CONDUCTED BY WILLIAM TOD HELMUTH, M.D., GEORGE W. ROBERTS, PH.B., M.D. M ATYPICAL FORCEPS OPERATIONS.* BY GEORGE R. SOUTHWICK, M.D., UNCHMEYER'S declaration that forceps was the most bloody of all obstetrical operations as compared with the dictum of the Berlin clinic that forceps was the safest and most beneficent of all operations, has led to renewed study and reports of the use and results of forceps in nearly all of the large Continental clinics. These reports of carefully observed cases since the introduction of asepsis are of special importance, as indicating the effect of the latter on the modern practice of obstetrics by the experts of Europe. In a general way it may be said that the German school holds firmly to conservative lines, especially as regards the application of the forceps at the brim of the pelvis and very generally declares against them if the head is movable above the brim. The Paris obstetricians, influenced by the axis traction forceps, follow similar lines, but use the high forceps more freely. The English school resort to forceps earlier than either, and in America where uterine inertia alone is accepted by many physicians as sufficient reason for interference, the forceps is used still more freely. This tendency to what one will call the abuse of a safe instrument and another will term the humane use of the forceps, deserves serious consideration. The results of experience are the final and most conclusive appeal to our judgment, and while it is not the writer's intention to quote details of statistics which can be found by those who are interested, a brief summary of the results obtained by the masters of the art is helpful in arriving at any conclusion. The maternal mortality from the use of forceps does not include usually cases infected before operating or those where previously existing complications are likely to prove fatal, such as eclampsia, minor pelvic contraction excepted. * Read before the American Institute of Homeopathy, Cleveland, June 1902. The infant mortality for the same reason applies only to infants which die during delivery or a few hours afterwards. Maternal morbidity, as shown by the rise of temperature above 100° F. in the puerperal state, with similar elimination of factors producing elevation of temperature independent of the mode of delivery, is more important in estimating results than mortality. A woman may finally recover in a crippled condition after a long illness, but those who recover without a rise of temperature above 100° will show much more accurately the character of the labor and delivery. The morbidity is not mentioned in all the reports, but as it is given in over 15,000 cases, it may be presumed to be fairly correct. The statistics given here in a general way are founded on the reports of the maternities of Dresden, Prague, Vienna, Berlin, Halle, Bonn, Munich, Basel, Tubingen, Budapest, and several other cities. The teaching of antisepsis produced remarkable results as early as 1885. At this time a report of 50,752 births in central Germany showed that the forceps were used once in 37.8 labors with 1.4 per cent. mortality for the mothers, and 9.8 per cent. for the children. The morbidity was not given. The strict observance of modern asepsis in all maternities has improved later reports. Twelve representative clinics show 30,737 births with an average use of forceps in 3.54 per cent. of the cases or about once in 33 labors. The least frequent use of forceps was in the Dresden clinic, where it was used once in 50 cases with no mortality of the mothers. The morbidity of the mothers was 23 per cent., i. e., only one woman in four had a temperature exceeding 100° F. during convalescence, and 12 per cent. of the infants perished. It is only fair to state that in this clinic the forceps is not applied to the head above the brim, version being the operation of election. The Basel clinic showed the largest proportion of forceps of the German clinics, but it is in a section of country containing a high percentage of contracted pelves. The forceps was used here once in 20 cases, or more than twice as frequently, with no mortality of the mothers, a morbidity rate of 24 per cent., and a mortality for the infants of 10 per cent. The average of the cases reported approximated closely to a morbidity rate of 17 per cent., which means that five out of six women delivered by forceps, have ternperatures less than 100° F. during childbed. It is freely conceded that the use of forceps should have no mortality in uncomplicated cases. The average infant mortality in these 30,737 cases was 10 per cent. It should be remembered that the statistics quoted are from clinics where exhaustion of the mother and flagging pains, without other clinical evidence, is not accepted as an indication for forceps, and where it is a general rule not to apply forceps unless the head has remained stationary in the pelvis for two hours after it has failed to advance or recede after it. The American physician, true to his instincts and innate chivalry, takes a more humane position, and uses the forceps much more freely, while his English cousin occupies the middle ground and believes firmly in high forceps. That prince of all instruments, the hand trained by experience and thorough familiarity with the mechanism of labor, occupies a higher place with us than elsewhere, and it is very natural that manu-dexterity should accompany Yankee ingenuity. We gradually have recognized the fact that manual dexterity counts for much in rectifying abnormal positions and flexions of the head which very often are the real source of difficulty in effecting a safe delivery. The hand of the expert sometimes fails, but it not infrequently simplifies a severe case of dystocia, and aids materially in rescuing mother and child from a perilous position. Abnormal positions of the head at the brim, or extension of the occiput can be corrected manually in many cases so as to allow the immediate application of forceps bi-parietally to secure the head in a new and favorable position, rather than to force immediate delivery which, on the contrary, should be performed slowly and carefully. This use of the hand in correcting brow, face, occipito-posterior positions and extension of the occiput in vertex positions, deserves wider