hours of natural effort we are meddling with a process greatly better let alone.

The process of dilatation of the cervix, the obliteration of the cervical canal, the relaxation of the lower uterine segment or the socalled ring of Bandl is a slow process. If given time the uterine contractions, pulling by the longitudinal fibers from above against a conical wedge within the uterus, gradually dilate the opening, making the heretofore contracted canal a cylindrical part of the uterine body, permitting the escape of its contents without great injury to its own structure or unnecessary pull upon the ligaments supporting the uterus. This dilatation can by no mechanical means known, be so safely accomplished as by the physiological process attending the phenomena. A certain degree of edematous infiltration of the lower segment results from the paroxysmal contraction and the relaxation, which requires time. This infiltration permits relaxation without laceration.

In the second stage of labor, in preparing the pelvic floor and vaginal outlet and perineum for the great distention that is to come, this infiltration is undoubtedly of the greatest value in permitting a relaxation without rupture. This process of infiltration requires time. In the second stage, especially in primiparæ, without very clear indication of necessity for hasty delivery, we should permit all the protective processes of infiltration, paroxysmal distension and recession, and gradual dilatation; ample time to prepare for the stretching that must otherwise result in laceration; which in the majority of cases physiologic law exacts. How unwise and how unscientific then does it become to resort to forceps before we have the best possible obliteration of the cervical canal and lower uterine segment which terminates the first stage of labor.

To apply the forceps high up before the head has entered the brim or descended into the excavation, even with a well dilated or dilatable lower segment, is a dangerous procedure. I quote from the "American Text-Book of Obstetrics": "It should be resorted to only in exceptional cases. The higher the head the more dangerous the procedure." How much more dangerous to apply high forceps before we have a proper dilatation and exert the strength often applied to the pull upon a lower undilated uterine segment. What are we pulling upon? We are dragging with all the force exerted, upon the uterine ligaments, the round ligaments, lower part of the broad ligaments and the uterosacral bands. If the bony structure of the pelvis resists us we then endanger the anterior supports of the bladder, urethra, and vagina. If our efforts are successful in dislodging the head from the rapidly dilated lower segments, what then occurs if we continue with our delivery? We bring the head down upon the pelvic floor and perineum to the second stage of labor which requires normally two hours and may normally require from two to six hours. Do we sit there

from two to six hours or permit a proper time for the proper relaxation of this pelvic floor? We should if we are to properly protect our patient. As a rule, when the forceps are on, the process is continual and the delivery completed within an hour at the outside. The result is unnecessary injury. We have not taken into consideration the value of time in this process. This picture is not overdrawn. A short time ago I was called to repair a primiparæ where the whole process of the three stages had been accomplished with the forceps in about four hours. The result was two tired physicians and a genital tract that looked as though a stick of dynamite had been inserted therein and exploded. No sugeon can by any sort of repair ever overcome the damage done. The only recourse is to make the best, by careful effort, of what was rendered irreparable. It is because I have witnessed this sort of work so long that I wish to call attention to the trite subject— the value of time and natural uterine efforts in parturition. Again, in induced premature labor, I have seen the process so unduly hurried that a small child rapidly delivered caused such shock that the mother never recovered. Do not understand me to be criticizing necessary haste when haste is plainly the lesser of two evils; but I wish to emphasize the dangers of too rapid delivery. I wish to state my conviction that in many cases of delivery today the forceps are used altogether too early and too often. We should not permit a woman to die of exhaustion, but the proportion of women dying of exhaustion and delayed labor are few compared with those invalided for life and dying from precipitate artificial delivery.

Is there need to again direct attention to the evil results of hasty and forced delivery in the normal but slow parturient woman? My experience answers this question in the affirmative most emphatically. Once a pelvic floor is severely torn I very much doubt if any care, no matter how skillful the surgeon, can restore it to its original tone and function. We may carefully adjust the torn muscle and tissue in sight or in reach but we cannot see or reach the upper margin of the support. Recognizing this impossibility, of complete restoration it becomes imperative that we use every means at command to prevent a condition being brought about which is incapable of repair. In my judgment the most efficient protection against calamities, farreaching in their immediate as well as remote effects, is in allowing plenty of time for the natural protective processes to physiologically prepare this tissue for its great distention. If given plenty of time a very difficult delivery, if forced, becomes relatively easy and free from danger. In many cases of prolapsus in later life the so-called rectocele and cystocele are due to too rapid delivery in the second stage of labor. No matter how carefully we may repair a perineum or how perfect our union, a vagina once torn from its pelvic attachments is very difficult if not impossible to repair. This detachment may be and usually is

subcutaneous and undetected till the woman has been on her feet several weeks.

There can be no reasonable doubt but that the early use of the forceps and the semivoluntary excessive bearing down of the patient, or in other words, too rapid movement in the second stage of labor, is the prime cause of this tearing away of the pelvic attachments of the vagina, the results of which are rectocele, cystocele, and later in life uterine prolapse. If this be true, in most cases we do our most efficient service by retarding rather than hastening the second stage of labor. With no contraindication I believe this procedure should nearly always be done by employing anesthesia and exerting manual pressure upon the distended perineum. This can usually be accomplished by giving the parts ample time to relax to their utmost. You are all familiar with the complete lacerations often found in cases of precipitate labor when there has been no opportunity to protect these tissues by compelling a slower process. They but teach us what not to do with our forceps and how to protect these structures when opportunity is given.

