two fingers of the right hand between the head and the sym-
physis pubis: passing them on either side of the symphysis, the tip
of the ear will be felt without difficulty: the finger must remain
applied to it while the vectis is being introduced: the instrument
should be held about the middle, between the two forefingers and
thumb of the left hand, and the handle directed obliquely down-
wards and backwards towards the coccyx, in order that the blade
may lie flat iqDon the head when the instrument is passing be-
tween it and the fingers of the right hand. This is difficult to do
when the vectis is very abruptly curved, and therefore the curva-
ture of the blade makes a very essential difference in the value of
the instrument. If too much curved, it cannot easily be applied;
if too gradually curved, like the forceps, it will slip from its
position if any force be used in extraction. You must, therefore,



MANNER OF USING THE VECTIS. 175

attend to this point particularly, in tlie selection of tlie instru-
ment you use. When the blade is so applied, press it gently
forwards with a slightly oscillating motion, until the edge reaches
the ear, which is now placed exactly between the finger and the
vectis. The handle must, therefore, be depressed still more, in
order that the edge may pass over the ear ; when this is safely
accomplished, the finger may be withdrawn, and the vectis passed
forwards to its proper position. The direction of the handle is
now completely altered, and looks downwards and forwards, its
junction with the blade corresponding nearly to the sub-pubic
ligament. A^Tien the instrument is thus applied, " then (in the
language of Dr. Denman), grasping the handle of the instrument
firmly in the right hand, wait for the accession of a pain," which,
although absent before, almost always returns when this new
irritation is applied to the uterus. While you assist the pain at
this stage of the operation, great caution is required. It is here
that the mischievous principle of the action of the instrument, as
a lever, may do so much injury. If the pubis, or ischio-pubic
ramus be made the fulcrum, the soft parts must be contused, and
a slough may be the result. If, to avoid this, the fingers of the
left hand press the blade strongly against the head, and thus
guard the soft parts from pressure, making, as it is said, a fulcrum
of the fingers, the lever is only altered from one of the first order
to one of the second. In the first, the pubis is the fiilcrum. In
the second, the head and face of the child. Serious injury may
be done in either case. You should, therefore, carefully avoid
using the vectis as a lever ; and in order to do this the more cer-
tainly, it is better to pass two fingers of the left hand between
the head and the perinseum, and to grasp the shank of the instru-
ment with the remaining fingers; counter-pressure is thus made
similar to the forceps, and the vectis may be used solely as a
tractor. Again, in the language of Denman, we would say,
" Wlien the pain ceases, let the instrument rest, and on its return,
repeat the same kind of action, alternately resting and acting, in
imitation of the manner of the pains." Proceeding thus cau-
tiously, the head will soon advance and press strongly on the
perinasum. The introduced fingers may then be withdrawn, and
the vectis maintained in its position, rather for the purpose of
acting with it, if the pains should again become feeble, than to



176



LECTURES ON PARTURITION.



extract the head bj its means, if the uterus be sufficient to expel
it; thus the perinasum will be better secured from injury.




Extraction with Vectis.*

When the vectis is used to correct mal-positions of the head,
it is better not to use one too much curved; one blade of the
forceps will often answer in these cases; the head is higher in
the pelvic cavity, and does not generally press on the perinseum ;
too great a curvature would interfere with its introduction; while,
on the other hand, there is seldom occasion to use it as an ex-
tractor, because, when once the correction is made, the head will
readily descend without assistance. Independently of its limited
power, the vectis is liable to some disadvantages from which the
forceps is free, and which should be guarded against. It is
necessary to grasp the instrument very firmly, and sometimes to
exert your strength to keep it in its place. Sometimes the vectis
will not retain the head so securely that the instrument may not
slip, and though it is easily replaced, still a good deal of force is
necessary to keep it in its position. If, in such a case, the handle
be smooth and round, there is also a risk that it may turn in the
hand without your knowledge, and therefore do mischief. The
handle should always be made rough, and with one side, at least,
flat.

