The following case will show what can be done by taking nature for a guide: On the 14th of November, 1866, a remarkably fine, well-made lady, twenty-five years of age, and just nine months married, took labour at 2 o'clock, a.m. I was sent for, and saw her at 8 o'clock, a.m., at which time the head of the child was well down through the pelvis and nearly rested on the perineum. The head was covered by the still undilated uterus, the os uteri being the size of a two-shilling piece. The vulva was very small, but did not then seem rigid. The pains were natural, the os slowly dilated under their influence, and in another hour, at 9 a.m., it was fully open, and the head distended the perineum at every pain. I looked forward to a speedy delivery, and took my place by the bedside. The head came lower and lower, pushing the distended perineum before it, and at each pain a small portion of a very hairy scalp was protruded through the vulva. In this position I remained from 9 a.m. to 2 o'clock p.m., just five hours, during which time the pains were increasing and more violent, distending the perineum to a frightful extent. I wished to give her chloroform, but she refused to have it. The perineum seemed like a bag into which the head was driven with every inten tion to tear through it. The soft parts over the head from the edge of the anus to the fourchette, measured nearly 3 inches; the anus was distended at every pain, showing fully an inch and half of the interior of the rectum. During the whole of this time there was no further dilatation of the vulva, and no advance of the head forwards; the whole force of the uterus seemed to be directed towards driving the head either through the perineum or through the rectum. It became quite manifest that one or other of these must occur, for there did not appear to be the least chance of the head escaping through the vulva. When matters were in this state at the end of five hours most desperate struggle, I argued with myself, that if nature so often puts an end to such difficulty by the yielding of the fourchette and anterior fibres of the perineum, the best way to rescue my patient from the frightful laceration that was so impending would be to imitate nature, and enlarge the opening of the vulva. Accordingly, seizing the moment when a furious pain, that almost drove the head through everything had subsided, I introduced one blade of a probe-pointed scissors between the perineum and the head, and divided an inch of the soft parts. The very next pain passed the head out through the vulva with the greatest ease, without a single fibre being torn, or the slightest extension of the opening I had made. The recovery was perfect. No treatment beyond ordinary washing was adopted, for the wound, which healed spontaneously, so that the nurse in attendance remarked to me some days after, that I ought to have taken measures to prevent it healing so well, for there would be the same trouble at her next labour. By this simple imitation of what nature so often does I terminated a most difficult and perilous labour 66 without the slightest ill result to the patient. I find, in two recent authors, allusions to an operation similar to that which I have just described. Doctor Hall Davis, in his very excellent work," says :In organic or structural rigidities due to hard cicatrices from former sloughings, sometimes depending upon plastic operations extended too far forward to admit of the exit of the head, these means (chloroform, warm fomentations, unctuous applications, and warm water enemata) may fail. In two cases, last year under my care, such cicatrices were the obstacles, and not yielding to chloroform, in one a rent was inevitable, which, however, left an adequate perineum behind. In the other case, rupture being expected every moment, I summoned the surgeon who had operated, and suggested his making a slight bilateral incision downwards, and outwards to the extent of a quarter of an inch. This sufficed, and the child, living, immediately passed out without any extension of the incisions, which had healed in two days afterwards; thus the perineum was saved." In the last edition of the highly valuable work of Mr. Baker Brown, he observes:-"In cases where rupture seems inevitable during delivery, Dr. Blundell recommended and practised the plan of relieving the tension of the perineum by a slight lateral or oblique incision during a pain, thus actually producing a laceration, but one of no moment, if it serve as intended, to prevent the tear along the median line, where it naturally takes place, and proves of serious consequence. This plan I concur with, and would practise when chloroform failed or could not be administered. MM. Paul Dubois and Chailly-Honoré advocate an oblique incision of the vulva towards the perineum about a third of an inch long, either to prevent altogether the rupture of that region when much distended, or when the laceration is unavoidable, to favour it at a spot where it may produce the least mischief. The writers support their views by the history of successful cases." Since reading the above quotation I have searched through Dr. Blundell's work, and not finding any allusions to the operation in question, I inquired from Mr. Baker Brown, and he has kindly informed me, that he attended Dr. Blundell's lectures, and heard him advocate the proceeding. b I am quite sure that none of the members of the society will imagine that I undervalue the well-known means so advantageously employed to induce relaxation of the perineum and vulva, such as bleeding, antimony, chloroform, warm fomentations, and lubricants, or the protection to be obtained by careful support of the perineum; my object in this communication is to impress upon them, that in extreme cases, such as I have described, after all ordinary means have failed, and frightful injury is impending, a simple operation in imitation of what nature does will avert the danger, and place the patient and her offspring in safety.-12th January, 1867. Parturition and its Difficulties.-P. 13. 