estimated from the distance remaining between the ends of the handles when they are pressed together in the act of delivering the head nor from the amount of force employed to bring them towards each other. 4th, and lastly, that the diameters which cross the compressed one, far from increasing in proportion to the diminution of the compressed one, do not in general augment to the extent of a quarter of a line, and in fact are sometimes even lessened."

The above-mentioned results, procured by so distinguished a writer as Baudelocque, ought to suffice for removing any disposition to regard the forceps as a compressing instrument, and so put us on our guard against the propensity to use it for such an object; but let it be considered that the head does not fill up the pelvis as a nail fills up the hole into which it is driven, but it is always caught and arrested by two or perhaps four points on which it is impelled, and we shall see that if we do use it to squeeze and reduce the size of the head, we shall only reduce those diameters that are already small enough, and augment those that are already too large; for it cannot be adjusted on points that are in such close contact as to constitute a real arrest. The proper view to take of the instrument is, that it is a substitute for labor pain, supplying the want of expulsive force when wholly absent, or aiding it when insufficient to effect the delivery. Impossibilities are not to be expected from it; yet in all cases where it is inapplicable, we are privileged to resort to other far less pleasant

means.

It is common to apply the forceps to the head, only, after it has got fairly into the excavation, and the nearer the head is to the external organs, the more easily may the instrument be adjusted. Hence, in the management of a labor, though we may perceive the signs that indicate the use of instruments, we feel at liberty to wait until the presenting part can take an advantageous position, preferring to lose a little time, for the sake of greater facility and assurance of safety. Whenever the head has sunk so low as to get the vertex just under or behind the sub-pubal ligament, we experience little difficulty in placing the branches, successively introduced, in their proper positions, because the rotation being completed, the bi-parietal diameter does not occupy the entire transverse dimension of the pelvis; but when we have to apply it before rotation has taken place, there is great difficulty in getting either the first or the second branch directly over the side of the head; and when we fail to adjust the branches accurately in opposition, we either cannot make them lock, or we lock them in such a way that one edge of the instrument contuses or cuts the part of the scalp or cheek on which it rests, leaving a scar, or actually

breaking the tender bones of the cranium, while the other edge cuts the womb or vagina by its free and projecting curve-in fact, the forceps is designed for the sides of the head; and if, under the stress of circumstances, we are compelled to fix them in any other position, we always feel reluctant to do so, and look with painful anxiety to the birth, to learn whether we have done the mischief we feared, but which we could not avoid.

I ought to mention, that cases occur in which the forceps seems to be clearly indicated, but in which, on trial, we cannot apply them; the size and position of the head being such that we cannot by force or dexterity get the blade of the instrument betwixt it and the bony wall; in such a case skill and judgment ought to be employed, and, when we cannot succeed, we must be content to know that we cannot, and that no one else can. Further, we can sometimes adjust the forceps perfectly, but cannot effect the delivery, because the parts are too small. Here, also, we ought to suffer no feeling of mortification to vex us for want of success; we should feel assured that we have exerted a sufficient degree of strength and dexterity; and being satis fied that our duty has been in so far done, we lay aside the forceps to resort to ulterior measures.

The forceps cannot be applied unless the parts are favorably disposed; for instance, the os uteri must be dilated and gone up over the head. The vagina and perineum also must be in such a condition that we need have no fear of lacerating any of those parts; else, the operation is contraindicated. A man shall hardly be justified who inserts his forceps within the os uteri. He must wait until the circle has risen above the parietal protuberance and can no more be felt.

Either the pains must have been proved insufficient for their office, or else the exigent demand for delivery, arising from hemorrhage, convulsion, or other states, must establish the indication. We should be inexcusable, if we should use them where the pains are still of vast force, and fail of success on account of a preternatural resistance. If we judge that the power of the pains is already as great as the patient ought to bear, we ought not to apply the forceps, in order to add to forces which are already of a dangerous degree of intensity.

The motive for the use of the operation should be clearly understood as referable either to the mother and child; to the mother alone; or to the child alone. The consent of responsible and interested persons should be obtained; the motives for the operation should, if possible, be clearly explained to the woman herself, and truthful, yet reasonable promises should be made to provide for her safety and

comfort, both of which requiring that it be done. If time permits, some professional friend should be invited to witness and sanction the operation.

The position of the presentation should be well known; and, if needful, should be verified by the introduction of half the hand or the whole hand into the passage. The bladder and rectum should be evacuated, the latter by an enema, and the former by the catheter; the last precaution ought never to be neglected.

The bed should be prepared by bringing the end or side of it quite to the end or side of the bedstead, and then covering it with blankets and sheets of sufficient thickness to prevent the bed from being soiled. Part of a sheet should reach down to the floor, on which some cloths ought to be placed, to receive the fluids that commonly escape during the process of delivery.

The patient should be brought to the side or end of the bed, as the case may be, lying on her back, with the end of the sacrum resting near enough to the edge to admit of the most unrestrained access to the parts by the hand and the forceps. The feet should rest on two chairs or on the laps of her assistants, sitting with their backs turned to the patient, and far enough from each other to allow the operator to stand or sit between them; the patient always being covered with a light sheet or blanket, according to the temperature of the apartment.

