.

pain, and the laceration, once begun, may extend so as to allow the child to escape into the peritoneal sac.

Whenever, then, the head is found to be so situated that it will neither advance nor retreat, it may be said to be locked, and the case ought to command the greatest care from the medical attendant.

It is manifest that, if the arresting points of the pelvis touch the head at its parietal protuberances, no possibility exists of applying the forceps in that direction; there is not space enough to admit of the blades, and if they are to be applied to the head, it can only be on those parts that are free from great pressure, as the forehead on one side, and the occiput on the other; and this must be done notwithstanding any fear of contusing the face, of which there is some risk, but which very risk becomes less the more it is borne in mind.

When the attempt to deliver is about to be begun, the forceps should be well pressed together, so that, when the lever-like movement takes place, their blades may not be allowed to slip or slide on the forehead, which would thereby be liable to excoriation, or even to be deeply cut by their edges, formed, as is well known, for application to a convexity different from that of the face. The motion from handle to handle, assisted by a sufficiently powerful traction, will, ordinarily, succeed in disengaging the head, and getting it down into the excavation; upon which the blades ought to be removed, and, if the pains prove strong enough, they need not to be reapplied; but, in the lack of a proper force, they should be adjusted anew, and on the sides of the head, for which their curves were fashioned, and to which only they are really adapted.

In making compression, let it be carefully remembered that the compression is not designed to diminish the diameters, but only to hold the object more securely or steadily: any amount of compressive action beyond this indispensable one is mischievous, as tending to augment the difficulty by forcing the parietal protuberances more decidedly against the arresting points. I succeeded by this means in drawing a head through a pelvis so faulty in its antero-posterior diameter, that I could readily touch the sacrum, by introducing only the forefinger into the vagina. The patient was a very small woman of color, to whom I was called in consultation by a young medical friend; the child was dead, but not injured by the instrument. So great was the difficulty, that I at one period entertained very seriously the idea of performing the embryulcia. If I had known the child to be dead, I should have greatly preferred to do so.

In these cases, the operator, who alone can estimate the degree of force he employs, is the sole judge as to whether that force is too great

to be compatible with the safety of the woman: should he, upon a due consideration of it, deem it wholly unsafe to proceed, or impracticable to succeed by any legitimate exertion of his strength, there remains the resource, sad as it is, of the perforator. Now that we have the advantage of the stethoscope, we can with great certainty, determine the question of the life or death of the foetus in utero: and where we find, upon auscultation, that its life is extinct, we need have but little hesitation in applying the perforator, in order to reduce the size of the skull by extracting its contents. In doing this, however unpleasant the operation, we remove much of the danger arising from a further continuance of the pressure on the soft parts of the mother. In case the stethoscope reveals the fact that the foetus is still living, we should feel constrained to wait so long as to overstep, perhaps, the boundaries of prudence.

But it does not always happen that the head is locked in the direction and situation above pointed out. The vertex may be jammed down behind the pubis, and the forehead in front of the promontory. Here the forceps can be legitimately adjusted; and they admit of the application of a greater force, and it will be probably found less difficult to unlock and rotate the head, in consequence of the greater convexity of the points of arrest. Some degree of rotation ought to be given to the head by means of the forceps until they succeed in getting it down into the excavation, whereupon the vertex may be rotated back again to the arch of the pubis, and so withdrawn.

Impaction of the head cannot take place at the superior strait; the form of that opening is such that its heart-shaped circumference cannot be filled by the head of a child; there would always be found a part of it in which not only the blade of a forceps, but a couple of fingers, would find passage; but after the head has sunk below the strait, the conical figure of the excavation perhaps admits of its whole circumference being occupied by the head, which fills it up completely, and so completely that the forceps can find no space in which to pass. Let the attempt, however, be made, and in every unavoidable case, where it fails of success, the head can be opened, and the skull made to collapse.

The Forceps in Pelvic Presentations.-It only remains for me to relate the manner of applying the forceps in breech or footling cases, wherein the head refuses to come away after the shoulders are delivered. I have already said, that it is my invariable rule to have the forceps in readiness, in every instance in which I discover that the head is to be the part last born.

When the instrument is wanted for such a use, it is wanted suddenly-immediately; and the medical attendant fails in his duty, who finds himself in want of forceps for this purpose, and is obliged to send for them; for a child perishes while a messenger is going a hundred yards, or putting on his boots.

There is no need of my going again at length over the causes that render the forceps necessary on these occasions. It is enough to know that the expulsive powers are wanting, either from disproportion, from cessation of efforts both voluntary and involuntary, or from mal-position, and that if the head continues undelivered but a few minutes, the child is lost.

Supposing that the shoulders are delivered, and the face in the hollow of the sacrum; let a napkin be wrapped round the body of the child, including the arms, which should be placed against its sides, so as to keep them out of the way. Then, giving the body to an assistant, let it be held by the thighs or hips, in a position nearly perpendicular, so as to press the nucha against the arch of the pubis; or its back may be carried over nearly into contact with the mother's abdomen, to get it out of the way. The left-hand blade, guided by two fingers of the right hand, is then to be passed in at the left side of the vagina and applied to the head, covering it in the direction from chin to vertex. The right-hand branch is next introduced, with similar precaution, into the inferior and right side of the vagina, and so conducted on to the head as to embrace it from chin to vertex. As soon as the instrument locks, the tractions are to be commenced, and there will be, in general, little delay in the extraction, if the handles be raised as the head emerges; they requiring to be elevated, just as is needful in the delivery of occipito anterior positions. If an accoucheur should attempt to perform this operation for a patient in any other than the dorsal decubitus, he would find himself greatly embarrassed.

