slight perineal laceration; owing to cough. Ergot ineffectual.

do.

do.

None. Child died from pressure. Post-partum restrained by ice and pressure.

did not unite

do.

Died

do.

short do.

do.

Lived

None

ORA

Barnes's

do.

do.

do.

None

OLA

do.

do.

do.

do.

None

do.

do.

do.

do.

laceration of perineum. One suture. Healed well. Phlegmasia dolens of both legs a fortnight after delivery. None.

Dr.

do.

do.

do.

do.

None.

do.

Simpson's

Swayne do.

None

1878

do.

do.

1878 1879

do. aet. 40 Mult.

1879

Prim.

Mr. S. H.

1879

do.

Dr.

Swayne

Swayne

1879

Mult.

Mr. S. H.

1879

Prim.

Dr.

1880

do.

Swayne

Swayne

Mr. S. H. Mr.

1880

do. set. 30 Prim.

1881

Prim.

Dr.

do.

Result to Mother.

OLA

45 Prim.

1881

used.

None

set.

1880

ORA

Forceps

do.

Mult.

do.

None

Position

of Head.

short do.

do.

Prim.

Consultant.

dr.

Original

or

Swayne

Mayor

Dr. Challacombe

Swayne do.

Swayne

None Dr.

Swayne

None Dr.

Swayne

do.

parietal eminence,

Slight

do.

do.

None.

do.

do.

do. do.

First delivered by forceps; second by Twins. nature. Retained placenta and hemorrhage.

do.

do.

do.

do.

None.

FRA

Denman's short Barnes's

do.

do.

Perineum

OLA

do.

do. OLA

None

Child had sloughing ulcer on and crack behind the ear.

hemorrhage

short Barnes's

do.

None

Simpson's

do.

do.

Stillborn

do.

do.

Lived

Simpson's

do.

do.

do.

do.

8

9

short Barnes's

torn

to

sphincter

ani.

Two

sutures. Good union. Child appeared to have been dead some hours. Perineal laceration. Healed well.

None. Perineum torn to Healed well. Do.

sphincter. Do. 10

Two sutures.

JOSEPH

Primipara Multipara.

ON SWAYNE GRIFFITHS

,

Date.

Dr.

Mult.

Mr. Baretti

Prim.

Mr. Dobson

Swayne

7

8

9

10

None

ORA

Barnes's

Did well

Lived

None.

Dr.

FLA

do.

do.

Stillborn

Child

OLA

do.

do.

do.

Swayne do.

apparently

Patient had some

Mult.

Dr.

Swayne

None

do.

do.

do.

Lived

None.

do.

None

FLA

do.

do.

do.

None.

do.

do.

None

OLA

Simpson's

Perineum torn to Healed well. Do.

do.

do.

None

ORA

do.

do.

None

FRA

do.

882

do.

do.

882

do.

Mr. S. H.

Swayne

882

do.

Mr. Lansdown

882

do.

Dr.

882

Mult,

do.

882

do.

do.

Swayne

do.

do.

do.

do.

do.

Died

None

ORA

do.

do.

Lived

Dr.

FLA

do.

do.

do.

Swayne

and

dysuria days.

Prim,

short Barnes's

died from

Child died in

phalos

and

None.

long pressure.

bloody

sphincter.

an

urine for

Two sutures.

Do. hour from

ectopia cordis.

Paralysis of left side forceps pressure.

large

exom-

of child's face from

ORA

do.

Died

do.

She died after five days from uraemia and albuminuria. Child had a slough behind each ear.

None

OLA

do.

Did well

do.

Lacerated well.

None

do.

do.

do.

do.

None.

Simpson's

do.

do.

None.

do.

do.

None.

Stillborn

do.

None

do.

perineum.

Two sutures.

Healed

883

Prim.

do.

None

do.

short do.

883

Mult,

do.

None

do.

do.

do.

883

do.

do.

None

do.

do.

do.

Lived

883

Prim.

do.

None

do.

do.

do.

do.

appeared to have been dead for many days. Hydramnios. Labour induced. Want of uterine power. Ergot given with good effect. Hour-glass contraction, and adherent pla-

Prim,

do.

None

do.

do.

do.

do.

Slight

Child

centa. laceration of

Healed.

do.

do.

None

do.

do.

do.

do.

FORCEPS

Prim.

6

DELIVERY.

88

5

None.

perineum.

One suture.

183

4

3

1884

Mult.

Dr.

Swayne

None

Position

of Head.

OLA

do.

None

do.

do.

do.

