I. PERFORATION.
This is the most ancient of all methods for reducing the size of the head, and it consists in the artificial opening of the vault of the skull, in order to give exit to the brain, in addition, exceptionally, to the removal of pieces of the bone. Innumerable instruments have been devised for the purpose. Sadler and Levy have given a succinct description of all. We will note here simply the most important.
a. Cutting Perforators.—Those devised by Hippocrates, Albucasis, Paii, Guillemeau, Mauriceau, Roederer, Stark, Wigand, Waller, and others. These are to-day practically all rejected.
b. Scissor Perforators. —Those of Bing, Wallbaum, Smellie (Figs. 133 and 134.) Naegel6 (Fig. 135), Levret, Stein, Denman, Brunninghausen, Siebold, Basch, Simpson, Oldham, Greenhalg, Blot (Figs. 137 and 138), etc. The last is decidedly the best, particularly since it is absolutely harmless to the mother and the accoucheur.
c. Trephine of Joerg, Mende, Ritgen, Kilian, Leissnig (Fig. 136), Braun, Martin, etc.
As we have said, the best instrument is Blot's. It is composed of two blades. When closed the dull edge of each covers the sharp edge of its fellow. By pressure at D the blades open like Smellie's scissors.
The indications for resort to perforation, are: 1. The Fcetus is is indicated whenever the dispro portion between the head and the pelvis renders spontaneous delivery difficult, in particular where, if the forceps is used, damage to the ma ternal parts might result.
2. The Fcolus is living.—Whenever the capacity of the pelvis justifies, the forceps should first be tried, always, however, taking care not to dam age the mother. If, after three to four attempts, the forceps does not bring down the head, we believe it disadvantageous to the mother, and of no advantage to the child, to persist longer. We should perforate, and then resort to craniotomy or not according to the case.
One of the great advantages of perforation is that it may be resorted to before complete dilatation of the cervix. The cervix need only be dilated sufficiently to allow of the passage of the instrument. Under the influ ence of the contractions of the uterus, the skull empties itself of its con tents, the bones collapse, and we have frequently seen labor terminate spontaneously where instrumental extraction would have been called for had the head remained intact. Usually, however, perforation is in sufficient, and cephalotripsy must follow it.
In Holland and in Belgium, the perforated head is extracted by means of the lever. Tarnier prefers the forceps, particularly where the contrac tion is not great. We resort, in such instances, to Bailly's cephalotribe, which we will shortly describe.
We have stated that before perforating a few attempts should be made to deliver by the forceps. If this fails, it is advantageous to still hold the head in the forceps blades, and perforate between them, for thus we may fix the head by directing an assistant to make gentle traction on the handles; and further, by compressing the handles we assist in the expres sion of the cerebral matter and in causilig the bones to collapse. Often thus we may complete extraction with the and thus do away with the necessity of inserting the blades of the cephalotribe. We cannot insist too strongly on perforating before using the cephalotribe, else we may deliver the mutilated foetus and to our horror see it live for some minutes.
Operative must consider this successively where the before-coming head, or the face, or the after-coming head, presents. We always use Blot's perforator.
1. Presentations the preliminary precautions and the position are the same as in any obstetrical operation. Since the tion itself is not painful, chloroform is only requisite when, in addition to perforation, immediate extraction or cephalotripsy is requisite, and then narcosis should be induced to the surgical degree. The rectum and blad der should always be first emptied. An assistant should steady the head firmly through the abdominal walls at the superior strait. The operator introduces the index and middle finger of the left hand into the vagina, and inserts them into the cervical canal against the head. The perforator is then guided by these fingers, and its point applied perpendicularly against the fcetal head. It is not essential to perforate through a suture or fontanelle, but the point of the instrument is pushed boldly down to the bone, and then the instrument is rotated from right to left, and from left to right, in order to facilitate the passage through the bone. As soon as the instrument has penetrated the cranial cavity, by pressure on the handle the blades are opened, and the instrument is moved in every di rection in order to thoroughly break up the brain. Pressure on the handle is then relaxed, the blades close, and the instrument is withdrawn. In these manceuvres the maternal parts are exposed to absolutely no risk.
On the withdrawal of the instrument blood and cerebral matter gener ally issue from the vulva. (Fig. 139.) 2. Presentation of the in this instance, is a trifle more difficult. The instrument may be made to penetrate either through the orbit, the frontal bone, or the palatine arch, the last offering the greatest difficulties. We prefer the frontal bone, although we do not agree with Naegel6 and Grenser in believing it indispensable to perforate through the frontal suture.
3. The –Here manipulation is still more difficult, since the body of the child is in the way and the occipital bone is so thick.
We must, therefore, perforate either under the chin, or else, as is pre ferable, through one of the posterior lateral fontanelles. (Fig. 140.) Chailly prefers perforating through the palatine vault for the reason that he believes the point of the instrument is less likely to slip. IIe recom mends the insertion of two fingers into the mouth, forcible depression of the inferior maxilla, and penetration with Smellie's scissors through the palate into the skull.
Perforation alone rarely suffices. Cephalotripsy must ordinarily be superadded. For extraction of the head, blunt and sharp hooks have been recommended (Figs. 141 and 142), but we absolutely condemn them oir account of the risks which they entail. Bono forceps have also been devised (Fig. 143), and the simplest of all is that of Danavia, described by Baudelocque, and recommended by Pajot. This instrument, however, is often not effective, owing to the yielding of the bones, and either the forceps or the cephalotribe is better.