1. Indications from the Side of the Mother.—Pelvic Deformity.
a. Pelves of 3.9 to 3 inches.—The operation is only exceptionally called for, since forceps and version ordinarily suffice for delivery. In case the infant is dead, however, it is preferable to resort to the cephalotribe, since thus the mother is spared the risk of energetic tractions.
b. Pelves of 3.3 to 2.7 inches.—First try the forceps, then the perforator and Bailly's cephalotribe.
In this instance the cephalotribe gives fairly satisfactory results.
c. Pelves of 2.34 to 1.93 inches.—The forceps has little chance of suc cess. With the cephalotribe Stanesco, in 18 cases, had a mortality of 22.22 per cent.
d. Pelves of at least 2.5 inches.—Authorities differ as to the choice of methods. It is our opinion that the cephalotribe should be used as long as it will pass. Stanesco gives the following figures: Pelves from 2.5 to 2.15 inches, mortality 41.17 per cent.; pelves of 2.15 inches, 3 cases with 3 recoveries. Maygrier gives the following figures: As was to be expected, the mortality rate increases with the degree of contraction, as also the difficulty of the operation. To obviate this Pajot proposed repeated cephalotripsy without traction. In reference to this operation, he says: " Struck by the numerous failures of cephalotripsy in exaggerated pelvic contractions, remembering the deplorable consequences for the women of the use of excessive force, and objecting to the Caesarean section practised from choice and not from necessity, I have proposed a new method under the name of repeated cephalotripsy without traction.' After the skull has been perforated, the first application of the cephalo tribe should be made as early as possible, with the usual precautions. After crushing the head, I endeavor to turn it by means of the instrument, so as to place the diminished diameter in the contracted portion of the pelvis. If this rotation cannot be made with ease I abstain, for experience has taught me that the uterus itself will usually mold the diminished head and rotate it, with less risk of injury than by artificial rotation. The instrument is to be withdrawn without making any attempt at traction whatsoever; it is reapplied a second and a third time, the head again crushed, and after each crushing the instrument is withdrawn, always without traction. The woman is placed in bed, and according to her general condition and the uterine contractions, I repeat these multiple crushings every two, three, or four hours. When the head has been com - pletely crushed, the trunk ordinarily presents obstacles which necessitate one to two crushings. By this method I have had six successes in eight
cases, in the presence of extreme pelvic deformity, where many accoucheurs would have resorted to the Caesarean section." e. Pelves contracted at the Inferior Strait or an the Excavation, by Tumors, Exostoses, Spondylizeina, Spondylolisthesis.—It is impossible to fix exact limits. Everything depends on the degree of contraction. The same holds true of fibrous tumors, osteo-sarcomata, etc.
2. Indications from the Side of the Reins.
Such are excess of volume of the head, advanced ossification of the skull, complicated or irregular presentations, in particular those of the face, fatal monstrosities, the death of the foetus, etc.
As for the contra-indications to cephalotripsy, we know of but one, and this is the opposition of the mother. In such an instance we must either let the woman die undelivered, or else resort to the Cesarean section.
The operation is performed in four stages: 1. Insertion of the blades. 2. Locking of the blades. 3. Crushing of the head. 4. Extraction, where Pajot's method is not followed.
• Introduction of the Blades.—The woman having been anesthetized and placed in the obstetrical position, the head, perforated or not, (it is our practice always to precede cephalotripsy by perforation), is to be steadied at the superior strait by an assistant. The blades are to be inserted so as to grasp the head firmly by its base, in order to crush it at its most resisting part. The blades, hence, are usually applied at the sides of the pelvis, and usually, indeed, this is the only way the cephalotribe may be employed, since the pelvic contraction is ordinarily in the antero-posterior diameter of the superior strait, and the greatest space exists at the extremi ties of the transverse diameter of the pelvis. The rule in a nut-shell, however, is to grasp the head how and where we can, remembering always that the cephalotribe is a thicker and more massive instrument than the forceps, and that the space in which it must work is very limited. Patience and gentleness, therefore, must characterize the insertion of the blades. Down to 2.34 inches Bailly's cephalotribe may be used, and this instru ment being scarcely at all different from a strong forceps with narrow blades, the insertion is very much simplified; but below 2.34 inches we are obliged to use Depaul's instrument, or that of Blot or Tarnier, where the blades are narrow, and therefore it is not so easy to grasp the head. Whatever instrument is used, it must be inserted deeply, so as to seize the base of the skull well, and often the lock will he in the vagina.