MR. 1)OWELL on the Forceps in Craniotomy. 83

ART. tX . - -The Forceps in Craniotomy. By T~O~AS I)OW~LL, L.I~.C.S.I., ]~nnlskean, Co. Cork; formerly Resident Surgeon Ang!esey Lying-in HospitaL, Dublin; late Assistant Surgeon H. M. Bombay A r m y ; and formerly Lecturer on Practical Anatomy in the 01~ginal (now Ledwieh) School of Medicine, Peter-street, Dublin.

CRA~CIOTO~Y is an operation whose reckless performance was long a stain upon the medical profession of this country. I t is at once both crud and clumsy, and can only by a stretch of courtesy be called a scientific proceeding. I have long been of this opinion, and I have found the forceps such an efficient and innoxious instru- ment that I have discarded the use of the perforater, except in those cases in which I have tried the forceps and found the assistance given by it insufficient to bring about delivery. When' compelled to perforate, I formerly made traction with the crotchet; of all the instruments commonly used to promote delivery after perforation, I believed it the best; and, following in the way of my predecessors, I continued to use it, till the occurrence of the following case happily showed me a more facile mode of proceeding; since then with me the perforater has waited on the forceps in cases where' the disproportion between the head and pelvis is great, to step in and remove the difficulty by reducing the bulk of the head, when by grasping it with the forceps it may be delivered with the same ease as if the parts were originally well proportioned.

On the 20th of January, 1861, at: 8 p.m., I visited Mrs. B., aged twenty-three, primipara. I was told she had been in labour from the morning of the previous day; that the pains had- been very strong, that they-had now ceased; and that the patient was very weak. When at the bed-side, I found her quite exhausted, the skin was cool and clammy, she complained of thirst; the pulse.was 128, smai~- and weak. On examination I found the os uteri dilated, the fetal bones overlapping, and the head firmly impacted' in the inlet of the pelvis. The soft parts of the mother were hot and' tender; she had passed no urine since morning, and` expressed no" anxiety to do so. t passed the catheter; a few drops only came away. The case was evidently one requiring instrumental aid, and delay was likely to be injurious. I t was now necessary to determine what form the assistance should take. I am usually in- fluenced ~ in my choice of instruments by the event of the fetus'~

r

84 MR. POWELL on the Forceps in Craniotomy.

being living or dead at the moment of operation. I f the child is dead, and I think delivery would be hastened by reducing the bulk of the head, I never hesitate to do so ; but if there is no reason to think the child is dead, I try to avoid perforating, for I feel it is my duty to give the child a chance of its life. In this case I failed to find the fetal heart, but I had no reason to think the child was dead; I accordingly applied the forceps. The introduction of the blades, as is usual, caused a renewal of the uterine contractions ; but these contractions, with all the assistance I deemed it safe to give them, were insufficient to move the head from its position; having continued the traction for as many as five pains without any result, I considered I would not be justified in continuing my efforts, and that I had no alternative but to perforate. Withdrawing the forceps, I proceeded to open the child's head in the usual manner, and then to fix and make traction with the crotchet. This instrument I had always found inefficient, but I never experienced its total inadecluacy to cope with a difficult case till now. Piece after piece of bone came away, fixed point after fixed point yielded, and still the head remained unmoved. I continued my efforts till every process of bone in which the crotchet could be fixed had crumbled before it, and the crotchet lay powerless in my hand. At this moment it occurred to me to try the forceps. I applied it (this time, owing to the reduced size of the child's head, with much greater ease than on the first occasion). No sooner did I make traction than I found the head descending, and in less than three minutes, to my very great satisfaction, the head was delivered and the child was born in due course. I found the mother was then in a very weak state; the continued unavailing efforts with the crotchet had ~ most depressing, mental as well as bodily, effect. I administered wine and aromatic spirits of ammonia, and before I left her re-action had set in; from this out her recovery ~vas satisfactory, and unmarked by any unusual event.

