Certain objections to the use of the traction-forceps must, however, not be overlooked. Their cost is far greater; but when we consider the amount of energy saved and the diminished risk to both mother and child, this is com pensated for. Their length is an objec tion in one direction only: the difficulty in finding a vessel large enough for sterilization. Their liability to slip in the hands of the inexpert is far greater than that of the ordinary forceps, and when this accident occurs the damage done to the maternal structures is far greater and deeper than the slipping of the ordinary instrument. Yet, in the hands of the expert, a slipping instru ment is not very uncommon, and should at once suggest that a persistent use of this or any other instrument is fraught with considerable danger in a given case; other measures should be instituted in order to deliver.
[This point cannot be emphasized too strongly. A slipping forceps is either a misapplied forceps or else the instrument is contra-indicated by position or presen tation. E. H. GRANDIN.] Axis-traction forceps give a better chance to both mother and child. Theo retically the transverse grasp of the child's head is the right one, but prac tically it is often impossible. Robert Jardine (Brit. Med. Jour., Aug. 20, '98).
During the time from 1892 to 1895 there took place in the Copenhagen Royal Maternity Hospital 6294 confine ments, 242 of which were terminated by forceps. The axis-traction forceps was used in 45 cases. The head should either be fixed on in the pelvic inlet before the forceps is applied; then, if properly per formed, the operation is free from dan ger, but the mortality to the child is rather high-16 per cent. being still-born. Stadfeldt (Bibliothek for Laeger, '98).
The simplest, easiest, and most power ful method of applying axis-traction with the ordinary forceps is as follows: The patient being in the ordinary left lateral position, the blades are inserted so that the lock falls together. The handles are permitted to assume their natural position close to the symphysis pubes and pointing forward. They are allowed to remain during the whole process of extraction in this, the position that they naturally assume, pointing more and more forward as the head descends. To extract, the forceps is grasped at or above the lock with the left hand, and the hollow of the right hand is placed on the posterior surface of the extremities of the handles, so as to he able to push with the right hand ana pull with the left, by an action somewhat similar to that used in nick ing a stroke with a paddle. Then, keep ing both arms the whole time rigid and extended, the operator's chest, facing the patient, is placed in the desired line of traction, which, with the head at the brim, is a straight line passing from the patient's umbilicus through her coccyx, and reaction is made with the operator's back from the coccyx. T. .Archibald
Dukes (Brit. Med. Jour., Nov. 5, '9S).
VERSION.—In version we recognize but one procedure, and that is the true internal version. This manoeuvre is in dicated in all cases when the presenting part fails to engage or when the pre senting part is ar abnormal one, such as occurs in abnormalities, as transverse positions, prolapses funi, etc.; when haemorrhages in placenta prrevhE must be checked; and in cases in which, be cause of a malposed vertex, engagement fails. As pelvic contraction is the most frequent cause for the non-adaptation of the head, the limitations must be fixed as closely as possible. We are told that a 3 pelvic inlet is the lowest limit in which version is warrantable. This calculation is purely arbitrary and uncertain. Such close figuring must de pend on the accoucheur and is largely a matter of personal equation. It is again the question of passage-way and passen ger. A head that is slightly larger than the pelvis can always be delivered by version no matter what the size of the pelvis is. If when version is to be per formed the patient is placed in the Walcher position. a pretty large head can always be brought through a rather small pelvis, if the head be kept well flexed by suprapubic pressure and guided through the largest possible diameter.
Statistics from Leopold's clinic of ver sion and extraction in narrow pelves. From January, ISSS, to May, 1892, there were 6090 labors and 143 versions (2.3 per cent.) ; 16 of these were for placenta prwvia, the patient being generally placed on her back and an anmsthetic given. Version was made by one or both feet. There was sometimes twist ing of the cord. Extraction was made after version, except in 11 cases, in which spontaneous version as far as the umbilicus was awaited. Rosenthal (Ceti. tralb. f. Gyniik., p. 125, '93).
Version with the patient in the prone position (face downward) has the follow ing advantages: The outlet of the pelvis is directed above with the patient prone, giving the operator much more room for the insertion of the hand. The operator's hand and arm are in the position of pronation, giving a better use of the muscles and tactile sense. This posture widens and opens the uterus and vagina; the contraction-ring disappears in these cases. Risk of bruising the soft parts is less with the patient in this position. The patient has a pillow under the chest, her head turned to one side, while the operator may sit beside her, using either hand for version. By this posture two dangers are minimized: tearing the uterus from the vagina and air-embolism. Patients suffer less pain in this posture. Mensinga (Centralb. f. Gynlik., No. 23. '961.