The instruments, at all seasons of the year, should be placed before using them in a bowl of tepid water; and, when warmed, they should be anointed with sweet oil, which adheres to them better than lard. Lastly, the parts should be freely anointed with lard.

The forceps are differently applied, according as the head is differently placed.

If the vertex present, and rotation have taken place so as to bring the point of the head just below or behind the sub-pubal ligament, the left-hand blade is to be taken in the left hand, and the fore and middle finger of the right hand should be passed upwards as far as conveniently can be done, betwixt the left ischium and the child's head, somewhat towards the posterior part of the pelvis or the left sacro-iliac junction. The branch should be held across the right groin, in a direction from above, downwards and inwards, so as to let the point of the blade be near the vulva, in which it is next gently and slowly introduced, allowing the concavity of the old-curve to be in contact with the convexity of the head. In proportion as it advances, the point is directed upwards towards the plane of the superior strait, the handle coming downwards as the introduction proceeds, care being taken to direct the point by the two fingers which guide it

as far as they reach. If any obstruction or difficulty is met with, let it be overcome by gentleness and dexterity, and not by force. For example, if the point comes in contact with an ear, that organ might be lacerated by any rude force, and a great deal of caution ought to be observed in order to protect the child from such a maiming, and the medical attendant from such a disgrace. At length the blade is introduced sufficiently far to show that the point is nearly even with the chin, and the old-curve in proper contact with the side of the cranium and face, and that it covers the ear.

The end of the handle should now be depressed, so as to force the edge of the perineum a little backwards, and then given in charge to one of the assistants, while the right-hand branch is taken in the right hand, and the fore and middle fingers of the left hand are introduced into the vagina, on the other side, as in the case just described. The branch is laid across the left groin, looking from above downwards and inwards, and the point of the blade is passed into the vagina above the first branch. This one should also be at first directed towards the sacro-iliac junction of the right side, and elevated as it proceeds so as to be brought at last into exact opposition to the left-hand branch. If any difficulty occurs in bringing it forwards enough, the two left-hand fingers that are guiding it will serve to slide it edgewise into the proper position. The branches are now to be joined at the lock; and the union of the branches is very easily effected if the opposition of the two counterparts is accurate. If the opposition be inaccurate, the locking is impossible, and ought not to be effected by force. When locked, let the handles be brought near enough together to make sure that the head is firmly grasped, and then the instrument is to be withdrawn a little, in order to effect its complete adaptation to the convex surface of the cranium, which it grasps in its jaws.

If the handles come not near enough into contact, that circumstance proves that the head is not properly seized; and nothing further should be done until the error is corrected. If they gape more than an inch and a half at the ends, they are not adjusted upon the parietal bones; but are obliquely set on the frontal and occipital regions. They ought to be a little more than an inch apart at the ends.

Whenever, during the process of introduction, a pain comes on, all action ought to be suspended until the pain has ceased. If this precaution be not observed, there is danger of contusion, or laceration by the blades of the instrument.

It frequently happens that the first or left-hand blade passes readily up to its proper position, and takes its place on the side of the head and face, without causing the least disagreeable sensation or the smallest

embarrassment to the accoucheur; but, when he attempts to put the other blade into position, he either fails to insert it as deep as the first one, or, having done so, finds himself baffled in every effort to lock the joint.

The first blade has perhaps taken up so much space as to have thrust the head strongly over against the right side of the pelvis; leaving no passage betwixt it and the cranium along which to make the second blade glide.

Fig. 125.

Upon the failure, after fair trial, both of the counterparts should be withdrawn. Perhaps a new pain may now succeed in forcing the presenting part a little onwards; or, perhaps, after wholly withdrawing the right-hand branch, the surgeon may succeed in using the left blade as a vectis to bring the head into a better attitude; so that, when the attempt to adjust the clamps is renewed, no difficulty is found to remain. He shall often succeed in adjusting the right-hand blade as a vectis, when he shall have withdrawn the left-hand blade.

When the two parts of the instrument are introduced far enough, they may have been so imperfectly adjusted that the concave edges of the new curve may be almost in contact, while the convex edges divaricate very much, the ends of the handles having

their flat surfaces obliquely placed, as in Figure 125. Let the Student carefully examine this figure, and learn from it how to comprehend the meaning of this obliquity of the manubria which is difficult to understand without such explanation. It is not necessary for me here to make another figure, to show that, if the obliquity of the flatfaces of the manubria should be the reverse of what is here seen, it would be because the convex edges of the new-curves are too near, and the concave edges too far from each other. The instrument could not hold in such a position but would slip off behind, or in front, and destroy the vagina. This could not happen except where the accoucheur has placed the instrument too near or too far from the coronal surface of the head. An inexperienced person is very apt in this case to suppose the very reverse, or that he has placed the concave edge of the new-curve too far from the pubis and too near the sacrum; whereas,