July 20th, 1862.--It is now eighteen months since I last saw lYirs. B. She left this neighbourhood a few months after her confinement, and I heard nothing of her till to-day, when a relative came to ask my advice under the following unhappy circumstances:--

She said, about a month ago, Mrs. ]3. was taken in labour of her second child; that her state varied from day to day; and that, at the end of five days from the first occasion of her pains, she was delivered, with instruments, of a dead child, by a neighbouring practitioner. She remarked nothing unusual till the third day

~/IR. POWELL on, the Forcelgs in Craniotomy. 85

after delivery, when she found she could not retain her urine. This state had continued up to the present time, and she was very much troubled by it.

I t would appear the head became impacted, as in the first labour ; but not being promptly relieved, the inevitable sloughing and vesieo-vaginal fistula followed.

The records of this case show, in the first place, the advantages to the mother of timely delivery, recently advocated by Dr. Sinclair, in this Journal;a in the next place, and pre-eminently, they show the difficulty at times experienced in effeeting the passage of the fetal head through a contracted pelvis.

Iu using the forceps to make tr~action after perforation we obtain the following advantages:--(1) The unpleasant failure and delay at times experienced with the crotchet is avoided; (2) all danger to the mother by the slipping of the crotchet, or of wounds by the pieces of bone is avoided; (3) the mangling of the child's head is reduced to a minimum, and the appearance of the child (a desirable matter at times) is preserved; (6) we can make traction in the most efficient manner; (5) the whole operation, including perfora- tion and extraction, may be performed in from three to five minutes m a rapidity unattainable with the crotchet. The following case illustrates this practice : -

On September 27, 1862, Mrs. D., aged forty, was taken in labour of her second child. She had been a widow eighteen years. Her first child was born when she was but twenty years old. On September 28, at 8 a.m., labour had ceased, the os uteri was still to be felt between the head and the pubes, and the soft parts were rigid and unyielding. She said she thought the child was dead-- the emphysema of the scalp and the fetor of the discharges showed it was so. Owing to the rigid and unrelaxed state of the soft parts I thought delivery would be facilitated by reducing the bulk of the child's head. I accordingly perforated, and then applied and made traction with the forceps. The operation occupied about five minutes; and the woman recovered without a bad symptom.

In two other cases i have extracted with the-forceps, after per- forating, with equally good success.

I t may be thought the injury the erafiial bones receive from the perforator may so affect their resistance that they will not afford a hold to the forceps, or that the forceps might slip off the

a On the Timely Use of the Obstetric Forceps. Vol. xxxii., p. 60.

86 MR. POWELL on the Forceps in Craniotomy.

collapsed head. This leads me to say a word on the shape of the forceps to be used.

I consider Churchill's forceps the most proper to use after perfora- tion, inasmuch as the parts offering resistance to it when traction is made are uninjured by the perforator, being supported by the bones forming the base of the skull. The advantages of this shape are ----(1) the widest part of the forceps, when in use, corresponds to the widest part of the child's head; (2) the forceps passes much more fully around trod above the head, thus preventing the possibility of slipping; (3) the blades, in the act of introduction, have a tendency to impinge upon, almost to hitch in, the fetal structures, thus conducing very much to the safety of the maternal structures, and to safety in the use of the instrument itself. Its disadvantage is, that it is more dii~cult of application than the old form, particularly when tile head is high up.

I t may, perhaps, be objected to this practice~ that it is impossible or very difficult to apply the forceps in cases requiring perforation. When speaking of the practice of the Dublin Lying-ln Hospital during Dr. Shekleton's mastership, Dr. Sinclair ~ says:--" We never perforated without first trying to extract the fetus with the forceps." Taking into account the large practice of the hospital, we may accept this as proof of its being possible to introduce the forceps in craniotomy eases.

A great variety of "craniotomy forceps" has been devised to effect delivery when the crotchet has failed; they appear to be equally ingenious and inefficient. A n instrument invented by Dr. Ziegler, of Edinburgh, and figured in Dr. Churchill's work, has ~vco blades, armed with teeth, to be applied outside the cranium, They somewhat resemble the blades of the ordinary forceps, but are much less curved, a third blade is supplied that converts it into a eraniotomy forceps of the ordinary form. The fault of this and of the other craniotomy forceps, is that they attempt to hold the flat bones of the cranium, whose cohesion and power of resistance is destroyed by the pefforater.

T,oo cir.