the head making for the time being a unit, indicate that the blades are in the proper position. That these include nothing more than the headno prolapsed cord, or projecting border of the uterus, and no vaginal fold-has been guarded against by the careful manner of their introduction; but if there be any possibility of such an accident having occurred, the sole means of resolving the doubt is to "introduce one or two fingers to the level of the blades, as well in front as behind."

The traction, as before stated, should, as a rule, be intermittent; full force must not be employed at first; it may not be necessary at all, but if required it should be reached gradually; pulling with the forearms, or with one of them at first, the arms being by the side, is a practice that has been advised. Usually, if the power be given the right direction, it need not be great; in rare instances the accoucheur has to exert considerable force, but it must be his own, unassisted by that of another. In some instances the operator may find an immediate forceps delivery carrying greater danger to the mother and to the child, or both, than will a delay until nature's forces have moulded the foetal head, thus facilitating the transmission through the birth-canal, and therefore the effort at instrumental delivery must be postponed until such moulding has occurred.

Should the forceps be removed before the head is delivered? Such removal has been strongly recommended in recent years by Freund, Goodell, Lusk, and others and was the practice of Taylor, of New York, for many years before his death. It is the revival of an old practice. "Among the German authors, Boër, and after him Joerg, Carus, and others, have recommended removing the forceps as soon as the head is engaged in the vulva, if there is no indication for the immediate termination of the delivery." (Naegele and Grenser.) Madame Lachapelle strongly advocated this plan. The object sought by the removal is to prevent injury to the perineum by thus taking away the addition to the head circumference caused by the blades of the forceps. The objections that have been made to this practice are, that while the accoucheur is removing the instru

ment a violent contraction may suddenly expel the head, and he being otherwise occupied, is powerless to give any protection to the perineum; or nature's forces, on the other hand, may be unequal to the expulsion, and a reapplication of the forceps be necessary. Moreover, we have in the forceps the best means of retarding the exit of the head until the vulvar orifice is sufficiently dilated, and at the same time giving it proper direction when that exit is made; the forceps may be used so that the perineum will suffer less injury than in normal labor.

After this general consideration of the application of the forceps, next will be presented the method in which the instrument is used in different presentations and positions.

HEAD-FIRST LABOR. Cranial Presentation, and (1) Occipito-pubic Position. In this position the head was so small that it entered the inlet with its occipito-frontal diameter in relation with the anteroposterior of the former, instead of with one of the obliques or the transverse; or, and this is the more frequent case, anterior rotation, instead of direct descent, has placed the occiput at the subpubic ligament, or in the pubic arch. The blades of the forceps are necessarily placed in direct relation with the sides of the mother's pelvis, and upon the sides of the child's head. In a primipara the nearer the head is to the vulvar orifice, the more difficult the introduction of the guiding fingers, but this introduction need go no further than the parietal protuberances, for if the rim of the os uteri has cleared these it has retracted as far as the child's neck; passing the blades deeply in is unnecessary, and may do serious injury. After locking, which is easily done, the traction should be somewhat downward at first, if the occiput has not come in front of the subpubic ligament; but if it has, or after it has been brought thus in front, the handles are gradually raised so as to assist deflection, the occipital end of the long head diameter being outside the pelvis, and the normal delivery of the head taking place by a rotation

upon its transverse axis through the arc of a circle, suboccipital diameters measuring the distance from the lower margin of the pubic joint to the anterior margin of the perineum. Care must be taken to observe this normal mechanism in forceps delivery. If immediate extraction of the child is not imperative, let the head be held back until the parts are sufficiently dilated, and gradually lead it out, the nucha being made to hug the subpubic ligament. At the end of the extraction of the head, the handles of the forceps will be near to and almost parallel with the mother's anterior abdominal wall. Only one hand is needed for the forceps, and the other should be used to note the condition of the perineum and to protect it from being torn.

2. Occipito-sacral Position. After the application of the forceps, the pull must be upward and somewhat forward, increasing the head-flexion, until the occiput emerges over the anterior margin of the perineum, and then the head is delivered by extension, the nucha pivoting upon the anterior border of the perineum.

Some accoucheurs, among whom Charpentier may be mentioned, always attempt anterior rotation, and it is only when this attempt fails that delivery over the perineum is accepted.

