DEEP VULVO-VAGINAL INCISIONS, on one or both sides, is a means of dilating the vaginal outlet when, from imma turity on the part of the patient, spasm or old cicatrices make delivery highly dangerous to the integrity of the parts or impossible. Starting at a point supe rior to the posterior fourchette and mak ing a deep cut obliquely downward and outward from the vagina effects an in cision through, not alone the sphincter ani, but also through the anterior fibres of the levator-ani muscles. This gives a diamond-shaped wound, which can be readily stitched up after the delivery. Its advantages over a simple episiotomy are evident, when we remember that 4neh a very superficial incision has al ways a tendency to tear farther and so produce irregular lacerations, difficult to sew up, instead of clean, surgical in cisions which come together with great nicety by suture.
FORCEPS.—This most important and useful instrument in the entire domain of obstetrical surgery is both conserva tive and preservative. Conservative in the sense that it saves both mother and child the results of physical injury; pre servative by actually anticipating the possibility of immediate or ultimate death of the mother or her unborn child. Still, the forceps should never be used unless there are positive indications for its employment. The head must be in a normal position, or so relatively nor mal that operative interference will readily convert it into one. It is always better, however, to convert faulty posi tions by manual methods before having recourse to instrumental interference. In a face case, chin behind, for instance, manual flexion of the head should be re sorted to, to convert it into an occipito anterior, forceps delivery being then ac complished. It is only applicable when the membranes are ruptured and the os is dilatable or nearly fully dilated. The head must he engaged or at least fixed at the brim.
Series of 2926 deliveries in the Base] Hospital, between May 1, 1887, and De cember 31, 1893, of which number 156, or 5.33 per cent. of the total number, were delivered by the forceps, and of these 129 —83.3 per cent. — were pri iniparte. Presentation in the second
position was the most frequent cause for their use. Loss of blood was estimated at 19 ounces on the average. In 132 cases-84 per cent.—perineum was rupt ured, and wound healed by primary union in 92 cases. Mortality from all these deliveries was 1.28 per cent., but this was not due to the application of the forceps. Infant-mortality was 12.2 per cent.,-5.7 per cent. being the result of use of forceps. Their use is recom mended when pains diminish owing to prolonged labor, when the head is in a proper position, and when the second stage has lasted more than two and a half hours. Schmid (Jour. Amer. Med. Assoc., Dec. 15, '94).
Results of use of forceps in 2920 labors. Birth was completed by forceps in 3.63 per cent. of cases. Majority of cases were primiparm, between 20 and 30 years old. In 60 per cent. of cases the mother was lacerated. Maternal mor tality was 4.7 per cent., while 11.32 per cent. of children perished. Of mothers, 1.8 per cent. had septic infection. Con clusion reached, from comparing the use of forceps with other methods of de livery, is that the forceps is the bloodiest method of delivery, and that its mor tality-rate renders it a serious procedure for mother and child. Other means of accomplishing delivery should be ex hausted before recourse is had to the forceps. Shirk (Monats. f. Geburts. u. Gyniik., B. 1, H. 6, '95).
Conditions and the indications held at Budapest to justify the use of the for ceps are: that the os uteri must be com pletely dilated; membranes ruptured; the head must be presenting in a position suitable for the forceps, or at least its greatest circumference must be lower than the brim; the head must be of a suitable size and consistence; and there must be no contraction of the pelvis, or if contraction is present the head must have passed beyond it. In 11,064 cases of labor at the Budapest Lying-in Hospital, there were 115 forceps deliveries = 1.04 per cent. In 1895 the percentage was as low as 0.32 per cent. Of the 115 cases, 101 w ere primiparm and only 14 multip ar, so that the proportion is nearly SS per cent. to 12 per cent.