PERFORATION.

Variety of perforators.—Indications.—Mode of operating.—Extraction.—Crotchet.—Embryulcia.

The perforation is that operation “where we make an opening into the cranial cavity, and, by allowing the brain to escape, thus diminish the bulk of the head.” (Obstetric Memoranda.)

Perforation is one of the most ancient operations in midwifery, for in former times it was the only means of artificially delivering the child when the head presented: hence we find that from the age of Hippocrates down to the last century, midwifery instruments almost entirely consisted of knives or lancets for piercing the foetal head, and blunt or sharp hooks for extracting or dismembering the child.

Thus Hippocrates, Celsus, and Albucasis, and others, have described a variety of such instruments and given full directions for their use.

Variety of perforators. No instrument has been so greatly modified or has appeared under such different forms as the perforator; but it is not our object to enter into any detailed account of its history, for it would not, like that of the forceps, lead to any useful information; we shall, therefore, content ourselves with mentioning those few which have been in general use during the last century. They are chiefly of the scissor kind; the two most commonly known are the perforators of Dr. Smellie and M. Levret: the former are merely strong long-handled scissors, the backs of the blade being neither exactly sharp nor blunt,[105] and furnished each with a projecting shoulder or rest to prevent them from entering too far. Levret’s perforator, which is extensively used in this country under the name of Dr. Denman’s perforator, and which was originally invented by Bing, of Copenhagen, is also formed like scissors, but has its cutting edges outside; the blades are also furnished with rests or shoulders like the Smellie perforator.

A useful modification has been invented by Professor NaegelÉ, which supplies a considerable defect in the two above-mentioned instruments, viz. the necessity of using both hands to open the blades, thereby requiring that the hand which guides the instrument in the vagina should be removed at this moment: for this purpose the blades do not cross at the lock as the others do, by which means the grasp of one hand is sufficient to squeeze the handles together, and thus make the blades diverge in order to dilate the opening. A similar one has been invented by the surgical instrument maker, Mr. Weiss, but it does not appear to be quite so safe.

The object of these instruments is not merely to bore through the skull, but to break down the parietal bone to a certain extent, in order to enlarge the opening: a slight curve of the blades is advantageous, because their points thus impinge more directly upon the skull, and enter it at once without running the risk of slipping along the surface.

Indications. “The perforation is indicated, first, in all cases where the labour is dangerous for the mother, and where the antero-posterior diameter, although more than two inches and a half, is so small that the head which presents, cannot be delivered by the forceps. Secondly, it is indicated where the head is much larger than natural, as in hydrocephalus.” (NaegelÉ, MS. Lectures.) For a more detailed and special account of the precise circumstances under which it will be required, we must refer to those different forms of Dystocia, where it is occasionally required, particularly our fourth species, viz. Dystocia Pelvica.

Much discrepancy of opinion has existed as to how far the operation itself was justifiable, and has, therefore, given rise to very different results in the practice of different schools. The most obstinately prejudiced against perforation was the late celebrated Benjamin Osiander, of GÖttingen, who asserted, that it was never necessary, for, where others were obliged to open the head, he would deliver the patient by means of his forceps, an instrument which, from its great length and the various hooks &c. for applying additional hands, was capable of exerting a degree of force which nothing could justify. In France, the predilection for using exceedingly powerful forceps to a degree, which in this country and the greater part of Germany would be looked upon as very injurious, if not dangerous, has tended to render the perforation a comparatively rare operation: thus out of somewhat more than twenty thousand labours at the MaternitÉ, of Paris, only sixteen were delivered by this means. Of the ninety-six cases in whom the forceps was applied, no mention is made as to the result with respect to the mothers; but, from the description of a forceps case at the HÔtel Dieu which we have received from an eye-witness, the force used must have been carried to a most unwarrantable extent.

The English practitioners have frequently been accused by their Continental brethren with being too ready in the use of the perforator; but, with one or two exceptions, the charge is not just, for, as already stated, we are not justified in subjecting an adult and otherwise healthy woman to so much suffering and danger for the sake of a child which, after all, will be probably sacrificed by the severity of the labour.[106]

Operation. In performing the operation we introduce two or three fingers along the vagina to the presenting part of the foetal head, and carefully guide up the perforator against it: these fingers will not only protect the soft parts from injury, but steady the point so firmly upon the skull, as to enable the other hand to bore through it without difficulty. Having passed the blades up to the shoulders or rests, we dilate the opening, first one way and then the other, to form a crucial incision: we now insert the instrument up to the basis cranii, breaking down the attachments and structure of the brain, and thus enabling it to come away with greater facility. To favour this object still farther, and make the cranial bones collapse more readily, we must pass a long elastic tube through the opening, and by means of a syringe, throw up a powerful stream of water into the cavity of the skull: if this be introduced to the base of it, the water will necessarily drive out the brain before it, so that with every stroke of the piston, a quantity of brain will be expelled nearly equal to that of the water injected.

