The Axis Traction Forceps. 
A PAPER READ BEFORE THE SOCIETY 
APRIL 17, 1895. 
DR. MARIS GIBSON, 
BY 
OF WILKES-BARRE, PA. 
[Reprinted from the Transactions oj the, Luzerne County Medical Society.] THE AXIS TRACTION FORCEPS. 
" But if all these medicines profit not, there must be used 
more severe and hard remedies, with instruments, as hooks, 
tongs, and such other things made for the nonce. And first, 
the woman must be laid along upright, the middle part of her 
body lying higher than all the rest, accompanied with women 
assisting her about, to comfort her and keep her down, that 
when the birth is plucked out she rise not withal. Then let 
the midwife anoint her left hand with the oil of white lilies or 
other that may make it souple and smoothe, and holding out 
her fingers, shutting together her hand, let her put it into the 
matrix to feel and perceive after what fashion the dead birth 
lyeth in the mother's womb, so that she may the better put 
in hooks and such other instruments to pluck it out withal." 
This selection is from the quaint old book of Thomas Rainaid, 
called " The Woman's Book, or the birth of Mankind," pub- 
lished in England in 1565, being the first English book on 
midwifery of which we have any knowledge. 
The practice of midwifery commenced in the earliest days of 
the human race, arising, as other branches of medical and sur- 
gical matters, from the needs of the people. Progress was, 
however, very slow. Hippocrates had an instrument, or more 
than one, for the purpose of assisting in difficult cases of labor, 
merely to extract the child without any reference to saving its 
life, and Galen describes something of the same kind. Rhazes, 
the Arabian, makes some reference to the use of the fillet in 
the 10th century, and Avicenna, one hundred years later, men- 
tioned the forceps by name, but his forceps had blades contain- 
ing teeth to take hold of the foetal head. 
The first forceps made anything like those we have now, 
was that of the Chamberlains, made in 1650, or about that 
time. This was a crude form of the short forceps with straight 
blades, having only the cephalic curve. From this has come, 
in a direct line, the whole vast multitude of obstetric forceps, 
some few of which have become famous, but the most only 2 
known to a small circle of the friends of the inventor, a few 
even never having passed the stage of drawing on paper. 
" Pajot once observed that he does not reproach a man for 
having invented a forceps, for that might happen to any one." 
The forceps of Chamberlain was practically the one form used 
for about one hundred years. They were different, but alike 
in having but one curve, and being short and straight. It 
could be used only when the head had descended to the pelvic 
cavity. About 1752 Levret, probably first, and Smellie soon 
after, added the pelvic curve. The present lock, such as the 
Simpson forceps has, was probably made before the time of 
Smellie, though Simpson calls it Smellie's lock. Tyler Smith 
says the lock was Chapman's. About this time the forceps 
were made longer, so that, with the added curve, it could be 
used under all suitable conditions of labor. The French 
forceps were from the first made longer and heavier, and 
much stronger than the English, and was a really formidable 
looking instrument. One of them described in Ramsbotham's 
book was inches long and weighed 2 pounds and 5 
ounces. 
For more than another hundred years this was all the essen- 
tial change made in the forceps. There were changes many 
and various, and improvements, but they were essentially the 
same forceps, having the two curves, pelvic and cephalic. 
Out of this the Simpson forceps were evolved, which he said 
had the Ramsbotham blades, which were essentially Smellie's, 
the Smellie lock, the Naegle handles,and his own longer shanks. 
And the Davis forceps, with blades carefully calculated to 
nicely fit the sides of the foetal head. And our own Hodge, 
who taught so eloquently the " Mechanism of Labor." How 
" the irregular convexities of the head fitted themselves to the 
irregular concavities of the pelvis, so that the more difficult 
the labor the nearer will be the approximation of the different 
circles and planes of the cranium to the planes of the canal 
through which it has to pass." And many others, that are 
mostly combinations, in different forms, of different parts of 
some others. But to-day a competent man would not be very 
badly off, in a usual forceps case, if he had with him a good 3 
Smellie forceps. He would be much better equipped than Dr. 