The forceps is more generally used in the practice of midwifery,

and is an instrument of much more extensive application. It may

be employed when the head is at the outlet, in the cavity, or in

the brim, of the pelvis. Hence you will find, in obstetric authors,

two kinds of forceps spoken of — the long and the short forceps.

* In these sketches the perinajiim, etc., is exposed, to shew the position of the
head, which is faintly outhned.



F. OPERATION — HEAD RESTING ON PERINEUM.



177



It is necessary to bear in mind this distinction, because the mode
of operating with the latter is not the same as with the former
instrument. Tliis is the more important, because there seems to
be some degree of confusion in the description given by authors
of operations with the long forceps. For instance, when
the head is arrested high in the cavity of the pelvis, a longer
forceps is required than when it is at the outlet. The former
operation is therefore sometimes mentioned as a delivery by the
long forceps. In speaking of these operations, we would wish to
be understood to mean, not only a different kind of instrument,
but a different mode of applying it from that adopted when the
short forceps is used. In order to avoid this confusion, we shall
describe the operations required in three different cases: first,
ivhen the head is resting on the perin<2mn^ the operation with the
short forceps ; secondly, when it is arrested in the jJelvic cavity,
which might be considered an intermediate operation. And,
lastly, the operation with the long forceps, when the head is fixed
in the brim, of the j^elvis.




Passiiio- of the Pubic- Blade.



The operation, when the head is resting on the periatsuin, may
be undertaken in cases similar to those in which the vectis is
employed, and is preferable, if there be any diminution in the
transverse measurement of the outlet. The preliminary steps of
this operation are the same as for the vecti.s; but it must be
remembered, that the temperature of these, as well as of all obste-
tric instruments, should be raised to that of the vagina, and they

N



178



LECTURES ON PARTURITION.



should be greased before being introduced into tlie passages.
Having made tliese previous arrangements, the pubic blade of
the forceps, with the lock looking upwards, must be passed
over the head in a similar manner to the vectis, and when so
placed, the handle may be raised towards the pubis, and there
maintained by an assistant in its exact position. The handle should
not be m.oved to the right or left side, because it is of great
importance to observe the precise direction of the pubic blade
when the sacral blade is being introduced. Taking, then, the
lock of the former as your guide, as soon as the pain ceases, pass
two fingers of the left hand between the head and the periuEeum,
and holding the sacral blade lightly by the handle with the right
hand, endeavour to guide it so along the introduced fingers that
the edge of the sacral may pass along the lock of the pubic blade.
As the sacral blade passes forwards, and the locks approach each
other, the handle of the pubic blade should be taken in the left
hand, and drawn slowly towards the peringeum. In this manner
the locks will glide together, and the instrument be applied with-
out much difficulty.




Introduction of Sacral Blade.



When this is done, and the pains return, the handle of the
forceps should be held firmly, and, the perina^um being supported
at the same time by an assistant, traction made — at first, very
moderately, carefully observing the action of the uterus; and as
you perceive that the pains are inefiicient, the force may be
increased. With each effort the handle may be drawn, first, with
a slightly waving motion to eitlier side, and then upward, towards



F. OPERATION HEAD ARRESTED IN PELVIC CAVITY. 179

the pubis, in order that the head may pass in the axis of the
vagina. When the head advances, and you are satisfied that the
difficulty is overcome, it is better to leave the rest to the uterus so
long as it acts, because there is less risk of injury to the perinseum.
For the same reason, it would be advisable to unlock the forceps,
and to withdraw the sacral blade, leaving the pubic to be made
use of as a vectis. When the peringeum is tightly stretched over
the blade of the forceps, passing out with the head of the child, it
is very easily lacerated. The time that the operation occupies is
of no importance. The object you should have in view, is to
assist the action of the uterus, not to anticipate the pains, or to
hurry the delivery. Thus a considerable time may elapse before
the operation is concluded. Be careful, therefore, not to make
unguarded promises of prompt relief.