In the delivery of the oncoming shoulder, time again should be given. No doubt deep pelvic floor injury is often increased if not caused by a too rapid shoulder delivery. Time is here needed for rotation and adjustment of the bisacromial diameters to the anteroposterior diameter of the outlet. With the anterior shoulder behind the pubic bone, the cervicoacromial diameter permits the posterior shoulder to emerge first with less strain upon the pelvic floor. Whenever possible, with no contraindications aside from gently elevating the head, the posterior shoulder should be allowed to pass over the perineum with no effort at manual extraction whatever. This method of shoulder delivery is the natural one and simply requires letting alone largely till the physiologic forces complete their work. If any traction should be required in the delivery of a large child the posterior foreams should be gently flexed out over the perineum and at gentle traction upon the posterior shoulder made, allowing the yielding body to permit the delivery of the anterior shoulder under the pubic arch. Again, in the third stage or placental delivery the element of time is too often overlooked, and pushing from above and lugging at the cord below is resorted to instead of gently kneading the uterus and permitting a natural and complete delivery. You are all familiar with the saying that adherent placentæ are found mostly in the first few cases attended. It is surprising how seldom they are found later in our professional careers. It requires from five to ten minutes for the relaxed and relatively empty uterus to regain sufficient contractability to commence efforts of placental expulsion. Its first efforts are usually futile. More time and more stripping off by the retained blood are required. The only point we need to know is, has the uterus its tone? This, by manual touch through the abdominal wall, is readily

determined. If permitted, within fifteen minutes or a half hour the process will be completed in a way more satisfactory and safe than man has devised. Again, the value of time versus meddling!

CONCLUSION.

It requires time to bring about a proper condition of the cervix and lower segment of the uterus for the safe delivery of the presenting part. This is a variable time, and when there are no urgent contraindications this time should be given-be it three hours or three days. My experience and observation force me to conclude that this is very often forgotten at the beside, with lamentable consequences to our patients. The forceps are applied altogether too frequently and altogether too early in a great number of cases. When employed they are not used with sufficient deliberation, and results are brought about in minutes which, in order to properly protect the tissues, should take much longer time. The strain upon the tissues is too continuous to properly protect the child or the maternal tissues. The strain should be interrupted instead of continuous. The interval of strain should not exceed one-half minute without a relaxation. More time than is usually given is imperatively required if we are to relax instead of tear the tissues. We should not forget that we are pulling upon delicate structures which must oppose our strength with theirs, pound for pound. We should not forget that before time for relaxation has been given a force of fifty pounds will do more damage and accomplish less than a ten-pound pull with proper relaxation. We need to fix in our mind the time for the various stages of normal labor and conform as nearly as conditions will permit to these periods, not forgetting that more time in individual cases may be given when there are no plain contraindications. Watch the progress of natural labor with more of a readiness to assist natural processes than with an idea of taking the job entirely into our own hands. I quote the indications for the use of forceps from the "American Text-Book of Obstetrics."

(1) Indicated in lingering labor when the natural efforts are unable to effect delivery.

(2) When speedy delivery is imperative in the interest of the mother; as in hemorrhage, exhaustion, convulsion, advanced cardiac or pulmonary diseases, et cetera.

(3) When speedy delivery is indicated in the interests of the child, as in impending death of the mother or threatened asphyxia of the child.

And again, a quotation from Doctor John W. Clark in his "Résumé of Prolapsus," published in the June (1905) number of "Progressive Medicine," expresses the facts of this subject:

(1) Never encourage a patient in labor to bear down until nature excites this inclination.

(2) The use by the patient of tractors to increase the voluntary expulsion effort is questionable.

(3) Never apply forceps without a complete dilatation of the cervix. When a more precipitate delivery is necessary it is best to incise the cervix.

Never use forceps without a positive indication. Secure the gradual passage of the head through the vagina and over the perineum. The prevalent use of artificial force, the habitual use of the forceps without any prime indication for their use, the rapidity with which labor is consummated by these artificial means with the train of evils that follow this departure from natural physiological law is what I would emphasize.

Because a patient or her friends insist that something be done is no valid indication for harmful practice. It is our duty to protect our patient's health and happiness. Reputation, pleasing friends, making a brilliant display of our activity, the saving of valuable time for rest or profit, are none of them valid excuses for unnecessarily hastening this process to the ultimate detriment of those who rely upon our skill, our knowledge, and our candor in this hour of woman's greatest pain and peril.

TRANSACTIONS.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.

STATED MEETING, APRIL 2, 1906.

THE PRESIDENT, JOHN J. MACPHEE, M. D., IN THE CHAIR.
REPORTED BY FREDERICK C. KELLER, M. D., SECRETARY.

REPORTS OF CASES.

TUBERCULOSIS OF THE CARPUS.

DOCTOR VICTOR C. PEDERSEN: I wish to present this patient, a young woman who has suffered from tuberculosis of the wrist for many years. Several years ago a palmar operation was performed in a small town up the state, but there are no evidences that tuberculosis ever existed in the hand. Two years ago the wrist was operated on, a median incision being made, and a year ago two lateral incisions were made. The wrist is now free from pain, and except for the ankylosis of the joints which followed the first operation, there is no difficulty in using the wrist. In dealing with tuberculosis of the wrist, an operator often forgets the diverticulum of synovial tissue which passes upward between the radius and the ulna. At the last operation performed upon this patient, it was at this point that the first foci of tuberculosis was found. The largest synovial pouch passes forward between the surfaces of the metacarpal bones, and here was found the