When the perforation has been made, it will be desirable to wait a few hours before making any attempt to extract: we thus give the mother an opportunity of getting a little rest; the attachments of the cranial bones after a short time become more yielding, the head collapses more readily, and adapts itself better to the form of the passages. “In all circumstances,” says Dr. Osborn, “which admit and require precision, I would recommend the delaying all attempts to extract the child till the head has been opened at least thirty hours: a period sufficient to complete the putrefaction of the child’s body, and yet not sufficient to produce any danger to the mother. From such conduct, the beneficial effects of facilitating the extraction of the child, I am firmly convinced, by frequent experience, will much overbalance any possible injury which may reasonably be expected from the putrid state of the child and secundines in so short a time. The propriety, however, of this delay entirely depends upon the head being opened in the beginning of labour: for if we do not perform the first part of this operation till the labour has been protracted so long as that the woman’s strength begins to fail, we must expedite the delivery as speedily as possible, otherwise, the danger which we wish to avoid, will infallibly be incurred: no woman can suffer continued labour beyond a certain period without fever, inflammation, and the most imminent danger, if not death ensuing.” (Osborn’s Essays on the Practice of Midwifery.)

It has been recommended to perforate the head at the sutures, on account of the greater facility in passing the instrument through them: but that part of the head which is lowest in the pelvis, or which, in other words, presents, must necessarily be the most convenient, not only for the introduction of an instrument, but also for the evacuation of the brain. When the perforation is made at a suture, the edges of the bones gradually overlap as the head diminishes in size, and thus close the opening, a circumstance which cannot occur when it is made through a bone. Splintering the bone in making a crucial opening has been objected to on the ground that the sharp edges and spiculÆ are apt to wound the soft parts of the mother: of this, however, there will be but little danger so long as they are covered by the scalp, which we should be somewhat cautious of, and not tear or otherwise destroy the cranial integuments unnecessarily, for it has long since been remarked by the celebrated Peter Frank, that inflammation of the uterus produced by wounds from spiculÆ of bone or sharp instruments becoming blunt, &c., usually prove fatal: it is also desirable to disfigure the head as little as possible. Still, however, we are far from recommending the trepan-shaped perforators which have been used by Professors Assalini, Joerg, &c. as they cannot make a sufficiently free opening, nor break down the skull to the necessary extent.

Extraction. Where sufficient time has been allowed for the cranial bones to collapse, the finger inserted into the opening and acting as a blunt hook will, if assisted by the pains, be enabled to exert a sufficient degree of force to bring the head down to the pelvic outlet; by which time the action of the vagina and abdominal muscles in aid of the uterine efforts will soon succeed in pressing it through the os externum. By using the finger in this way we pull by that part of the head which is already lowest in the pelvis, and, therefore, run no risk of altering the position of the head and bringing it down in an unfavourable direction; this objection (among others) applies to the hook, whether it be fixed internally or externally, and thus frequently renders the passage of the head through the outlet and os externum more tedious, difficult, and painful, than it otherwise would have been. The craniotomy forceps are still more objectionable in all ordinary cases of perforation, for they not only alter the position of the head, but by tearing away portions of bone from time to time are very liable to wound the soft parts.

From our own experience, we would recommend the application of the common curved forceps in all cases where the pelvic deformity is not of a very unusual degree, for by this means the hand is equally grasped and compressed, the soft parts to a considerable extent are protected by the blades, and the whole mass brought down exactly in the position in which it presented. On several occasions where the craniotomy forceps and crotchet have failed to move the head, the midwifery forceps has been applied, and the delivery easily and quickly accomplished. Dr. Smellie recommends the crotchet to be applied on the outside of the head, and was evidently aware that its position was liable to be altered by this means. He directs the practitioner to “introduce it along his right hand with the point towards the child’s head, and fix it above the chin, in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold. Having fixed the instrument, let him withdraw his right hand, and with it take hold on the end or handle of the crotchet, then introduce his left to seize the bones at the opening of the skull (as above directed) that the head may be kept steady, and pull along with both hands.” (vol. i. chap. 3. sect. 7. numb. 4.) Where there was considerable difficulty in bringing down the head, Dr. Smellie used to introduce a second crotchet opposite to the first, like the second blade of the forceps, and having locked them together was thus enabled to apply a greater degree of force.

