blade sweeping upwards towards the child's chin, covering part of the ear, and coming off at the vertex. The handle will look towards the right thigh, and the pivot will point upward towards the right. The handle of the forceps should be very much depressed in this case, because, as the lock portion of the branch is inclined towards the right it leaves scarcely space for the introduction of the female counterpart, to be introduced on that side; but a considerable depression of the handle affords more space for the purpose. The branch being correctly placed, is put in charge of an assistant, while the right-hand blade, being guarded by the introduction of two fingers, is passed into the vulva at its lower or back part, and its point turned upwards towards the left, as the handle sweeps downwards towards the right. The joint is brought into apposition and locked.

As soon as a pain comes on, traction, combined with the lever-like action, must be instituted, and as the head descends, the mechanism of the pelvis compels the vertex to rotate towards the pubis, under the arch of which it soons begins to jut. This being effected the peculiarities of the operation are removed, and its remaining conduct is to be fulfilled as before.

Forceps in Occipito-Posterior Positions.-In those cases where the vertex, instead of coming to the arch, rotates backwards and falls into the hollow of the sacrum, the forceps will be more likely to be required, because the difficulties of expulsion are greatly enhanced by the position. In this, just as in all the occipito-anterior positions, the vertex must escape first, notwithstanding it is directed backwards towards the sacrum; but, in order to do so, it must glide down the sacrum and coccyx, and along the perineum, after having distended it enormously, until the fourchette slides backwards and upwards behind the occipital bone of the infant. In order to effect this, the occipito-mental diameter of the foetus must become parallel with the axis of the inferior strait, or at least it must become nearly so. Such, however, is the violence of the flexion required for that purpose, that much time is lost before it can be obtained, and in many of the instances the woman is exhausted, and the pains gone, before it can be accomplished.

The position is ascertained by feeling the large fontanel behind the pubis, or just within the arch, while the sagittal suture runs backward towards the sacrum.

When it is found that the forceps will be required to extract the head, let the male branch, held in the left hand, be introduced into the back and lateral part of the vagina, and conducted towards the chin as far as possible, carrying the instrument up near the left sacro-iliac

junction at first, and gradually bringing it forwards so as to apply it accurately to the side of the head. The oblique diameter of the head dips so much towards the sacrum, that it is impossible to embrace the head properly without depressing the handle very much, and thrusting the edge of the perineum very far back, which, though a little painful, cannot be avoided; otherwise, the head will be grasped coincidently with its perpendicular and not its oblique diameter. The instrument being held in this way by an assistant, leaves a sufficient space on the right side of the vagina for the introduction of the female branch, which, being adjusted and locked with the male branch, leaves the handles very much depressed.

Having ascertained that none of the external parts are pinched at the lock, and that the head is surely grasped, the first movement in extraction should be to raise the handles up a little, with a view to compel the chin to approach still nearer the breast, and make the vertex to glide down the sacrum and coccyx, assisting its descent by means of the lateral or lever action of the forceps: the intention of the operator should be to draw the vertex off the sacrum, off the perineum, off the fourchette, and then let the head extend backwards on the outside.

As the perineum in this labor must be enormously distended, it behoves that great care and patience should be exercised, lest it might give way. It should be well supported, and, as soon as the vertex clears its edge, the handles ought no more to be raised, but on the contrary, depressed, to let the vertex go backwards-a movement. exactly the reverse of what takes place in the occipito-anterior position. The head being delivered, the shoulders rotate in the excavation, and the right or the left one comes to the pubic arch, so that the rest of the process is concluded as in a first or second position, except that the front parts of the child, instead of the back parts of it, come out towards the front of the pelvis, which makes no difference of any import.

The application of the forceps for the occipito-posterior position, say the fourth or fifth, where rotation has not taken place, is more difficult than the one just above treated of. The blades are with much less facility applied, and, indeed, cannot take hold along the oblique diameter so completely as is to be desired; they rather seize the head along its vertical diameter at first, and are gradually brought into parallelism with the oblique one, as extraction proceeds. Reflection upon this circumstance is very needful at the time of the operation, lest the infant's head should be contused and ground, and even cut by the blades.

The introduction takes place as in a first or second position, the fourth corresponding to the first, and the fifth to the second. The handles must be well depressed in this case, and it will be allowable to make prudent efforts to rotate the vertex into the hollow of the sacrum -it being always understood that all hope of bringing it to the pubis has, after experiment, failed.

Forceps in Transverse Positions.-The head is sometimes situated transversely, the vertex resting against one, and the forehead against the other ischium. Let us suppose the vertex at the right ischium, and that it is intended to apply the male blade to the left side of the head, with a concave edge of the new-curve looking towards the occiput.

Therefore, let the left-hand branch be introduced into the left posterior part of the vagina, and, as the point enters more and more, the handle should be depressed, until the curve applies itself on the left side of the head in a direction from the vertex to the chin, or as nearly so as may be practicable. It should be understood, however, that the blade will scarcely apply itself in that direction, because the chin is not so near to the breast as it ought to be. When the blade is adjusted, its pivot looks to the right, and lies in a horizontal position, while the handle juts out obliquely towards the right thigh, which is much abducted.