1865. On Cephalotripsy. By DR. KIDD. Cephalotripsy, or the breaking down of the bones of the head, previous to extracting it from a narrow pelvis, is spoken of in German, French, and American works on midwifery, as an operation of the greatest usefulness and highest importance, an improvement, in fact, in scientific obstetrics only second in value to the introduction of the forceps, yet in our standard English works it is ignored entirely, or spoken of as an operation that could not, and has not, been attempted in this country. This repudiation of the operation may be traced to two causes—the formidable appearance of the instrument first recommended for its performance; and the mistaken idea that it should serve as a substitute for perforation of the head and evacuation of its contents, instead of these being essential stages in the operation. We are indebted to Sir James Simpson for a great improvement in the construction of the instrument; and though he has not published any account of it, so far as I am aware, I know from personal communication that he uses it in all the suitable cases he meets with, and that it is daily growing more and more in favour with him. It appears also from the records of the London Obstetrical Society that Braxton Hicks, Greenhalgh, Graily Hewitt, and others, are beginning to adopt it in their practice. I have myself had Sir James Simpson's cephalotribe for some time, and used it in such cases as required it, and am convinced of the correctness of the principle on which the modern operation of cephalotripsy is founded, and of the suitableness of the instrument we now possess for its performance, and I bring the subject before the Obstetrical Society because I think it full time that the merits of the operation should be fully discussed in a society that so fairly represents the Irish school of midwifery. The earliest cephalotribe known to us was invented by Assalini, and described in a work published at Milan in 1811; but till Baudelocque, nephew of the celebrated accoucheur of the same name, invented his instrument in 1833, the operation of cephalotripsy seems to have been but little practised. Since then the value attached to the suggestion has been evidenced by the very many attempts to improve the instrument. At the Exhibition of the London Obstetrical Society last year the following seventeen different forms of it were exhibited, besides three varieties of chain-saw forceps, an instrument that may fairly be classed with it; and Hodge's, and probable other forms were not represented :-Assalini, of Milan; Lazarewitch, of Charkoff; Baudelocque, Paris; Baudelocque, by Luer; Depaul, Paris; Depaul, by Charrière; Etlinger and Hugenberger, St. Petersburg; Martin, Berlin; Braun, Vienna; Nyrop, Copenhagen; Cohen, Hamburg; Rizzoli, Bologna; Hennig, Leipzig; Scanzoni, Würzburg; Killian, Bonn; Sir James Simpson, Edinburgh; Schöller. And of chain saw forceps:-Van Huevel, Brussels; Faye and Mette, Christiania; Lazatti Milan. The accouchers of repute who have advocated the use of the instrument are very numerous. I may mention Chailly, Cazeaux, Dubois, Leynseele, Scanzoni, Killian, Crédé, Kiwisch, Hodge, Bedford, and Pajot. Chailly says it has completely banished from obstetric practice crotchets and craniotomy forceps, and all such hooks and pincers. Dr. Hodge, Emeritus Professor of Obstetrics in the University of Pennsylvania, in his great quarto volume on the principles and practice of obstetrics, describes the introduction of the cephalotribe as an improvement in scientific obstetrics only second in importance to that of the forceps. In speaking of the dangers of craniotomy, he says: "The slightest consideration of the modus operandi of crochets, pincers, craniotomy forceps, and other varieties of tractors, demonstrates that they act not directly, but indirectly, in accomplishing the diminution of the head of the child, so that it may pass through the contracted passages. The head is in reality lessened-not by the tractors, but by the bones and soft tissues of the mother; for it is dragged through, for example, the superior strait of the pelvis, and this is the real agent which diminishes the head. The bony strait is covered by delicate and important tissues, such as the edges of the uterus, the vagina, bladder, &c. Hence such tissues are powerfully compressed between the bones on one side, and the head upon the other, greatly endangering their integrity and safety. The greater, therefore, the contraction the greater will be the risk to the tissues. No wonder then that there is danger of contusion, laceration, inflammation, ulceration, and mortification of these tissues in bad craniotomy cases. Hence accoucheurs have always dreaded craniotomy operations in confined pelves, as they have too often proved fatal, not only to the integrity of the bladder, rectum, and other tissues of the pelvis, but also to the life of the mother." The principle of cephalotripsy, according to Dr. Hodge, is that the head of the child should be reduced in size, by compressors, and not by the tissues of the parent, as in all the usual operations by the crotchet and craniotomy forceps:-"The importance of the principle now inculcated can hardly," he says, "be over estimated. Next to the introduction of the forceps into modern practice, the idea, when the preservation of the child's life is hopeless, of diminishing the size of the head by compressors, instead of dragging it through the contracted outlets of the body by mere force, to the great detriment and often destruction of the mother's tissues, seems one of the most important improvements in scientific obstetrics." Scanzoni, in his work, advocates the operation not less warmly. In the section on the influence of perforation on the life and health of the mother, he states that the fatality of the operation and the sad results VOL. XLIII., No. 85, n. s. that so frequently follow it, are not due to the perforation, but are the results of the efforts necessary for the extraction of the perforated head. We are convinced, he says, that the results will be more satisfactory for the future if a suitable perforator (he recommends a trepan) be used, and the extraction be made with a properly constructed cephalotribe. He further speaks of the usefulness of the cephalotribe for diminishing the head and extracting it; and in a section devoted to a description of the instrument, gives the following rules for its use: "1. The cephalotribe is necessary when, after perforation, the head is not expelled (the necessity for previous perforation was already insisted on). "2. Recourse should be had to the cephalotribe without previous perforation (which would then be impossible) when, the infant being dead, the inferior members and trunk have been expelled and the forceps cannot be applied to the head, which is above the superior strait, or in the pelvis, and cannot be extracted by manual efforts. By means of the cephalotribe the head can be seized firmly, reduced in volume, and delivered promptly without injury to the mother. "3. It may be used to extract the head when it has been separated from the trunk, and is engaged in the pelvis. "4. This instrument may be employed under the following circumstances to seize different parts of a dead fetus :— "a. To extract the breach of a dead child when there is a difficulty "b. To compress and extract the shoulder when it is delayed after "Conditions of operation : "1. It is necessary that the pelvis should have dimensions sufficient to allow the broken fetus to pass when we wish to extract with the cephalotribe. If it be less than Om-068 (2·69 English inches) in its shortest diameter the operation cannot be performed without exposing the mother to grave risks, if the child be mature, and no accoucheur |