The forceps used in this operation is altogether shorter than
that employed in either of the other operations. It is about nine
or ten inches long; the distance between the extremities of the
blades is about one inch and a half; that between the centre,
about three inches. The intention is to prevent the head
of the child being much compressed in the effort to extract
it. There is some difference, however, in the construction of
these instruments, which will be understood by the examples
placed before you. The short forceps of Dr. Denman* had the
extremities of the blades closer, but the handles were very short,
with the same object, that of preventing much compression. The
short forceps of Dr. Conquest f has the fenestras wide, in order
that parietal prominences may pass through them. Dr. Aitken's
and Dr. Collins's:}: are very similar in shape, and correspond with
the description we have just given, only that Dr. Aitken's has a
small moveable roller between the handles, to prevent compres-
sion.

The operation, ivhen the head is arrested iri the pelvic cavity, is
one which requires a much more attentive consideration, because
it is here that the difference in the practice of the most
experienced accoucheurs is so remarkable. We have already
submitted to you our reasons for the rules proposed for your adop-
tion. They are, 1st, Not to interfere, or to apply the forceps, if
the head be slowly advancing, unless it should happen that danger-
ous constitutional symptoms are approaching. 2ndly, Not to
*(Vifle fig. 3, p. 227.) f (Vide fig. 5, p. 227.) I (Vide %. 4, 6, p. 227.)



180 LECTURES ON PARTURITION.

apply the forceps ivhen the head is impacted. The view of the
operation which we wished you to take would confine it to cases
of arrest. It is of importance, therefore, to make a very careful
examination, per vaginam, before the delivery is determined
upon. First, to ascertain that the head is arrested. Sometimes it
ceases to advance, while the tumour on the presenting part
increasing, is mistaken for its further descent. Both fingers,
therefore, should be introduced, and passed high up, between the
head and pelvis, in' the interval of the pains, to determine the
arrest. Secondly, you should decide on the degree of disproportion.
In cases of arrest, the ear can generally be felt, which cannot be
done without great difficulty in cases of impaction. Hence, as a
general rule., to feel the ear is a diagnostic mark of this distinction ;
but you should not confine your attention to this point alone,
because it sometimes happens that when the head is arrested, it is
so placed that the ear cannot be felt, especially if the head be
lengthened, and a tumour be formed upon it. The object of the
rule is to determine the amount of space there is for the introduc-
tion of the instrument. Therefore, if the ear be out of reach,
while the fingers can be passed with facility between the head
and the pelvis — if the catheter can be passed easily — if you can
press the head back without difficulty — and if the vagina be not
swollen from 'the extreme pressure — then the forceps may be
applied. Thirdly, you must decide u-pon the time of its application.
It appears to me that /owr hours would be quite sufficient to allow
the head to remain in the same position, to authorise your inter-
ference. But if there be the least indication of pain, swelling, or
heat in the passages, you should not delay one moment from the
time that these symptoms present themselves, when you are satis-
fied that the forceps may be applied. Promptitude is the secret
of success, and in nothing is it more evident than in the case we
are supposing. It is possible the pains may be strong and fre-
quent, and it is generally a safe recommendation not to interfere
so long as the uterus seems to have sufficient power, but rather
to wait until the pains become feeble, or the action of the uterus
is suspended. Nevertheless, in the case before us, you cannot
act upon such a rule. If the head be arrested — if the pains be
strong but inefficient — if inflammation set in — to hesitate
to deliver must be considered the most mischievous vacilla-
tion. Every hour spent in these useless efforts of the uterus,



