There exists some disproportion between the head and the birth canal, due to over size or faulty position of the head, or to undersize of the outlet.

The pains are strong and the expulsive efforts are well directed. But all effort meets with defeat because of the opposing diameters of the boney outlet. The space of their circumference is filled by the presenting portion of the head when advanced by a contraction. The head fills the space in proportion to the compression it has undergone. The caput succedaneum extends beyond the tuberischii and protrudes from the vaginal orifice. Each effort at expulsion will seem to promise delivery of the head. But examination will find the parietal bosses behind the tuberischii and the inion behind the symphasis pubis. The antero-posterior diameter of the head that presents is too long to allow the inion to pass from under the pubic arch or over the perineum if it is posterior. During the absence of pain the head recedes, freely if the cavity of the pelvis is roomy and less so if not. The movement of psuedo, extension observed, when the head is pushed down by a contraction, and which so often deceives the inexperienced or the careless into believing the head is advancing, is due to the head revolving slightly upon its transverse diameter in the effort made to pass the outlet. The gradual increase in the size of the caput succedanuem adds to the deceptive promise of delivery to the disheartened patient.

Vigorous efforts, voluntary and involuntary will continue according to the woman's strength and endurance, but sooner or later they will assume the characteristic behavior of expulsive efforts that meets with obstruction. If relief is not given the patient begins to show signs of exhaustion. The uterus becomes irritable and sensitive to the touch; pains become excruciatingly painful and "choppy," overthrowing the equipoise of the patient's nervous system. The soft parts become swollen, contused and redematous, while the child dies or is born in extremis. No case should be allowed to reach this pitable and dangerous state before relief is given.

The diagnosis should be made early. The changed character of the pains and the behavior of the patient while

under their influence should give early warning to the accoucheur of what lies before him. The forceps should be applied and delivery effected before signs of exhaustion begin. Greater traction force is needed here than in group one, with proportionately greater compression of the head. The integrity of the perineum and the lower third of the vagina are greatly endangered. Laceration is more than likely to occur, and is inevitable if the inion is posterior, unless the head is very small and the outlet large.

III. To produce flexion of a partially extended head that is more or less firmly fixed. The conditions that give rise to this form of dystocia, usually occur in the cavity of the pelvis. The cases we would include in this group are those in which rotation has taken place or is nearly completed, so that the application of the forceps to the sides of the pelvis applies them to the sides of the foetal head. This form of arrested head usually occurs just within the outlet. It is chiefly due to a hand of the foetus falling under the chin or some other displacement of an arm that prevents flexion. The foetus is crowded into the pelvis by the uterine contractions, and by retraction when the fruit-water is spent. The forceps applied, traction is made horizontally until the head reaches the floor of the pelvis and presents well at the outlet. The advance of the head gives the chin a chance to escape the obstructing hand or arm, when flexion is readily accomplished by lowering the occiput if anterior or raising it if posterior. After flexion is produced, delivery of the head, in anterior position is easy with or without further use of the forceps.

The diagnosis of this difficulty is not easily made and must be largely presumptive. In cases where the diagnosis may be reasonable assumed, the inlet is usually wide and the cavity fairly roomy. The adjustment of the forceps blades can point to the difficulty. One blade will slip easily into place, while its fellow will meet with obstruction that prevents it from slipping home. This is due to the tip of the blade coming in contact with the shoulder of the same side that has been driven into the pelvis and passed the side of the face. The projecting hand fills the grove between the shoulder and the side of the face. It is then difficult to insinuate the tip of the blade between the shoulder and the side of the face.

When accomplished the offending hand or

arm is pushed away and the blade slips home. Difficulty in adjusting the tip of one blade followed by ready flexion and delivery should point to a displaced hand or arm.

IV. The forceps is indicated for the relief of maternal suffering. The greatest danger from their use, for this purpose arises from the resistance of the perineum terminating in its rupture. Whether the cause lies in the vis a tergo or the vis a fronto as supplied by the forceps, or both combined, the too rapid advancement of the head endangers the perineum. In this group of cases the vis a tergo is efficient, the patient is in good condition; there is no obstruction offered the advancing head except that of the slowly dilating perineum. But the patient suffers and frets under the burden of pain laid upon her. To relieve her the forceps are applied, but it must be remembered that traction by means of the forceps lends added power to the force behind. If these combined forces are out of proportion to the dilatability of the perineum, rupture is inevitable and unnecessary damage is done.

If the time for applying the forceps is rightly chosen and the forces in hand are well controlled we may have the happiest results. We may not only escape a possible rupture from bad use of the forceps, but may prevent a probable rupture if the case had been left to spontaneous delivery. The period of suffering may be shortened from one-half to two hours, with absolute safety and comfort to mother and child. At no time, all things being equal, should this boon be denied the patient.

V. A forceps operation is usually undertaken for the greater safety of mother and child. In this group we choose to consider those cases in which the child alone is considered; (a.) When the child is debilitated and small and is not likely to withstand the vicissitudes of labor, though of average duration. (b.) Where the mother gives the history of having borne children that have died during labor, pending spontaneeus delivery or soon after. (c.) When the head has been upon the perineum under pressure long enough to threaten the child's life, or better, before it seriously endangers its life. (d.) In cases of partum hæmorrhage. An escape of blood during an intermission of pain, if marked points to a premature separation of the placenta, or larceration in some portion of the birth canal. When this occurs, little time should be lost in determining the site of the hæmorrhage. If not found in a laceration we must act upon the supposition that the hæmorrhage is placental and apply the forceps. The integrity of the perineum should be of secondary consideration, for a wound will heal easier than life can be restored to the child.

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EDITORIAL.

THE UNFOLDING OF OBSTETRICAL ART.

INCE the day of Adam and Eve children have been born. But the manner of their being born has been so left to the kindly offices of nature and the midwife, that the early history of obstetrics affords little of scientific value to the student of today.

Since the establishment of maternity hospitals, there has been marked growth in knowledge of obstetrical science. Much of what we now know that is best of the subject eminates from the these centers of practical study.

Still advancement in the light of more modern times has been slow. Theories have been advanced to be rejected after careful study and observation. Measures and facts of real practical value have been overthrown by opposition, born of preconceived notions, while many valuable methods

have had to fight their way into favor by a slow process of development from the crude to the more perfect. A notable instance of slow unfolding is furnished by the history of the obstetrical forceps. Somewhere in the 11th century Avicenne devised an instrument for saving the child. In 1554 Jagnes Rueff described a similar instrument. Little or no improvement having been made during the four hundred years or more. Another century rolls by when the Chamberlen forceps appears, 1647. An instrument involving the principles of the forceps of today. For a long time, nearly a century, they were made the object of mercenary traffic by the Chamberlens and others, as well as of opposition. In 1747 the secret of Chamberlen was published, when Levret added the pelvic curve, and lengthened the blades. A few years later Smellie further lengthened the blades and increased the pelvic curve for high operations. From Chamberlen to the forceps of today, what a change! Slow but sure has been this advance in spite of traffic, opposition and absolute condemnation.

Another instance is found in the history of abdominal Palpation as a means of diagnosis. In 1601 Mercutius Scipio described it for the first time, a few others followed him at different times with indifferent results.

Wigand in 1813 made an attempt to show its importance and fix its rules, still it was thought of little use. Later, Mattei for the first time developed all its details and demonstrated its importance, not only for the diagnosis of preg nancy but of presentation and position, and for version by external manipulation. But his researches were not received by obstetricians with the appreciation they deserved. It was not until 1865 when Tarnier returned to it, followed by his illustrious pupils, Pinard, Budin and others, that it received general appreciation. For nearly three hundred