W. C. Blackman was, who practices in *Davidson county, Tenn., 
who says, in the Medical Record, that, being far from home 
and having no instruments with him, he delivered two cases 
with a shoemaker's forceps, and both mothers and children 
lived and did well. The worst thing about the Smellie for- 
ceps was that they were covered with leather, and certainly 
could not be made aseptic. But this was a time when it was 
a usual custom to cover the blades with some kind of soft 
leather or gutta percha. Ramsbotham discusses this practice 
and says: "It was the old fashion to cover each blade entirely 
with leather, that it might be less formidable to sight; that in 
locking it little noise would be made; that it might be softer 
to the woman's person and not so likely to do injury." This 
practice was, in his opinion, objectionable on many grounds. 
It takes up room, and is not so easily applied, and, more than 
all, " it has been supposed that infection, the virus of syphilis 
or gonorrhoea for example, has been carried from a diseased to 
a healthy person." He suggests that " if such a sad accident 
could be possible, the coating should be abandoned or changed 
every time it is used." 
He says, further, the only coating I would admit is one of 
gum elastic or silver wash. He quotes from Wallace Johnson 
(new system of Midwifery, 1769), who says: "If the instru- 
ment is covered with wash leather, humors which are infectious 
may be absorbed and conveyed from one patient to another." 
He recommends that morocco leather be substituted. He 
adds : "Indeed, danger may arise from this also, if care be not 
taken to wash them very clean with soap and water after every 
time that they are used. Nay, rather than neglect this I could 
wish them not to be covered at all." Ramsbotham says, in a 
foot note, that Simpson's forceps are coated with gum elastic, 
which is not liable to the same objections as a coating of 
leather. All this may seem strange to us, who live in this 
aseptic age, but it was many a long year after that when sponge 
tents were used to dilate the cervix and pieces of sponge to 
tampon the vagina. 
Chapman, who wrote the first description of the forceps, 4 
calls it "a noble instrument," and Smellie was the most noted 
champion of it; but when Bard came to write his book, the 
first treatise on midwifery in the United States, while he quoted 
many other writers, he made no mention of Smellie's teaching 
only to say that he considered him a dangerous man and his 
teachings unsafe. I have read somewhere of a physician who 
said he liked to see a doctor show a rusty forceps, for that 
proved that he did not often use them. Blundell says, quoted by 
Dewees, " I do not like to see an elegant pair of forceps. Let 
the instrument look like what it is, a formidable weapon, 
Arte non vi may be usefully engraved on one blade and cave 
perineo on the other." 
The next change in the forceps is the present, the axis 
traction era, and the essential thing added to the forceps by 
this is, in some form or other, the perineal curve, so that 
traction can be made in the line of the pelvic axis. This is 
accomplished either by having the handles bent so as to clear 
the perineum when traction is made in the pelvic axis, or by 
tractions rods attached somewhere to the forceps, for the same 
purpose. Herman had traction rods in 1840; Hubert had 
traction rods in i860; Morales made a perineal curve in 1868, 
and the same year Aveling brought out his sigmoid-shaped 
forceps. But nothing much came of any of these until Tar- 
nier presented his instrument in 1877. Since that time the 
subject has been much discussed, and several physicians have 
essayed to devise axis traction forceps. Of some of these I 
have only- been able to find the name in the instrument maker's 
catalogue. That is all I know about Howard's Tarnier in 
Ford's catalogue, Braun's triform, Corning's and Burges' for- 
ceps in Tiemann's catalogue. Galabin of London, Knox of 
Chicago, and Dewees of Kansas made longer handles and a 
perineal curve like Aveling's sigmoid forceps. 