application in connection with the use of forceps than has been given it. The success or failure of such manipulation is important in electing forceps at the brim or version, and if the effort is not successful the operator can proceed at once to either version or forceps without detriment to the mother. The secret of success in some cases lies in pushing the head back, rotating the body of the child by its shoulder with the aid of the external hand, then flexing the occiput with the fingers passed well over it and following this manipulation by applying the forceps at once to secure the flexion of the occiput anteriorly. The election of high forceps or version must depend somewhat on the dexterity of the operator with the one or the other operation, and especially upon the skill of the assistant which he can obtain. It has been well said that the skill of the assistant in version should be equal to that of the operator. In the German clinics where such assistance is available to express the aftercoming head during ex traction, version is almost invariably preferred to the application of the forceps to the presenting head above the pelvic brim. It is not unusual in England to apply the forceps in such conditions if the cervix is soft and two-thirds dilated with no disproportion between the head and the pelvis. Germany is very conservative in this operation, as her records show an infant mortality of 10 per cent. from high forceps, and the danger to the mother exceeds that of an ordinary abdominal section. The report of the first 1,000 cases delivered at the Johns Hopkins Hospital shows a better result, and is confirmatory of the English practice. If the conjugate at the brim measures 10 cm. or over, the forceps is applied tentatively, and if the head does not descend after two or three tractions, version is performed. There was no mortality from either forceps or version in these cases. The infant mortality after forceps in deformed pelves was 9.52 per cent., and after versions, 26.66 per cent. The latter is much more than the statistics given by Wolff for aseptic cases in which the maternal mortality is half of 1 per cent., and the infant mortality is 12.45 per cent. The application of the forceps at the brim should be made as nearly as possible over the parietal bones, and requires no small degree of skill. It has been well said that high forceps is an operation for the expert, and version for the novice, when the two operations are considered. It is hardly necessary to urge the value of some form of axis traction forceps in preference to the long forceps. The position of the patient may not seem important, if Walchers' position is not used, the writer much prefers to have the patient lie on her left side with the thighs well flexed and the hips over the edge of the bed. Axis traction is thus performed more efficiently, and the head is grasped more readily by the forceps. Walchers' position, which consists in placing the patient in the dorsal position with the hips over the edge of the table and allowing the legs to hang down, is very important for either forceps or the extraction of the head after version, as it increases the anteroposterior diameter of the brim one centimeter on the average. One of the chief objections to the high forceps operation, apart from the fetal mortality, is the injury to the fascial attachments and support of the pelvic organs, independent of perineal laceration, which leads in after life to sagging of the uterus, bladder, and vagina, and to relaxation of the pelvic floor. Mere plastic operations on the cervix and perineum do not repair this kind of an injury which the early application of the high forceps is liable to produce. It is an ordinary clinical experience which should lead us to follow closely the conservatism of the German school. Cases of pronounced albuminuria are notable exceptions to such conservatism. The writer is convinced that when uterine inertia first appears and progress is slow the patient should be delivered if practicable. The extra pain and fatigue from dystocia favor the development of eclampsia. Dystocia in the second stage of labor is often due to poor flexion and imperfect rotation of the head in either occipito-posterior or anterior positions of the vertex. The occipito-posterior positions often rotate forward when the floor of the pelvis is fairly reached and seemingly at the very last part of a prolonged labor. Conservatism seems eminently wise, but some cases must be delivered, and it is worth while to see what can be done by a hand, aided if necessary, by one or both blades of the forceps to flex the head and very carefully to rotate the occiput just anterior to the transverse diameter of the pelvis when the natural forces will complete the rotation. Flexion and rotation are the essentials for success. Push the head up a little to dislodge and flex it. Apply the forceps carefully over the parietal bones and by gentle rotation under the guidance of the hand and, remembering how easy it is for the forceps to slip over the head without turning it, bring the occiput forward and re-apply the forceps for the final delivery of the head. It has been suggested to apply the forceps with the pelvic curve reversed to flex the head by pulling down the occiput, after which the forceps are removed and reapplied with rotation of the head. This should not be attempted except by an expert, and then only as a last resort. Breech cases have been considered unsuitable for the use of forceps, but there are some cases with both legs extended over the body of the child where the ordinary means of delivery fail. A number of such cases have been delivered safely by forceps, and the operation seems justifiable when the child's life is at stake. A forceps should be selected where the tips of the blades do not approximate as closely as with the usual instrument. It is desirable to apply the blades over the trochanters and flexed thighs, rather than on the pelvis of the infant. It may be asked why there should be so much discrepancy in maternity and private practice in the frequency with which forceps is used. It is not fair to ascribe it always to meddlesome midwifery or the convenience of the practitioner. It is more often due to the humanity of the physician who sees his patients recover without |