None

ORA

Barnes's

do.

None

1884

do.

None

do.

1885

Prim.

do.

None

do.

1885

do.

do.

None

FRA

1885

do.

Mr. S. H.

Dr.

1885

Mult.

1885

do.

1886

Prim, set. 40 Prim.

Dr.

Swayne

Swayne

Swayne

None

None.

do.

do.

None.

do.

do.

Slight perineal

do.

do.

None.

do.

do.

Perineum torn to sphincter. Two sutures. Healed well. Perineum torn to sphincter. Two sutures. Healed well. Post-partum hemorrhage, checked by ergot and pressure. None.

do.

do.

None. None.

Simpson's short Barnes's

do.

do.

OLA

do.

do.

do.

ORA

do.

do.

do.

do.

OLA

do.

do.

Stillborn

do.

None

ORA

do.

do.

Lived

do.

None

do.

Simpson's

do.

1887

1887

Mr. Corbould

Dr.

1888

Prim.

Dr.

None

do.

do.

do.

do. do.

do.

None

OLA

short Barnes's

do.

None

ORA

Simpson's

do.

short Barnes'

do.

do.

Simpson's

do.

Stillborn

do.

Lived

Swayne do.

Swayne

None

FRA OLA ORA 6

short do.

7

Healed

do.

None

Swayne

One suture.

do.

do.

short Barnes's

Dr.

Swayne

tear.

&c.

well. Do.

Simpson's

OLA

Complications, Sequela,

Lived

Dr.

do. set- 35 Prim, aet. 36 Mult.

do.

well

Result to Child.

Mr. Baretti

1887

1888

Result to Mother.

Simpson's Did

Prim.

Mult.

1887

used.

short do.

ast. 33 Prim.

1886

Forceps

184

Consultant.

A ttendant.

8

9

do.

Perineum ruptured to sphincter ani. Two Healed well. sutures. Perineal tear went through external sphincter. Two sutures. Healed well. None. Perineum torn to sphincter. Three sutures. Healed well. Hour-glass contraction.

None. died /'ChildOne

from pressure. Lacerated perineum. suture. Healed well. Hour-glass contraction. Hand used.

Hour-glass

contraction. 10

DR.

Original

or

JOSEPH

Primipara Multipara.

ON SWAYNE GRIFFITHS

Date.

Swayne

Pi;im.

Mr. S. H.

888

Mult.

Dr.

88g

Prim.

14

Mult.

8go

Swayne

Swayne do.

Mr. Griffiths

Did well

Lived

OLA

do.

do.

None

FLA

do.

do.

do.

None

OLA

do.

do.

do.

Dr.

FLA

Simpson's

Dr.

Swayne

do.

do.

do.

do.

None

do.

-do.

do.

do.

do.

Barnes's

do.

Stillborn

ORA

Simpson's

do.

Lived

do.

Stillborn

Prim,

Mr. Fendick

Dr.

Dr.

None

do.

Swayne

do.

Swayne

890

do.

890

do.

890

do.

891

Mult.

Mr. Baretti

Prim,

Dr. Colman

do.

do.

Mr. M. Smith

do.

FLA

do.

Mr. Baretti Dr.

Swayne do.

Dr.

Swayne

None

OLA do.

short do. do.

do.

Lived

Mr. Ewens

Post-partum hemorrhage, checked by pres-

sure and ergot. Partial laceration of perineum. Two sutures. Healed well. Placenta retained by hour-glass contraction. Perineal tear to sphincter. Two sutures. Healed well. None.

Two Perineal laceration to sphincter. sutures. Healed well. Some hour-glass contraction of uterus. Bad laceration of perineum. Union not complete. No after-operation. None. Child

died from pressure.

glass contraction. Slight perineal tear.

Some hour-

One suture.

Healed

well.

from irregular contraction. Hand used. Child marked on forehead each side.

None

do.

do.

do.

do.

Dr.

do.

Barnes's

do.

do.

do.

do.

Simpson's

do.

Stillborn

Perineal laceration. Two sutures. Healed well. Child died from pressure on cord by

Simpson's long

do.

do.

Child died from pressure on head or cord.

Swayne

do. short

do.

'

do.

short do.

Swayne

Dr. Lees

Swayne

Simpson's

10

9

short Barnes's

None

Prim. set. 38 Mult.

Dr.

FRA

8

do.

FRA

DELIVERY. FORCEPS

Dr.

7

Hemorrhage

forceps.

185

X. Vol. 37. No.

Mult.

6

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