which the obstruction is not great, and only a comparatively slight diminution in the size of the head is required, cephalotripsy is infinitely the easier operation. The facility with which the skull can be crushed is sometimes remarkable, and those who will take the trouble to read the reports of the operation published by Braxton Hicks, Kidd, and others, cannot fail to be struck with the rapidity with which the broken-down head may often be extracted. This is far from being the case with the craniotomy forceps, even when the obstruction is moderate only; for it may be necessary to use considerable traction, or the blades may take a proper grasp with difficulty, or it may be essential to break down and remove a considerable portion of the vault of the cranium before the head is lessened sufficiently to pass. During the latter process, however carefully performed, there is a certain risk of injuring the maternal structures, and, in the hands of a nervous or inexperienced operator, this danger, which is entirely avoided in cephalotripsy, is far from slight. The passage of the blades of the cephalotribe is by no means difficult, and I think it must be admitted that the possible risks attending it are comparatively small. On account, therefore, of its simplicity and safety to the maternal structures, I believe cephalotripsy to be decidedly the preferable operation in all cases of moderate obstruction.

When we approach the lower limit, and have to do with a very marked amount of pelvic deformity, the two operations stand on a more equal footing. Then the deformity may be so great as to render it difficult to pass the blades of even the smallest cephalotribe sufficiently deep to grasp the head firmly, and even when they are passed, the space is often so limited as to impede the easy working of the instrument. Besides this, repeated crushings may be required to diminish the skull sufficiently. I attach but little importance to the argument that the diminution of the skull in one diameter increases its bulk in another. The necessity of removing and replacing the blades on another part of the skull, and of repeating this perhaps several times, in the manner recommended by Pajot, is a far more serious objection. To do this in a contracted pelvis involves, of necessity, the risk of much contusion. Fortunately cases of this kind are of extreme rarity, much more so than is generally believed, but when they do occur they tax the resources of the practitioner to the utmost.

On the whole, the conclusion I would be inclined to arrive at with regard to the two operations is, that in all ordinary cases cephalotripsy is safer and easier, whereas in cases with considerable pelvic deformity, the advantages of cephalotripsy are not so well marked, and craniotomy may even prove to be preferable.

The first step in using the cephalotribe is the passage of the blades. These are to be inserted in precisely the same manner, and with the same precautions, as in the high forceps operation. In many cases the os is not fully dilated, and it is absolutely essential to pass the instrument within it. Special care should, therefore, be taken to avoid any injury to its edges, and, for this purpose, two or three fingers of the left hand, or even the whole hand, should be passed high up, so as thoroughly to protect the maternal structures. In order that the base of the skull

FIG. 196.

may be reached and effectually crushed, the blades must be deeply inserted, and, in doing this, great care and gentleness must be used. As the projecting promontory of the sacrum generally tilts the head forward, the handles of the instrument, after locking, must be well pressed backward toward the perineum. If the blades do not lock easily, or if any obstruction to their passage be experienced, one of them must be withdrawn and reintroduced, just as in a forceps operation. Care must be taken, as the instrument is being inserted, to fix and steady the head by abdominal pressure, since it is generally far above the brim and would readily recede if this precaution were neglected. When the blades are in situ, we proceed to crush by turning the screw slowly, and as the blades are approximated the bones yield and the cephalotribe sinks into the cranium. The crushed portion then measures, of course, no more than the thickness of the blades, that is, about one and one-half inches. This is necessarily accompanied by some bulging of the part of the cranium that is not within the grasp of the instrument (Fig. 196), but in slight deformity this is of no consequence and we may proceed to extraction, waiting, if possible, for a pain, and drawing at first downward in the axis of the pelvic inlet, as in forceps delivery, then in the axis of the outlet. The site of perforation should be examined to see that no spicule of bone are projecting from it, and if so they should be carefully removed. In such cases the head often descends at once, and with the greatest ease. Should it not do so, or should the obstruction be considerable, a quarter turn should be given to the handles. of the instrument, so as to bring the crushed portion into the narrower diameter and the uncrushed portion into the wider transverse diameter. It may now be advisable to remove the blades carefully, and to reintroduce them with the same precautions so as to crush the unbroken portion of the skull. This adds materially to the difficulties of the case, since the blades have a tendency to fall into the deep channel already made in the cranium, and so it is by no means always easy to seize the skull in a new direction. Before reapplying them, if the condition of the patient be good and pains be present, it may be well to wait an hour or more, in the hope of the head being moulded and pushed down into the pelvic cavity. This was the plan adopted by Dubois, and, according to Tarnier, was the secret of his great success in the operation. Pajot's method of repeated crushings, in the greater degrees of contrac

Foetal head crushed by the cephalotribe.

tion, is based on the same idea, and he recommends that the instrument should be introduced at intervals of two, three, or four hours, according to the state of the patient, until the head is thoroughly crushed; no attempts at traction being used, and expulsion being left to the natural powers. This, he says, should always be done when the contraction is below two and one-half inches, and he maintains that it is quite possible to effect delivery by this means when there is only one and one-half inches in the antero-posterior diameter. The repeated introduction of the blades in this fashion must necessarily be hazardous, except in the hands of a very skilful operator; and I believe that if a second application fail to overcome the difficulty, which will only be very exceptionally the case, it would be better to resort to the measures presently to be described.

FIG. 197.

Prof. Alex. R. Simpson, of Edinburgh,1 has suggested the use of an instrument which he calls a "basilyst." Its object is to break up the base of the foetal skull from within, after the method. originally proposed by Guyon. The screw-like portion of the instrument (Fig. 197), which is inserted through the perforation made in the cranial vault, is driven through the hard base, which is then disintegrated by the separate movable blade. If experience proves that this instrument can be readily worked, it promises to be a valuable addition to our armamentarium, since it will effectually destroy the most resistant portion of the skull, without risk of injury to the maternal structures, and thus very materially facilitate extraction.

