Narich proposes the following procedure: Extend the head by intro ducing the fenestrated blade between the pelvic walls and the foetal face, and using it as a lever. Then perforate about it inch above the root of the nose. Make tractions downwards, accompanied by rotation, which will bring the bi-malar diameter towards one or another side of the sacral excavation. We may thus use the cranioclast in cases where the conjugate is diminished even down to inches.
If the objections to the cephalotribe are true when applied to the clas sic instrument, they are not at all applicable to Bailly's instrument, ex cept, unfortunately, that it cannot be used in pelves diminished below 2.5 inches. We have used it fully fifteen times, and it has never slipped, has always extracted the head, has always crushed the base of the skull when the blades were inserted deeply enough. We have lost but two women, and in these repeated attempts at delivery had been made before they were seen by us. It should be remembered that Narich's experi ments were made on a bronze pelvis, and surely the conditions in the living woman are very different. Whatever the results obtained in Germany, the cranioclast, we think, should remain an instrument of excep tional utility. Above 2.5 inches we would recommend Bailly's cephalo tribe, and below 2.5 inches the cranioclast.
[We have not often, we are very thankful to say, been obliged to muti late the living fcetus, and, therefore, we cannot dogmatize in regard to the superiority of the cranioclast over the cephalotribe, and vice rersii, although we prefer the former instrument. Our general practice is, where the case is seen in time (before or just after rupture of the membranes, and before engagement), to perform bipolar version and endeavor to extract where the conjugate is not diminished below 21 to 3 inches at the brim. Thus we may possibly obtain a living child, and if we cannot ex tract we can still perforate. Below 21 inches the cranioclast is just as effective an instrument as the cephalotribe, and being less bulky is far less likely to injure the maternal parts. Why then ever use the cephalotribe ? Thorough perforation and evacuation of the cerebral matter, followed by careful insertion of Braun's cranioclast and crushing by means of it, will certainly accomplish all that the cephalotribe can, and not do what the cephalotribe may, damage the mother.
Such we believe to be sound practice, for the present. We repeat, however, that we look forward to the approach of the day when custom will sanction resort to an operation in case of the living infant which will give it a chance and yet not increase the maternal risk.—Ed.] •