3. Left Occipito-anterior Position. Supposing the head to be in the pelvic cavity, the left blade, which is introduced first, is passed to the left side, and posteriorly, so that it corresponds with the left sacro-iliac joint; very frequently the introduction of this blade determines anterior rotation of the occiput, and then the position is simply occipitopubic, so that the introduction of the second blade is the same as has been described. But when this rotation does not occur, the right blade is "directed at first below, to the right and posteriorly, then brought by a very extensive spiral' movement to the level of the right ilio-pectineal eminence." After the blades are applied and locked, traction with anterior rotation, and delivery of the head as in occipito-pubic position follows; no attempt at rotation, however, should be made until the head has reached the pelvic floor.

Should the head be at the inlet, still the effort must be made to place the blades at the sides of the head. The simple rule given by Pinard applies in common to these, and to all oblique or diagonal positions which the head may occupy in the pelvis. Place the two blades at the two extremities of the empty oblique diameter; by such diameter is meant that in which the transverse diameters of the head are, and especially the biparietal, because this diameter does not occupy all its extent, there being always a space left between the former and the pelvis.

1 This is known as the method of Madame Lachapelle, and has been described by her as follows: "If the branches are to be placed diagonally, that is, one behind on one side, the other in front upon the opposite side, it will suffice to pass directly the branch which ought to remain posteriorly over the sacro-sciatic ligament-nothing arrests it. The other can be easily managed, if I commence with it. Held in the hand as a pen, and leaning it across over the opposite groin, I insinuate the point of the blade in front of the sacro-sciatic ligament, then as it enters further I lower the handle, bringing it by degrees between the thighs, until it inclines strongly below. By this movement I have made the end of the blade describe a spiral, which the fingers in the vagina direct and complete. This movement carries the blade at the same time in front and above. necessary to encircle the head by an oblique passage, which represents a line extending from the sacro-iliac ligament to the horizontal ramus of the pubes, and traced on the interior of the basin. The movement is effected in the twinkling of an eye, without the least pain, without the least bruising." The spiral movement is not to be employed in cases in which the head has not entered the inlet.

It is

Winckel teaches that even if the head is transverse in the pelvic inlet it is necessary to apply the blades of the forceps to the oblique diameter, and he regards it as a mistake to apply one blade over the brow and the other over the occiput, because the child is thus easily injured, and besides the antero-posterior diameter of the head is too large for the cephalic curve and the instrument easily slips off.

Dr. Fry, of Washington, at the meeting of the American Medical Association, 1889, showed a forceps invented by him for application to the sides of the head when it was transverse with reference to the pelvis, that is, in the antero-posterior diameter of the latter, and reported cases in which he had successfully used the instrument.

Milne Murray,' from experiments made with the cephalotribe upon the heads of dead fœtuses, concluded that the foetal skull is compressible in an anteroposterior direction by the sliding of the occipital and frontal bones under the parietals; and that the compression is not accompanied by any appreciable increase of the transverse diameters. Thus in a minor degree of flat pelvis in which forceps delivery is indicated, the blades may be applied over the ends of the antero-posterior diameter.

4. Right Occipito-posterior Position. The introduction of the blades is done in the same way as in a left occipito-anterior position. The head is brought to the pelvic floor, then anterior rotation' attempted, which, if successful, requires removal, and then reapplication of the forceps; but if the attempt should fail, the occiput must be delivered over the anterior margin of the perineum.

5 and 6. Left Occipito-posterior Position and Right Occipito-anterior Position. The only difference in the introduction of the blades is, that in many cases it is difficult to introduce the second, right or posterior blade, after the first or left blade has been placed in position; hence, if this difficulty occurs, the right blade is introduced first, but of course the handles must be crossed before they can be locked. The difficulty may be obviated by following the method of Stoltz. After introducing the right blade, raise the handle and pass the left blade beneath it, and then the handles occupy their relative normal position without having to cross them after the application of the blades.

Ostermann3 advocates if the head be transverse, or if it be oblique,

1 Edinburgh Obstetrical Transactions, vol. xiii.

It is claimed that in natural labor anterior rotation does not occur until the head has reached the pelvic floor. This statement is too absolute, for the rotation may occur before there is the least pressure upon that floor. But in artificial rotation, as made by the forceps, no effort should be made to this end until the floor is reached by the descending head. Traction should be made simultaneously with the effort to produce rotation, and it is important, too, that the forceps should be used to keep the head well flexed. Richardson, of Boston, very ingeniously applies the forceps with the anterior and posterior pelvic curves reversed, in order to effect rotation, removing the instrument as soon as the desired change has been accomplished, and then reapplying if necessary in the normal position of the blades. Barnes holds that instrumental rotation is only exceptionally useful, more rarely necessary, and is not free from danger.