Prof. A. R. Simp

son's basilyst.

Extraction by the Craniotomy Forceps.-Should we elect to trust to the craniotomy forceps for extraction, one blade is to be introduced through the perforation, and the other, placed in opposition to it, on the outside of the scalp. In moderate deformities, traction applied during the pains may of itself suffice to bring down the head. Should the obstruction be too great to admit of this, it is necessary to break down and remove the vault of the cranium. For this purpose Simpson's cranioclast answers better than any other instrument. One of the blades is passed within the cranium, the other, if possible, between the scalp and the skull, and the portion of bone grasped between them is broken off; this can generally be accomplished by a twisting motion of the wrist, without using much force. The separated portion of bone is then extracted, the greatest care being taken to guard the maternal structures, during its removal, by the fingers of the left hand. The instrument is then applied to a fresh part of the skull, and the same process repeated until as much of the vault of the cranium as may be necessary is broken up and removed.

2

Dr. Braxton Hicks has conclusively shown that in difficult cases, after the removal of the cranial vault, the proper procedure is to bring down the face, since the smallest measurement of the skull after the 2 Obst. Trans., 1867, vol. vii. p. 57.

Edin. Med. Journ, vol. 1879-80, p. 865.

removal of the upper part of the cranium is from the orbital ridge to the alveolar edge of the superior maxillary bone. This alteration in the presentation he proposes to effect by a small blunt hook made for the purpose, which is forced into the orbit, by means of which the face is made to descend. Barnes recommends that this should be done by fixing the craniotomy forceps over the forehead and face, and making traction in a backward direction, so as to get the face past the projecting promontory of the sacrum. The importance of bringing down the face was long ago pointed out by Burns, but it had been lost sight of until Hicks again drew attention to it in the paper referred to. In the class of cases in which this procedure is valuable, the risk to the maternal passages, from the removal of the fractured portions of bone, must always be considerable, and it is of great importance not only to preserve the scalp as entire as possible, so as to protect them, but to use the utmost possible care in removing the broken pieces of bone.

Extraction of the Body.—When the extraction of the head has been effected, either by the cephalotribe or the craniotomy forceps, there is seldom much difficulty with the body. By traction on the head one of the axillæ can easily be brought within reach, and if the body does not readily pass, the blunt hook should be introduced and traction made until the shoulder is delivered. The same can then be done with the other arm. If there be still difficulty, the cephalotribe may be used to crush the thorax. The body is, however, so compressible that this is rarely required.

[FIG. 198.

[FIG. 199.

Straight craniotomy forceps.]

Curved craniotomy forceps.]

[The craniotomy forceps chiefly in use with us were devised by the late Prof. Charles D. Meigs for his second operation upon Mrs. Reybold, of Philadelphia, in 1833, and have been used repeatedly since, either as tractors or for reducing the size of the foetal head, in cases of

deformity of the pelvis. Some obstetricians prefer the less curved and broader-bladed instrument of Great Britain as a tractor; but for the general purposes of picking away the cranial bones and drawing down the base of the skull in cases of extreme pelvic deformity there is no more simple appliance than that of Dr. Meigs.

To act upon an oval body like the foetal head, Dr. M. was obliged to prepare two forms of forceps-straight and curved-to be used as might be required according to the part of the skull to be broken down or drawn upon. These are lightly made, serrated, and twelve and a half inches in length.—ED.]

Embryotomy.-There only remains for us to consider the second class of destructive operations. These may be necessary in longneglected cases of arm presentation, in which turning is found to be impracticable. Here, fortunately, the question of killing the foetus does not arise, since it will, almost necessarily, have already perished from the continuous pressure. We have two operations to select from, decapitation and evisceration. [And a third, the improved Cæsarean section.-ED.]

The former of these is an operation of great antiquity, having been fully described by Celsus. It consists in severing the neck, so as to separate the head from the body; the body is then withdrawn by means of the protruded arm, leaving the head in utero to be subsequently dealt with. If the neck can be reached without great difficulty -and, in the majority of cases, the shoulder is sufficiently pressed down into the pelvis to render this quite possible-there can be no doubt that it is much the simpler and safer operation.

The whole question rests on the possibility of dividing the neck. For this purpose many instruments have been invented. The one generally recommended in this country is known as Ramsbotham's hook, and consists of a sharply curved hook with an internal cutting edge. This is guided over the neck, which is divided by a sawing motion. There is often considerable difficulty in placing the instrument over the neck, although, if this were done, it would doubtless answer well. Others have invented instruments, based on the principle of the apparatus for plugging the nostrils, by means of which a spring is passed round the neck, and to the extremity of the spring a short cord, or the chain of an écraseur, is attached; the spring is then withdrawn and brings the chain or cord into position. The objection to any of these apparatus is, that they are unlikely to be at hand when required, for few practitioners provide themselves with costly instruments which they may never require. It is of importance, therefore, that we should have at our command some means of dividing the neck which are available in the absence of any of these contrivances. Dubois recommended for this purpose a strong pair of blunt scissors. The neck is brought as low as possible by traction on the prolapsed arm, and the blades of the scissors guided carefully up to it. By a series of cautious snipping movements it is then completely divided from below upward. This, if the neck be readily within reach, can

The illustrations given are taken from the instruments devised by Dr. Meigs as an improvement upon his original pattern, and will be seen to differ from those usually presented in American obstetrical publications.-ED.]