III. CRANIOCLASTY.
Devised by Simpson in 1860, the cranioclast is in reality a bone-forceps. The name craniotractor, suggested by Mund6, is peculiarly appropriate, since it describes the action of the instrument exactly.—Ed.] The instrument is composed of two blades, (Fig. 157), the one smooth and fenestrated, the other solid and roughened, fitting into the first. When closed, the blades, slightly curved, resemble, as Gueniot says, the bill of a duck.
The use of the instrument is preceded by perforation, and then the solid blade is applied within the skull, the fenestrated externally, and through their approximation, the bones are crushed. The instrument may then be withdrawn and the expulsion of the head be left to Nature, or else it may be used as a tractor, and delivery thus completed.
The objections to Simpson's instrument are that it is tbo short, and therefore can scarcely be used above the superior strait, and further its lack of curve. Braiin has lengthened and curved it, and has added a compression screw. (Fig. 158.) [These modifications make Brafin's in strument not only an efficient tractor, but also an efficient compressor. Being lighter and less bulky than the cephaletribe, and accomplishing the same end, we personally prefer it, especially since it may be used in cases of deformity where the cephalotribe, on account of its bulk, cannot. —Ed.] Wasseige thus states the advantages of the cranioclast: 1. It is a smaller instrument than the cephalotribe. 2. We may make traction with it as readily as by the body of the foetus. 3. The instrument rarely produces any lesions of the maternal parts. 4. It never slips, and if perforation has been effective, it always delivers. 5. Braiin's instrument may be used .
in cases where the contraction at the superior strait is as low as 1.5 inches. 6. It may be used in case of all presentations. 7. It may be applied on hemicephalic and acephalic foetuses.
Barnes, who is a great advocate of the cranioclast, recommends, before traction, the removal of portions of the vault. Burnes, contrary to the assertions of Hull, has shown that the removal of the vault reduces the base of the skull, and that if the head be brought down even as in case of face presentation, only the diameter between the orbits and the chin presents at the strait, and this diameter is scarcely one inch. If then the
conjugate is 1.5 inches, and the transverse 3 inches, cranioclasty is suffi cient for delivery. Below this the Cmsarean section is requisite.
Although the inventor of the cranioclast, Simpson much prefers ver sion, and he bases this preference on the following figures: Cranioclasty 251 cases, mortality 1 in 5; version 169 cases, mortality 1 in 15. Further, he states that, ceteris paribus, version is resorted to earlier than cranio tomy, and, therefore, will offer greater chance of success, the maternal mortality increasing always with the duration of labor.
Since 1862, the cranioclast tends in Germany to replace the cephalo tribe, and Brafin uses it exclusively. Rokitansky, up to 1871, had used it 5• times in BratIn's Clinic: before-coming head 47 times; after-coming head 5 times.
Braun, from 1871 to 1878, used it 82 times: Before-coming head 63 times; after-coming head 19 times. Mothers recovered 59; mothers died 23. Of the 23 deaths, 6 were in good condition before operation, and 17 in bad condition.
The causes of death were: Eclampsia 1; peritonitis 6; physometra 2; spontaneous rupture of uterus before operation 14.
Bidder, from 1873 to 1875, has used the instrument 32 times success fully.
Fritsch has used it 41 times, with 7 deaths. Braun always perforates with the trephine.
[The trephine best subserves the purpose of perforation of the before coming head, and NaegelCs scissors of the after-coming. After perfora tion with either, a sound or similar blunt-pointed instrument should be inserted into the skull, and the brain thoroughly broken up, especially the medulla, lest a gasping, still-living infant, be brought into the world to the horror of the attendants.—Ed.] Wiener, of Breslau, comparing the results obtained from cranioclasty and cephalotripsy at the Clinic, from 1865 to 1876, gives the following figures: Perforations, 101: Before-coming head, 92; after-coming head, 9. Primiparte, 41; bipartt, 25; triparaa, 18.