only 6 did not have another infant. Of these one died some years after the event; one was an aged primipara; one an illegitimate birth; leaving only three healthy young working-class wives in whom further labours might have been expected.

On the whole question of the use of forceps, I submit that the risk is being exaggerated at the present time. Any damage that is done is apparently done because some very simple rules are broken. If we all waited till the os was fully dilated and the second stage well advanced over two or three hours; and if we applied the sound surgical rule that when operation is indicated the sooner it is done the better for the patient; and if the most complete care were taken in antisepsis, there need be no such dreadful exhibitions as are described in Dr Comyns Berkeley's address.

After all, this controversy is a perennial one-it is not being raised by any means for the first time. In the end of the seventeenth century it was the great de la Motte who permitted himself to say that "he who keeps secret" (and a fortiori, he who objects to the use of) "so beneficent an instrument as the harmless obstetric forceps deserves to have a worm devour his vitals for all eternity!" But the opposition was strong enough to succeed in lessening the frequency with which forceps were used, so that we find in Hamilton an abstract of Madame la Chapelle's practice in 1816 in the Hospice de la Maternité in Paris. Of 15,380 patients, only 93 were delivered by forceps, or 1 in 165 cases, which has quite a modern look about it. She gives some account of 49 of these cases. "Seven women were thirty hours, two were thirty-three hours, one forty-eight hours, two three days, two several days, and one had been three days under the first stage. Thirteen women of the 49 died. Twenty-six infants were born alive."

Clearly then Madame la Chapelle was not a defender of the usage. Hamilton himself, though he deprecates keeping a woman in labour for more than twenty-four hours in the first stage, yet says that in forty-eight years' practice he only applied the forceps in 33 cases.9 The advocates of the forceps appear to have rallied again, for Haeser, writing in 1875, alludes to it as the one of the most beneficial instruments ever invented.10 And Barnes says of it: "Take, for example, the noblest (instrument) of all, the forceps. The more perfect we make it, the more lives we shall save, and the more we throw back into

reserve those terrible weapons which only rescue the mother at the sacrifice of her offspring."

I

What are the alternatives to forceps delivery? Cæsarian section or craniotomy seems most in favour. This being a paper which is concerned with country midwifery, the Cæsarian operation is practically out of court. Probably in days to come it will be simplified. It is not a difficult operation even now, and the younger generation may take the cases into the nearest Cottage Hospital and do them or have them done; but the time is not yet. As for craniotomy, a revolting procedure, I have only done it once on a dead baby in a tramp lodginghouse. I had applied forceps (this was long before the axis traction forceps came in), and after perforation I finished off with forceps. The mother did well, and the operation itself is not difficult, but it is revolting in all its aspects, and I venture to think there is yet a better way. Version is my next resort, and I do not understand the modern prejudice against it. have used it in all the cases, nine in number, in which I have failed to deliver by means of the forceps, and I have had no bad results such as are so graphically described in Dr Shannon's valuable paper, "The Failed Forceps Case and its Treatment." 12 I note that though he, like most others, inclines to Cæsarian section or perforation, yet on occasion he resorts to version. I should say that all of these occurred before 1895, with the old Simpson forceps. Since using the Milne Murray instrument I have had none. What used to happen was that in an occipitoposterior presentation, if much pressure were put on, the forceps began to slip, and the danger arose of them suddenly giving way and causing extensive laceration. In such cases I used to take them off, pass in my left hand, turn, and deliver if necessary with the forceps to the aftercoming head. I agree with Barnes,13 who says: "The head will come through the pelvis more easily if drawn through base first than if by the crown first."

All the mothers recovered without morbidity except the first, away back in 1887, who had a mild sepsis. Four children were alive. They were mostly working women of the agricultural labour class, a very migrant tribe, so I cannot trace all of them; but one I delivered quite normally two years afterwards, and another eighteen months afterwards of twins, version being again performed with good results both for mother and children. Another condition in which we are warned against version is hydrocephalus, where craniotomy again is prescribed. In both

my cases of hydrocephalus I performed version. In the second I had to apply forceps to the aftercoming head, and Barnes' dictum above quoted was justified. In point of fact the hydrocephalic head comes away with surprising ease when so treated. I had a case showing this not long ago. A young locum tenens sent for me to help him with what he described in his message as "locked twins." On my arrival I found a footling presentation, and what had misled the young doctor, a large swelling above the pubes, soft, fluid, and with some bony points in evidence. I washed up and examined. There was no sign of another head, and the swelling seemed continuous with the rest of the child's body. So with a very little traction the whole head came down with a "cloop" like the cork out of a bottle. All three women became pregnant in due course of time and all had normal labours.

Version is at the present time rather underrated. Besides these nine "failed forceps" versions, I have done it thirty-one times in this series for many conditions, losing fifteen children, including the nine monstrosities. All the mothers recovered. One woman, a tradesman's wife, had it performed four times. Her first child was still-born, delivery by forceps. Sixteen months afterwards she had a footling for which version was performed, a difficult case where the arms were over the head, one requiring fracture to get it down. That was in February 1897. In October 1899, she had another footling which was also turned, more easily this time; in April 1902 yet another footling, also turned. She rested until July 1908 when she had a breech presentation, where version was also done. This concluded her obstetric history, and of gynæcological history she has none.