DANGER OF DELAY WHEN THE FORCEPS IS REQUIRED. 181

onlj increases your difficulty — only renders the operation more
hazardous — and diminishes your chances of success, because the
application of the forceps to parts already inflamed must contuse
them to a certain extent, and if so, the contusion will terminate
in slough. Although agreeing with Dr. F. Ramsbotham in many
of the principles of his practice, I find myself opposed to him on
this question. The summary of symptoms which he gives to
authorise the use of the forceps, when labour does not continue
twenty-four hours, seems to me to be founded upon a principle
very hazardous to the safety of the mother. He states, " If,
then, the pains are subsiding gradually, or have entirely dis-
appeared; if the strength is failing, the spirits sinking, the
countenance becoming anxious ; if the pulse be one hundred and
twenty, one hundred and thirty, one hundred and forty, in the
minute, the tongue coated with white slime, or dry, brown, and
raspy; if there have been two or three rigors; if, on pressing the
abdomen, there is great tenderness of the uterus; if there be
green discharge; if there be preternatural soreness of the vulva,
with heat and tumefaction of the vagina ; if the head have been
locked for four hours, and made no progress for six or eight
hours; if the patient be vomiting a dark, cofiee-ground-like
matter; if there be hurried breathing, delirium, or coldness of
the extremities, then we are warranted in having recourse to the
forceps, although the labour have not lasted the limited period of
twenty -four hom^s, or even twelve ; and we should be acting injudi-
ciously to allow the case to proceed until the last four symptoms
appear, without relief being offered."* Dr. F. Eamsbotham enu-
merates these symptoms, to authorise the delivery of the locked
or impacted head — a case in which I have already stated that I
do not think the forceps can be at all safely employed; but to
apply the instrument when inflammation has advanced to such
an extent as to engage the constitution in an irritative fever, and
only to deliver before the last four symptoms of exliaustion
appear, and that, too, when the head is impacted, seems to me to
be dangerous in the extreme. I am the more anxious, therefore,
to impress upon you the importance of not waiting, or with-
holding your assistance, the moment such symptoms commence ;
but if, unfortunately, it should happen that they have advanced
to the degree so well described by Dr. Ramsbotham, then the
* Ramsbotliam's Ob. Med., p. 313 and 314.



182 LECTURES ON PARTUEITION.

safety of the mother must be your first consideration, and you
should select the operation that will best secure it. With this
view, I again repeat, perforation is your only resource, although
I admit it to be a Yerj painful alternative. When you have
determined upon the necessity for delivery by the forceps, and
the time for performing the operation, the same preliminary
arrangement should be made as in the former instance, using still
greater caution in your antiphlogistic measures. Hence, if the
vagina be swollen and hot, the urine retained, the pulse quick,
depletion, some time before operating, would be advisable, the
urine being, of course, removed. If the ear be felt, the pubic
blade may be passed in the same manner as in the preceding
operation, but if not, the presentation must be carefully examined.
You can usually trace the lambdoid suture passing upwards from
the posterior fontanelle; direct the pubic blade along this, and it
will guide it to the ear. You may also take the rule, with regard
to the pelvis, laid down by Dr. Rigby, and introduce the first
blade behind the trochanter, still bearing in mind its relation to
the lambdoid suture: thus the first step of the operation can be
generally taken successfully. The passage of the sacral blade is
rather more difficult. It may be introduced in the same maimer
as in the former instance, but its advance is frequently checked
as it approaches the brim of the pelvis. If such should happen,
be very careful not to use force in pressing it forwards. It is
better to act with the pubic blade, for a short time, as a vectis,
and if the head advance even slightly, the opposite blade will
frequently glide into its place.

Wlien the forceps is applied, it is well to dislodge the head
from its situation in the first instance, because it constantly hap-
pens that in these cases of arrest some accidental displacement of
the head is the cause of difficulty, which the uterus cannot alter;
but when the head is relieved, it will glide into the correct posi-
tion, and may be delivered without difficulty. If, however, you
find that with the following pain the head is still arrested, the
forceps must be seized firmly, and, in order to secure your hold, a
coarse napkin might be placed loosely round the handles. A
steady and powerful traction should be maintained so long as the
pain continues, and when it ceases, the grasp of the instrument
must be at once released, and remain so until the succeeding pain,
when the same steady trtiction may be renewed. Thus you will



r. OPERATION HEAD EIXED IN BRIM OF PELVIS.



183



generally succeed in bringing tlie liead tlirough ttie opposing part
of the pelvis, and as it advances more easily and approaches the
peringeum, again recollect to leave it as much as possible to the
efforts of the uterus. While the head is thus drawn through
the pelvic cavity, you should bear in mind the direction in which
it must pass; that when the forceps is in the axis of the pelvic
cavity, the shank of the handles would lie between the tubera
ischii, but when the head is in the hollow of the sacrum, the
handles would then be directed forwards towards the pubis. You
should therefore first draw, with a waving motion, directly
towards you, and as the head advances, direct the handles for-
wards. It is necessary also to observe the rotation of the head in
its lateral direction from the oblique towards the antero-posterior
measurement of the pelvis. At the same time, it is advisable
rather to follow than to guide the direction of the head in its
progress, because, as it descends, it will naturally change its posi-
tion, which might be prevented by the operator's awkwardness in
holding the forceps, and attempting too hastily to turn it.