As the left-hand branch projects towards the right, there will be some difficulty in finding room for the introduction of the right-hand branch; yet the first one can be temporarily pushed out of the way, so as to let the point enter at the inferior right side of the orifice of the vagina. When the curve is applied to the convexity of the cranium, it must be pushed upwards, backwards, and towards the left, so that its point may approach the chin, and the notch be brought in apposition with the pivot, and so locked. The head, being firmly held, may be moved in a direction from handle to handle, and moderately rotated, so as to dislodge it; and the tractions being commenced, it is found to descend, the forceps rotating along with it, until the pivot becomes vertical, and the fontanel appears at the arch.

In all the operations I have described, the male or inferior blade is to be first introduced, otherwise the female or upper blade cannot be introduced without getting it below the inferior blade. There is one position of the head, however, in which it is proper to introduce the female blade first-and there is but one-which I shall proceed to treat of it is that in which the vertex touches the left ischium, and the forehead the right ischium.

It is clear that, when the instrument has grasped the head in this position, the handles will project very much towards the left thigh in strong abduction; but if we introduce the male blade first, inasmuch as its handle will project towards the left thigh, it will occupy all the space on that side, and prevent the insertion of the second branch, for there will be left no place for the handle to be depressed in. To avoid this difficulty, therefore, take the female or upper blade in the right hand, and introduce it into the posterior and right side of the vagina, conducting its point as near as may be to the chin, and over the face to the right side of the head behind the pubis, leaving the handle to project towards the left thigh. Next, take the male blade into the right hand, and, turning the concave edge of the new-curve downwards, insert the point into the right side of the vagina, below the female branch. Let the foetal face of the clamp apply itself to the convexity of the head, and slide it onwards, and, in proportion as it enters, make it sweep round the crown of the head towards the back of the pelvis. In effecting this, the handle comes gradually down as the clamp gets on the left side of the cranium, and at last the lock is found to be where it ought to be, namely, under the upper or female blade, with which it is then to be locked.

When we have ascertained that the head is properly held, or grasped, we may proceed, as before, to move and to attempt to rotate it, and then deliver when the vertex emerges from beneath the symphysis pubis.

The Forceps in Face Presentations.-Among the sixteen thousand four hundred and fourteen women delivered at the Dublin Hospital, under charge of Dr. Collins, thirty-three had face presentations, and four of these had stillborn children, which is a little less than twelve per cent. of mortality in this labor. I have said enough in my observations on Face Presentations, at page 377, et seq., to make it unnecessary for me to repeat anything here in relation to the difficulties of that sort of birth. It is merely necessary to remark that the forceps, when their use is indicated in this labor, must be applied to the sides of the head by carrying the points of the blades nearly up to the vertex. In those examples in which the chin comes to the pubis, the handles need not be very much depressed; but in those in which the top of the forehead is at the pubis, the handles must at first be very strongly depressed, and, as the case proceeds, they must be strongly elevated, so as to get the chin down to the fourchette, over which it must slip, and then begin at once to approach the breast again, in the act of flexion. As soon as the chin is free, we allow the

handles to descend again, while we continue the traction until the head is completely emerged. I shall take this opportunity to state, that I conceive it impossible to have a better instrument for this particular labor than Davis's forceps, as made by Botschan, 35 Worship Street, London. It holds the head as in a basket, and is far less likely than any other with which I am acquainted, to bruise or in any way injure the child. Figures 80 and 83 show the difference between a face case, in which the chin comes to the pubis, and one in which the forehead is there, and also the manner in which the head is to be taken hold of by the forceps.

The Forceps in Locked Head.-The head is said to be locked, whenever two opposite sides of it are caught by two opposite sides of the pelvic wall and held so firmly that it can descend no lower, and either cannot, or cannot without great difficulty be pushed upwards again into a freer larger space. In general, when the head is thus locked, it is in its transverse or bi-parietal diameter, one parietal protuberance being held at the pubis, and the other at the projection of the sacrum. Supposing the pelvis to be only three and a half inches. in its antero-posterior diameter, and the head to be three and threequarters in its smallest diameter, then it might happen, as it does in fact happen, that the cone of the head should be driven, by the force of the long continued pains, into the narrow pass, the delicate bones of the head giving way, and becoming indented under the pressure of the promontory of the sacrum, and moving downwards until it becomes immovably fixed by the opposing points of the pubis and sacrum. This state would constitute what is called a locked head. Many evils result from this locking of the head. For example, the woman, after vain efforts and great sufferings, becomes feverish, and loses her pains altogether; or a state of constitutional irritation comes. on, marked by a frequent, small pulse, coolness of the extremities, sunken cadaverous appearance of the face, delirium, jactitation, and vomiting, which, if not soon relieved, are followed by death, hastening with rapid strides to end the strife. The pressure destroys the child; or it produces gangrene of the parts of the mother that are 'compressed, or causes inflammation to take place, succeeded by sloughing and its consequences. Or, the urethra, being effectually compressed betwixt the cranium of the foetus and the symphysis pubis, a total suppression of urine takes place, followed by its very serious consequences; or, lastly, the soft parts, perhaps the vagina, or possibly the womb, from being pinched as above stated, may give way during a