But, if the child be unfortunately born with the toes towards the pubis, and rotation in the subsequent stages cannot be effected, so that the face remains uppermost; if, in this case, vain attempts to deliver by the hand have been tried; then, let the woman lie on her left side, with the thighs strongly flexed; let the child be turned back as far as it can be done with safety to its neck, so as to bend the neck very much backwards. By giving to it this position, the forceps can be introduced in front of the child, the left-hand branch being first passed up on the left side of the chin and carried as far as the vertex; while the female branch is introduced upon the opposite side so far as to allow of its being locked with the pivot. As soon as the head is properly seized, let it be drawn downwards in such a direction as to cause the

chin to emerge under the arch; to which end, let the handles be at first somewhat lowered.

Where, however, it can be effected with proper celerity, it is better, for this application of the forceps, to bring the woman to the edge of the bed, and, allowing the perineum to project beyond it, cause her feet to be supported in the usual manner. The child, wrapped in a napkin, can well be intrusted to a kneeling assistant, as it is held nearly in a vertical or standing position. In this way the branches of the instrument have free access to the left and right sides of the vagina, and lock with the greatest ease in front of the throat. Except in such a position of the woman, I cannot conceive how it would be practicable to use the long forceps; but Haighton's or Davis's forceps could be applied while on the side, though not so easily as on the back.

Section of the Pubis.-I have little to say here in regard to the operation of Symphyseotomy, commonly called the Sigaultian section -an operation which was proposed and performed by M. Sigault, in the year 1777.

The proposition to increase the dimensions of the planes of the pelvis, by cutting asunder the symphysis pubis, excited, soon after the promulgation of it, a great sensation, throughout Europe, and many operations were soon afterwards performed with various success. It is probable, however, that the increase of amplitude of the planes of the pelvis is not so considerable as the friends of the section at first hoped for, and the dangerous traction of the tissues behind the separated pubes, and the gaping of the sacro-iliac junctions, one or both, were causes of ill success that have allowed it at last to fall into complete desuetude. So far as I know, the operation has never been done in this country. I feel not the least inclination to recommend the performance of it, and I refer the reader, who may feel interested in inquiring into the method, to M. Baudelocque's work on midwifery, and to the curious Essais Historiques Littéraires et Critiques sur l'Art des Accouchemens, par M. Sue, le jeune, Paris, 1779, 2 vols. 8vo. Dr. Churchill, in his System of Midwifery, p. 376, gives the statistics of the operation, as it has hitherto been done, and, in the most emphatic manner, discourages and condemns it.

Before I close this chapter, I must reiterate the expression of an opinion which I have already uttered at page 546—it is, that the obstetric forceps is the child's instrument; that the perforator, the crotchet, and the embryotomy forceps are instruments for the mother; and that the Cæsarean operation, in its spirit and intention, should be

devoted absolutely to the conservation of the mother alone: in saying so, I am not insensible of the great satisfaction enjoyed by the surgeon who, under the distressing duress which should alone compel him to subject a living woman to the Cæsarean section, is rewarded with the happiness of rescuing both the child and its parent from the jaws of an otherwise inevitable grave. I hold that no man has a right to subject a living, breathing human creature to so great a hazard as that attending the Cæsarean section, from views relating to any other interests than those of the patient alone.

I believe that the Cæsarean operation ought never to be performed in any case, whether the child be living or dead, in which, under a ripe and sound judgment and perfect knowledge of Midwifery, a decision may be obtained, that delivery per vias naturales is less dangerous to the woman than one by vivisection.

Now, as to a question concerning the smallest pelvis through which it is possible to deliver, I think it impossible to fix a minimum aperture through which a woman may be safely delivered. Elizabeth Sherwood was delivered having a pelvis of one inch and threequarters, and I twice delivered Mrs. R. with one under two inches; but to say that a pelvis two inches and three quarters is the lowest through which a woman can expel a child, is to speak contrary to the record. Indeed, the dimensions that render a Caesarean section indispensable, are variable dimensions; they never can be fixed and prescribed by precept or law, for one woman may have strength and courage and endurance to enable her to bear delivery in a pelvis of one inch and three-quarters, as in Elizabeth Sherwood's case, whereas, in another woman the lapses of her strength may be so rapid, and the exigencies of her condition so urgent, that, if she be not promptly relieved she will inevitably be lost. Hence, my assertion is correct, that the dimensions demanding the Cæsarean operation are variable. If we go down to diameters of one inch and a half, or to diameters of one inch, then the question of delivery per vias naturales is set aside. But we may find a case in which a woman, having a pelvis of two inches and a half, ought to be delivered by the section, because, we conclude she cannot live long enough to escape by the slow process of a crotchet operation. I should not hesitate, therefore, to recom mend the Cæsarean operation in a pelvis between two and two and a half inches in one case, nor would I hesitate in another case to prefer an embryotomy operation in a pelvis somewhat below two inches in its diameter.

I have been present in consultation where urgent demands and pressing arguments were in vain proffered to induce me to consent to