Application of Dr. liadforcl's forceps when the head is fixed in the brim, etc.
The operation when the head is fixed in the brim of the pelvis
differs from either of the preceding operations. The blades are



184 LECTURES ON PARTURITION.

applied over the occiput and face of the child, and not over the
ears. This may easily be done in the case to which we have
confined this application of the forceps ; but it would appear to us
extremely difiicult and dangerous to do so in other deformities of
the brim of the pelvis. Two fingers, and as much as possible of
the right hand, should be passed behind the trochanter, towards
the centre of the ilium on the superior side of the pelvis, and if the
anterior fontanelle be felt distinctly, the longer blade of the for-
ceps (if they are unequal) should be passed over the fontanelle
to the face of the child; the shorter blade may then be passed
in the opposite direction over the occiput, guiding it by the lock
of the introduced blade. When properly applied, the handles
look downwards and backwards towards the perinseum, and in the
axis of the brim ; traction must be made in this direction, and
when the pain commences, the handles of the instrument should
be held, as in the former case, firmly, and the force gradually
increased, according to the resistance. Two or three steady trials
will generally succeed in extricating the head from the brim,
when it will rapidly advance without assistance; the forceps
might be removed, but it is safer not to do so lest any impediment
might delay its further progress.

It is necessary to remember the change in the direction of the
head when it is passing into the hollow of the sacrum. The
blades of the forceps might also be changed, so as to direct them
over the ears of the child. Great caution is required in extract-
ing the head from the brim of the pelvis, because it is impossible
to use any force Avithout compressing the handles strongly
together. There is, therefore, danger lest the face of the child be
bruised, or, what is quite as likely, the frontal bone bent in. In
some cases, the edge of the blade of the forceps has been buried
in the frontal bone, even when the instrument was intended to
pass over both ears. Such a fatal accident would be much more
likely to occur in this operation, if sufficient care Avere not taken
to avoid it.

If the posterior fontanelle be felt on the superior side of the
pelvis, the longer or facial blade of the forceps should be passed
along the opposite side to the ilium, and then the occipital blade
behind the trochanter, as in the former operation. The head of
the child always lies in the transverse measurement of the brim,
with the occipito-frontal axis corresponding to it. There are only



VARIETY IN THE CONSTRUCTION OF THE FORCEPS. 185

two positions, one with tlie face to the superior, and the second
with the face to the inferior, side of the pelvis. The operation
in the second case is, therefore, just the reverse of that in the first
position.

In the construction of instriiments, some forceps are made
especially for this operation. It is considered objectionable (and
I think justly so) to operate with a forceps that has the blades of
equal lengths, because, when the instrument is applied, the occi-
pital blade will prevent the facial passing sufficiently far over the
face; its extremity may only reach the nasal bones, or be applied
over the frontal sinuses, and therefore the bone might be crushed
by the force employed in extraction. To avoid this. Dr. Davis
has contrived a forceps with unequal blades, in such a manner
that the curvature of the longer blade coidd be diminished or
increased if necessary. More lately. Dr. Radford, of Manchester
(who has had extensive experience in these cases of deformed
pelvis), has invented a forceps with unequal blades for the same
purpose (vide fig. 12, p. 229). The majority of practitioners, how-
ever, employ only one kind of forceps for these two operations,
which they call the long forceps. Dr. F. Ramsbotham's long
forceps (vide fig. 9, p. 229) has a shank between the handles and
the blades, and is so curved as to adapt itself to the axis of the
brim of the pelvis. Dr. Rigby has introduced Briininghausen's
long forceps* (vide fig. 10, p. 229), an instrument somewhat longer
than Dr. Ramsbotham's, having the second curve describing a
larger circle. The lock between the handles also is differently