The number of cases in which injuries were inflicted by the forceps amounted to 69= 60 per cent., only cases in which sutures had been used being included in these figures. The perineum was torn in 61 cases; in 47 of these the laceration was from 1 to 3 centimetres long; in 11 it extended to the intestine, and in 3 the sphincter was completely torn through. In only 1 case was a deep laceration of the os uteri observed, and in 1 a vesico vaginal fistula. No deaths occurred from the use of forceps. Von Walla (Monats. f. Geburts. u. Gyniik., B. 5, '97).
Forceps should not be applied until the head is under the brim, is well ro tated, and the os is dilated. If there is any danger to mother or child it is then justifiable to operate in the absence of these three conditions. Fehling (Brit. Med. Jour., Aug. 20, '98).
We do not sanction the application of forceps to the head above the brim ex cept for one indication, namely: when rupture of the uterus exists or is im pending. In all other cases we decidedly prefer the elective version, for fear of causing a rupture in threatened cases or of increasing the tear in already-pres ent ruptures. Again, we do not advo cate the true high forceps application, because non-engagement of the head means either a malposition or a pelvis that is relatively or absolutely con tracted.
In pelvic contractions, especially of a minor type, the mechanism of labor is different from that which takes place in normal ones. The head engages trans versely instead of obliquely, and is by perflexcd. Since .many pelvic contrac tions are antero-posterior. with compen sating increase in the transverse di ameter, it would appear that Nature con forms with what would be an ideal at tempt on her part to overcome the dys tocia. If the forceps is applied as usual along the sides of the pelvis, pressure is exerted from side to side; this, in our experience, is not compensated for by an overlapping of the bones, and the bi parietal diameter of the head is not in creased. According to direct observation, the pressure from side to side causes an increase in the biparietal diameter, which conforms to the contracted antero-poste rior diameter, and in this fashion in creases the pelvic contraction both rela tively and absolutely. For this reason version is elected, for, under the above conditions, the after-coming head, de scending, as it should, transversely. press ure is exercised by the antero-posterior contraction on the parietal bosses. This diminishes their diameter where the greatest contraction exists and affords compensatory side-to-side enlargement, which conforms to the enlarged trans verse diameter. This, we believe, ex plains the superiority and safety for both mother and child of version over the high forceps application.
The ideal forceps of our day for all purposes is the true axis-traction for ceps: that of Tarnier or Jewett. But its cost and the danger from its use are such as to make it an instrument emi nently fitted for the expert only. In the
ordinary forceps, the mechanism, as compared to that of the pelvis, does not come into operation, while, in the axis traction forceps, the head, together with the body of the instrument, obtains great freedom in mobility. A further great advantage in its use applies for cibly to the child. With the ordinary forceps the more powerful the extraction force applied, the greater the compression force exercised upon the fcetal skull, no matter how carefully done, no matter what amount of resistance force or ma terial is placed between the handles at any point to lessen the compression power. Too much space between the handles absolutely insures a loose or un steady application of the blades and con sequently far greater predisposition to slipping. This is entirely overcome in the axis-traction instruments, through which no pressure is brought to bear directly on the head, since all extraction force is applied directly to and from the cross-rods. Finally it is remarkable with what ease apparently difficult cases are delivered by their use with a minimum. force expended. The handles of the for ceps are an extremely useful guide as to the position of the head, and eonse quently an ever-guiding factor: a corn- I pass, as it were, as to the direction in which the force of the extraction is to be applied.
The indications for the use of the axis-traction instruments are in nowise different from those of the ordinary forceps. Nor does their application dif fer from that of the latter. It is only after they are locked and ready for use that the mechanism begins to differ. In their use the following rules must always be adhered to: The handles of the blades must be a guide 1 ence the utility of the handle-tips as in dices, for the tendency would then be to push the handles too rapidly forward and so give us a false conception of the true and ideal axis-traction; its effect would thus be spoiled and our energy rendered futile. Traction is then to be made and continued, the traction-handles carried farther and farther forward and upward until the head begins to crown. It is now advisable either to remove the for ceps, or, if the head is to be delivered solely by the forceps, the operator stands to one side of the patient, and grasps as to the direction of traction, no matter what their position. The position of the blade in its relation to the pelvis must never be taken into consideration and certainly must never influence us as to the direction of our traction energy. The button on the traction-handle, or the point of junction of the traction rods with traction cross-handle, must always be nearly in contact, just barely touching, and this relation must be maintained until the patient is prac tically delivered. To allow the two parts to come into contact will at once influ both traction-rods and forceps-handles in one hand, while with the other he manages the perineum.