The chief objection that is made to such rotation is that if the head be moved through more than one-fourth of a circle, the body being firmly held by the contracted uterus, and therefore not able to make a corresponding movement, injury is necessarily done to the spinal cord. The experiments of Tarnier and Ribemont have proved that this opinion is erroneous, for they have demonstrated that the torsion of the neck is distributed upon all the extent of the cervical column, and the first six or seven dorsal vertebrae. Tarnier states that exaggerated rotation exposes the spinal cord to injury less than does the great flexion necessary to be produced in order to deliver the occiput posteriorly.

Wasseige states (Des Opérations Obstétricales) that Van Huevel advised applying the new curvature of the forceps behind toward the occiput; as the blades only enter the excavation, it is, strictly speaking, possible, but, according to Wasseige, very difficult to execute, and he rejects it. The method differs only from that of Richardson in that after rotation is effected there is no removal and reapplication.

3 Ueber combinirte Zangenextraction. Zeitschrift f. Geburt. und Gynäkol. Band. xxv.

that is, in an occipito-posterior position, left or right, anterior rotation, the forceps being applied to the head, and an assistant acting by manipulation upon the shoulders of the child through the abdominal wall. His success has been the best proof of the value of this method. Of course, if the rotation has been from a posterior position, the forceps must be removed and reapplied before extraction.

In connection with Ostermann's method of anterior rotation of the occiput, the methods advised in two recent works will be mentioned, though they should have occupied a previous place. Grandin and Jarman' say: "With the cervix fully dilated the hand is introduced into the uterus. If the head has slightly engaged, it should be gently pushed up. The foetus is now grasped and slowly rotated in its long axis until the occiput is anterior. The hand should be slowly withdrawn until the head can be grasped, and in this position the operator waits for uterine contraction. When this has occurred the head is driven down and engagement ensues. It is wise to retain the hand until two or three contractions have taken place, so that the head may be firmly engaged."

2

Herman, after stating that the diagnosis of the position ought to be made by abdominal palpation early, and that anterior rotation of the occiput can easily be accomplished before the rupture of the membranes, proceeds as follows: "Suppose that the child's belly looks forward and to the left, its anterior shoulder will be to the right and in front. Standing by the side of the patient, put your hands on the abdomen, the right hand behind the child's anterior shoulder, the left hand in front of the posterior shoulder. Then by a repetition of gentle pushing movements push the anterior shoulder over toward the left side, and the posterior shoulder toward the right side. You will find it quite easy to move the child; only, as the pushes are given, not to the child, but to the uterus, part of the effect is to move the uterus. But a sufficient repetition of these movements will, unless the liquor amnii be unusually deficient, or the child's mobility for some other reason be abnormally restricted, bring the back in front."

APPLICATION OF THE FORCEPS IN HEAD-LAST LABORS. Manual delivery is to be preferred if possible. Winckel regards the forceps as indicated only in those cases in which the mouth cannot be reached, the occiput has rotated posteriorly, and the face remains stationary under the symphysis. Schröder rejected the forceps, believing that if manual traction could not succeed, it would be impossible with the instrument to extract a living child, and that it was dangerous for the mother. Budin regards the failure to deliver by manual means, which is quite exceptional, as in most cases due to contraction of the os uteri about the neck and head of the child, or to resistance of the pelvic floor, and that under such circumstances the forceps should be used.

In the application of the instrument, the occiput being in front, the child's body is raised, its back toward the mother's abdomen, and the forceps blades applied to the sides of the child's head and extraction made, the mental end of the occipito-mental diameter coming out first. But if the occiput is posterior, the child's body is raised up, its abdomen toward the mother's, the instrument applied as before, and now the occipital end of the occipito-mental diameter passes out first.

HEAD MOVABLE ABOVE THE INLET. In case the forceps is applied before the head has entered the inlet, an application which should be avoided if possible, an assistant holds the head by suitable pressure

1 Obstetric Surgery, 1894.

Difficult Labor, 1894.

3 Before the practitioner is in haste to adopt this treatment, he should remember that it is only in rare exceptions anterior rotation does not spontaneously occur.