Wells and Maher of New York, Briggs of California, Dewees 
of Kansas, Steavenson of Scotland, all have traction rods 
drawing from the lock. Prendergast of Philadelphia and 
Reynolds of Boston have loose traction rods drawing from the 
fenestraae. The Breus and the McFerran have a hinge in the 
blade; the Breus having traction rods drawing from the hinge 5 
about midway of the blades. Langstaff of New York has a 
Simpson forceps with a flat metal plate, five or six inches in 
diameter, and chain fast to it. He places the plate under the 
sacrum of the patient and throws the chain over the forceps at 
the lock after it is applied, and it does for him just what the 
Smith and Pajot movements do with the ordinary forceps. It 
exerts a downward force between the head of the child and 
the hands of the operator, and so draws the head away from 
the pubic bone. The McGillicuddy of New York, Fisher of 
Salt Lake City, and Grattan of England, have handles like the 
old Hubert forceps. The McGillicuddy has a Simpson forceps 
with traction handles that fit to the end of the handles of the 
forceps; the Fisher, a bar that fits over the lock ; and in the 
Grattan the handles of the forceps are jointed near the lock, so 
that they bend down. The Jewett, Milne-Murray, Lusk, Cul- 
lingworth, Simpson and Poullet have the traction principle 
like the Tarnier's. 
Looking over what has been done in this field, and reading 
the different papers and discussions that I have had access to, 
this conclusion is reached: That the axis traction principle is 
correct; that it is an event in the development of the forceps 
like the cranial curve of Chamberlain and the pelvic curve of 
Levret and Smellie; but that the earlier ones were heavy and 
complicated and unmanageable, and the later ones are in the 
line of advance and improvement. 
I have arranged in classes the different forms mentioned. 
1. The sigmoid of Aveling. 
2. Traction rods drawing from the lock. 
3. Traction rods drawing from the fenestrae. 
4. The hinged blades. 
5. The plate and chain of Langstaff. 
6. The traction bars of Hubert. 7. The Tarnier class. 
I would eliminate at once the 1st, 4th and 5 th, as not com- 
ing up to the requirements of the work. However, Doctors 
Barnes, Robert and Fancourt, in their book, consider the 
Aveling to be as satisfactory as the Tarnier. 
The 2d, 3d and 6th are practically alike in their action. They 
are simple, easily applied, and cheap-all good qualities. The 6 
loose traction rods can be applied to any forceps. Maher, 
however, has applied his to the Simpson, and has changed the 
handles and made them much more elaborate. Of those 
having traction bars like the McGillicuddy, when the bars are 
removed there is left an ordinary forceps; so in using any of 
these only one forceps would be necessary. Dr. Maher's 
traction rod is worked out on mathematical principles, and he 
makes strong claims for its efficiency, but not more that Dr. 
McGillicuddy does for his. 
Now, we have left only those of the Tarnier type, and these 
carry out the axis traction idea more fully than any of the 
others. Maher argues that there is no need to have four shanks 
passing into and through the vagina, which occurs in the Tar- 
nier instrument, but there is certainly a difference between 
drawing on rods attached at or near the centre of the head in 
the axis of the pelvis, and drawing on bars at the ends of the 
handles or attached to the lock, and the use of the handles as 
an indicator of the position of the head is certainly of much 
account. Maher calls his the ideal forceps, and it will un- 
doubtedly do good work. And Prof. Keiller, describing the 
Milne-Murray instrument, calls it the ideal tractor; but what 
is an ideal tractor ? Suppose we have a normal pelvic canal, 
and a normal head ready to engage at the brim, and normal 
maternal forces to drive it along. The head will enter the 
canal, and be propelled along the way, changed in its course 
by its own form and that of the canal. It will be extended 
and flexed, advance and draw back, rotate on and on, changing 
its direction at every point of the way, because the canal 
changes, until at last it rolls out of the vulva, and nothing has 
occurred that is not strictly natural and physiological. But 
suppose it is arrested at the brim or anywhere else, because 
either the forces are deficient, or the head is slightly too large, 
or the passage slightly too small, what shall we do ? Why, 
just supplement the deficient forces, or add to them enough to 
overcome the difficulty, and not to change any other condition; 
not to change the direction, nor the rate of its movements. If 
we could take hold of it with our hands we would soon feel, 
almost by intuition, how to exert the necessary force. Again, 7 
if we could put about it a network of some material, like the 
silken net of a balloon, with a strong cord at its center, and 
then could draw in the axis of the pelvis, which, at the brim, 
is in a line falling from the umbilicus to the point of the 
coccyx, and changes at every point till, at the vulva, it is at 
right angles to this line, we could easily supplement the natu- 
ral forces, and accomplish delivery. But these things we can- 
not do. If we can, however, place on the head the blades of a 
forceps and attach to them traction rods, so placed that in use 
of them the head would not be changed in its relation to the 
pelvis, except its own natural advance; would be neither flexed 
nor extended, would be entirely free to rotate naturally, and 
only be drawn along in its correct line of advance until it was 
delivered, that would be ideal axis traction, and the forceps 
that would do that the most easily, with none at all or the 
least injury to the maternal or foetal tissues, and having the 
fewest complications, and that could the most easily be made 
aseptic-that would be the best forceps. And the Tarnier prin- 
ciple does that more fully than any other. But taking, as it 
does, the character of French forceps from the days of Bau- 
dalocque, the Tarnier forceps is heavy and complicated and 
unmanageable, and some of its modifications are preferable. 