Let me put in evidence my last version case, which I fear transgresses some of the rules of present-day teaching.

No. 2179.-Mrs T., aged 31, i-para. Premature rupture of membranes, 5 A.M. Sent for district nurse during the day. No pains till evening, when nurse sent for me. Os fully dilated, pains strong. Anterior lip swollen, being pressed on by vertex. There had been bleeding going on since morning from a partial placenta prævia lying over the posterior lip. It was a head presentation, but felt curiously soft like a dead head, but foetal heart was going. Under chloroform, I tried to put on forceps, but could not get them on, so decided to turn. It was very difficult. Waters had gone fifteen hours ago and there seemed

no resiliency in the body. It took about two hours, and when I had got a foot down I had to fix a tape to it; then, with two fingers on the head, with traction on the foot, I got the version completed. As the body came down a spina bifida showed itself, and I then saw where I was. Forceps to the aftercoming head brought down a large hydrocephalus. One hoped to be at the end of one's troubles, but after waiting fortyfive minutes for the placenta to clear, it came, but with a sense of something giving way. Her condition was wonderfully good, so I gave her some pituitrin, o.5 c.c., and left her. She ran a slight temperature for two days, and as it was 101-4 on the third day I gave her chloroform and drew down the uterus. I found a very small amount of placental tissue adherent which I gently removed with my fingers and washed out the uterus. Temperature 98, pulse 100, on completion of the operation. On the sixth day pulse and temperature were normal and remained so. This patient has already become pregnant, and has had a quite normal delivery. It is not often that one meets with a combination of five abnormalities in one case.

I need hardly remind you that in pleading for the more frequent practice of version as against the lethal instruments, I am sinning in good company. Sir James Simpson, addressing this Society on 20th January 1847, put forth a similar plea, and quoted a case which takes rank as one of great historical interest. It was a case "very lame, with the lumbar vertebræ much distorted," where at the last pregnancy craniotomy had been used after forceps had been tried and failed. On this occasion ether was given, being the first case in which it was used in labour, and Simpson turned and extracted the infant in "not above two or three minutes," preferring, “above all, the transient and not necessarily fatal depression of the flexible skull of the foetus for the destructive and necessarily deadly perforation of it." As the patient "left her bed, dressed, and walked into the next room on the fourth day after delivery," one feels that altogether she might have met with similar treatment seventy years later, and thus might be regarded as seventy years in advance of her time.14

These reminiscences of country practice have carried me away from my main line of argument. But there is yet another subject of interest on which I should like to say something before resuming it, namely, the development of our knowledge of eclampsia during these forty odd years.

were

1000 cases.

Eclampsia and Albuminuria.—This toxic condition appears to be on the increase. In the first series of 936 cases, there three eclampsias, practically three per 1000 As any albuminuria at that time, being untreated, would most probably develop into eclampsia, we may take this as an indication of the prevalence of the condition. In 1165 cases under my care I had 10, 5 of albuminuria and 5 eclampsias, or rather under 10 cases per 1000. From case 1165 till my last case, No. 2120, were 955 cases, in which I had 5 eclampsias and 9 albuminurias, making 14 in all, being as near as may be to 15 per 1000. In the three series, therefore, the ratio runs up from 3 to 10 and 15 per 1000, a very definite increase. I may now detail some of the cases.

My first case, in 1887, was tragic. I was sent for to the country to see a girl said to be having fits. I found her, an unmarried girl, who had just come back to her mother, in labour, and having one convulsion after another. The second stage was well advanced, head nearly reaching the perineum, so I delivered with forceps at once, and then treated the convulsions as best I could but with no result, and death took place very soon. The case contrasted with a case of albuminuria and dropsy which I had had early in the year. A primipara, aged 22, seven months' pregnant in December 1886, had oedema of legs, thighs, and vulva, labia much swollen. Urine heavily loaded with albumen, with granular casts. Put to bed with appropriate milk diet, alkalies, and diuretics, the oedema largely subsided, but was not away by the date of her confinement, which came off on 15th January and was uneventful. Symptoms subsided, and by March the urine was practically normal. She had another child in December of that year, when there was no return of the albuminuria. She then, in December 1890, had albuminuria in a third pregnancy, without eclampsia, and since has had a large family without any trouble. From that time I always inquired as to symptoms suggestive of kidney mischief, and whenever there was albuminuria I treated with alkalies and milk diet with uniform success. But, in 1899, I had a case without any warning. She was a farmer's wife, a primipara, over 30 years of age. The first stage was rather long and I left her for a time. On returning I found her just going into an eclamptic fit. Fortunately, the second stage had begun and I was able to turn and deliver her of a living child. Under chloroform she came round. She had had no preliminary