Crotchet. The usual mode of applying the crotchet at the present day is to pass it into the cranial cavity, and endeavour to fix it upon some portion of the skull, which will afford a sufficiently firm hold for the purpose; the best spot is the petrous portion of one or other of the temporal bones. The plan of passing up the hook on the outside of the head is objectionable, for in most cases where there is much impaction of the head, it will be exceedingly difficult, if not impossible, to push the hook past it without much suffering and probable injury. Not wishing to differ from so great an authority as Dr. Smellie without reason, we have repeatedly tried this mode of using the crotchet, but invariably found that its introduction on the outside of the head was attended with so much difficulty and pain as to make us relinquish the attempt. His objections to passing the hook into the cranial cavity are not valid, for we should never try to fix it upon the “thin bones,” nor should we hold it in such a manner that, if it did slip or tear through, it would wound either our hand or the soft parts of the mother.

The common form of the crotchet in general use is but ill adapted for taking hold of any part within the skull: it is, in fact, the very instrument left us by Dr. Smellie for applying on the outside of the skull: and, therefore, that which was intended to take hold of a convex surface cannot possibly be also suited for one of the contrary form, viz. a concavity; for this reason, the shank of the hook requires to be straight, so that the point may project at a considerable angle, by which means it will take hold with much greater ease.

The point of the hook guarded by the finger should be cautiously introduced up the vagina, and passed into the cranial cavity; having fixed it, as above directed, the finger should be applied externally, so as to correspond with the hook inside: by so doing, if the point slips or tears through the bone, the finger is ready to protect the soft parts from it; the operator is equally safe from injury, for, by grasping the shank of the hook with his thumb and other fingers, his whole hand moves with it and gives him instant warning of its going to slip. Where the deformity of the pelvis is very great, it may be necessary to break down the bones of the head still farther, in order to produce greater comminution; but even here, so long as the bones collapse well together, it will be better not to displace them from their attachments, the whole mass will come down better and with less chance of injuring the soft parts. Where, however, this is admissible, we must give the head sufficient time to undergo that process of softening which is one of the early stages of putrefaction; the cranial parietes may be gradually removed, one after the other, until we have nothing remaining but the base of the skull and the face. Dr. Burns recommends us now to convert it into a face presentation with the root of the nose directed to the pubes: “I have carefully measured, (says he,) these parts placed in different ways, and entirely agree with Dr. Hull, a practitioner of great judgment and ability, that the smallest diameter offered, is that which extends from the root of the nose to the chin.”

Embryulcia. This is merely a degree farther than the perforation: it consists in evacuating the chest and abdomen of their contents, and thus enabling their parietes to collapse. It is chiefly had recourse to in cases of deformed pelvis, where the arm or shoulder has presented, or where the distortion is so great as to prevent the trunk from passing without its bulk being lessened. Dr. Smellie’s perforator with its scissor edges is best suited for this object. Having made an opening into the most presenting part of the thorax, we enlarge it by cutting away portions of the ribs and thoracic parietes, and removing the contents of the chest. The abdominal viscera are brought away in a similar way through a perforation in the diaphragm; and if this be not sufficient to let the trunk pass, the crotchet must be inserted into the brim of the child’s pelvis, which must be brought down doubled upon the spine, somewhat like the process of spontaneous expulsion.

The success of this operation, will, in a great measure, depend not only upon its being undertaken sufficiently early before the patient’s strength is exhausted, but upon a sufficient length of time intervening between the removal of the thoracic and abdominal viscera and the extraction of the child. The excellent rule of Dr. Osborn, above quoted, is peculiarly applicable here; for when softened by the effects of incipient decomposition, the body will sometimes even be expelled by the unassisted efforts of the uterus.

In a case of this sort, the perforation of the head is the last part of the process to be performed. It will be by all means, desirable not to separate it from the body, but to pass up the curved perforator along the neck, and make an opening behind the ears: this is effected without much difficulty, and the head can be brought away whole, or in portions, according to the nature of the case.