The best of these are the Simpson, which is the classical 
forceps of Sir James Y. Simpson, with traction rods added by 
Prof. Alexander R. Simpson, the Milne-Murray modification 
of the Simpson, and the Jewett modification of the Murray. 
Prof. Lusk's modification of the Tarnier is equally good. He 
recommends his in all high operations, in cases of occipito 
posterior, and in breech cases. 
Prof. Jewett's practice is to draw down the head with the 
axis traction forceps, and finish with the others. He has de- 
livered with the Simpson, and also with the Murray, and in 
those cases has been unfortunate enough to have a ruptured 
perineum. He, however, does not charge this to the forceps, 
for he says that certain perinei will rupture under any treat - 
ment, and with this I think we will all agree. He says, fur- 
ther, "In my experience, without episiotomy, lacerations at the 
vaginal orifice occur in 15 to 20 per cent, of first labors in 8 
spite of all other precautions with or without forceps. The 
Drs. Barnes consider the A. R. Simpson and the Lusk the 
most notable modifications of the Tarnier. They say: " We 
have used Simpson's, which the professor lengthened at our 
suggestion, and find it to work well. But we are unable to 
find any definite improvement upon Tarnier's last model. 
Prof. Lusk says the A. R. Simpson forceps are valuable when 
the head is in the pelvic cavity, but when it is at or above 
the brim he uses the Tarnier model with a perineal curve. Prof. 
Leishman says that while Tarnier was working at his idea of 
axis traction, from 1877 to 1879, he made no less than thirty 
different modifications of the instrument. 
Herman, in his book, "Difficult Labor," London, 1894, after 
describing this forceps, and speaking of its uses and advan- 
tages, says that "its defects are, first, its complexity, the num- 
ber of joints and crevices in which dirt may lurk, and hence 
greater difficulty in keeping them clean ; second, the continued 
compression of the head while it is applied. If forceps were 
often required when the head was above the brim, the advan- 
tages would outweigh the defects. But in nineteen cases out 
of twenty in which forceps are required, the head is in the pelvic 
cavity, and the ordinary forceps will do just as well as the axis 
traction. In most cases in which assistance is needed while 
the head is above the brim, turning is better than any forceps." 
The most enthusiastic followers of Tarnier's idea are the Ed- 
inburgh School, and I shall refer here to a paper* written by 
Prof. Keiller, of Galveston, Texas, an Edinburgh graduate. 
Speaking of Tarnier, he says: " Like all innovations of suffi- 
cient importance to attract general attention, his ideas met 
with much opposition and some ridicule; but, nevertheless, 
the principle of axis traction forceps on the true Tarnier lines 
is now acknowledged by the most advanced teachers to be the 
true principle, and this the only scientific instrument applicable 
to high and even low forceps operations, so much so that no 
Edinburgh specialist carries any forceps in his bag but some 
form of the Simpson-Tarnier type, and few recent Edinburgh 
graduates think of buying any other form of instrument." 
♦American Journal of Obstetrics, April, 1893.