front of the pelvis or manikin; then why complicate matters by a change of position, which, to say the least, is a very awkward one, particularly in introducing the long forceps, setting it according to the instructions of Hodge, and carrying it forward between the thighs as the head emerges? I have used the short forceps in an exhausted case with the woman on her side, but found it much less convenient for the various movements, although I soon delivered the foetus. As to the question of exposure, there is less in appearance than, in fact, in the

English position in many cases. If the patient and nurse are fastidious and careful during the use of the forceps, the accoucheur can manage without his eyes in a large proportion of cases; but the fault of exposure lies more frequently in the temporary reckless indifference begotten of pain and suffering in the woman, than in any act of the accoucheur if inclined to spare the feelings of his patient as much as possible.

The long forceps, with its pelvic curve, was specially designed for use at the superior strait of the pelvis, the curve of the blades, as in

the Davis instrument modified by Wallace, being intended to correspond with the direction of the occipito-mental diameter of the foetal head. The long superimposed shanks of several varieties of the long forceps will here be found valuable, as the lock is not introduced or the posterior commissure of the vulva widely stretched. If the head is entirely above the strait, the line of the blades must be changed

FIG. 183.

Application of the forceps with the head at the superior strait, the left blade held in place by an assistant.

correspondingly, in order to apply them properly and keep the line of traction within the coccyx; and even then, to draw in the proper direction, the left hand must act at first in a backward direction from the lock, while the right brings the handles downward, forward, and then upward; both hands describing a curve, but that of the right being much the greater. The peculiar forceps of Tarnier, Poullet, and Cleemann, being designed to meet this form of exigency, may be brought into requisition.

In latter years it has become much more common than formerly to introduce the forceps into the uterus before it is fully dilated, in consequence of the success claimed for the plan as carried out in the Dublin Lying-in Hospital. As this should never be done where the os is not readily dilatable, and requires much skill in execution, it is not safe to recommend its general adoption in cases of delay in private practice.

The forceps should not be introduced with any force, but the left blade should be slid in gently and with a spiral motion, and then the right, care being taken that they should also lock without force, which

Direction of the forceps as the head is being delivered.

they will do if properly adjusted. Traction is to be exerted slowly and during a pain, the whole movement being made to correspond with the natural one as closely as possible.

As the foetal head comes under the arch of the pubes the handles of the forceps must rise more and more from the bed, until at last they are over the abdomen as the head emerges from the perineum. This last movement of instrumental delivery should be a very slow one, for fear of rupture. It has been proposed to remove the blades before delivery is complete; but there is no occasion for this if the forceps is applied to the sides of the head over the parietal protuberances, as, where these protrude and the blades are flat and thin, there is very little additional space required. With such instruments as the old

Levret, Baudelocque, and Rohrer forceps, with looped or kite-shaped fenestræ and thick edges, this was a much more imperative direction than with the better instruments of the present day. With a Sawyer forceps the perineum ought to be safer and under better control than without. When the perineum is thought to be in danger, the process of distention should be retarded through two or three pains, or even more if required, instead of drawing the head through at once.

After the head is delivered, if the cord is not around the neck and therefore in danger from pressure, the body should be allowed to remain until the uterus has well contracted upon it, for fear of hemorrhage after delivery, from uterine inertia.—ED.]

CHAPTER IV.

THE VECTIS.-THE FILLET.

The Vectis. In connection with the subject of instrumental delivery, it is essential to say something of the use of the vectis, on account of the value which was formerly ascribed to it, which was at one time so great in England that it became the favorite instrument. in the metropolis; Denman saying of it that even those who employed the forceps were "very willing to admit the equal, if not superior, utility and convenience of the vectis." Even at the present day there are practitioners of no small experience who believe it to be of occasional great utility, and use it in preference to the forceps in cases in which slight assistance only is required. In spite, however, of occasional attempts to recommend its use, the instrument has fallen into disfavor, and may be said to be practically obsolete.

Nature of the Instrument.-The vectis, in its most approved form, consists of a single blade, not unlike that of a short straight forceps, attached to a wooden handle. A variety of modifications exists in its shape and size. The handle has been occasionally manufactured, for the convenience of carriage, with a hinge close to the commencement of the blade (Fig. 185), or with a screw at the point where the handle and blade join. The power of the instrument, and the facility of introduction, depend very much on the amount of curvature of the blade. If this be decided, a firmer hold of the head is taken and greater tractile force is obtained, out the difficulty of introduction is increased.

When employed in the former way, the fulerum is intended to be the hand of the operator; but the risk of using the maternal structures as a point d'appui, and the inevitable danger of contusion and laceration which must follow, constitute one of the chief objections to the operation. Its value as a tractor must always be limited and quite

inferior to that of the forceps, while it is as difficult to introduce and manipulate.

Cases in which it is Applicable.-The vectis has been recommended in cases in which the low forceps operation is suitable, provided the pains have not entirely ceased. There is no doubt that it may be quite capable of overcoming a slight impediment to the passage of the head. It is applied over various parts of the head, most commonly over the occiput, in the same manner, and with the same precautions, as one blade of the forceps. Dr. Ramsbotham says: "We shall find it necessary to apply it to different parts of the cranium, and perhaps the face also, successively, in order to relieve the head from its fixed condition and favor its descent." Such an operation obviously requires quite as much dexterity as the application of the forceps; while, if we bear in mind its comparatively slight power and the risk of injury to the maternal structures, we must admit that the disuse of the instrument in modern practice is amply justified.

FIG. 185.

NKETHEWS

FIG. 186.

Vectis with hinged handle.

Wilmot's fillet.

The vectis may, however, find a useful application when employed to rectify malpositions, especially in certain occipito-posterior presentations. This action of the instrument has already been considered (page 334), and, under such circumstances, it may prove of service where the forceps is inapplicable. When so employed it is passed carefully over the occiput, and, while the maternal structures are guarded from injury, downward traction is made during the continuance of a pain. So used, its application is perfectly simple and free from danger, and for this purpose it may be retained as part of the obstetric armamentarium.