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Please be advised that the following article contains a graphic discussion of surgical procedures, childbirth, difficult deliveries, stillbirth, and death.

Midwifery is one of the oldest medical practices. In its early days, difficult births and obstructive labours led to much suffering and to death of the mother and the fetus. Although instruments such as forceps have provided doctors with a means of assisting with difficult deliveries, sometimes the fetus may be too big or present in an unfavourable position to pass through the birth canal. Sadly, it is unsurprising that before the introduction of caesarean section, the fetus would die from asphyxiation (suffocation) during prolonged, difficult deliveries. Various instruments have been devised to aid the removal of the dead fetus from the uterus in an attempt to save the mother’s life from the threat of a retained fetus.

Steel Craniotomy Forceps/Cranioclast with Brass Handle. The Old Operating Theatre Museum & Herb Garret Collection.

Cranioclasts were invented and popularised in the Western world by Dr James Simpson in the mid-19th century. He realised that the size of the fetal skull relative to the mother’s pelvis was the main obstructing force to removing the dead fetus effectively via the birth canal. The cranioclast in the Old Operating Theatre collection broadly resembles a pair of forceps. It is made of electroplated steel with brass handles, with an elongated shape of just over a foot. This object was likely made by John Millikin, a local medical and scientific equipment manufacturer and supplier of dissection and surgical instruments at 3 St. Thomas’ Street between 1870 and 1885. This link between instrument-makers and medical practitioners was typical for London hospitals at the time. Decades before John Millikin opened his shop, his father (also named John Millikin) ran a similar business at 9 St. Thomas’ Street, near the site of the Old St Thomas’ Hospital, and was appointed as instrument makers to Guy’s and St. Thomas Hospitals from 1859. He moved his business several times between 1862 and 1863 to stay close to the Hospital, as the latter was relocated to make way for railway construction.

Cranioclasts generally consisted of a powerful pair of forceps with heavy, sometimes teethed blades that are pulled together through the use of a wingnut clamp, much like closing a pair of scissors. Following the perforation of the fetal skull, the fenestrated blade would be positioned on the outer surface of the fetus’ head, while the other, smaller blade would be inserted into the scalp. The blades would then be locked, crushing the skull of the fetus and decreasing its diameter. The fetus could be expelled by regular uterus contractions or extracted by obstetricians with an instrument resembling a hook. Cranioclasts and similar fetus-removal instruments presented a welcomed solution, as they neatly contained the content of the fetal skull during the extraction of the fetus, reducing the risk of deadly infections. In the developed world, the maternal death rate has dropped to one woman in every 10,000 births, but around the end of the 19th century, it was 70 deaths in 10,000. It may seem gruesome, but maternal deaths weren’t uncommon.

Princess Charlotte of Wales, heiress presumptive of the British crown. George Dawe, c.1817. Public domain, via Wikimedia Commons.

Despite its usefulness as an instrument, the cranioclast was seen as a drastic last resort that can be morally controversial. Doctors disagreed as to what pelvic diameter would make their use necessary, as it precipitated the death of the fetus and carried the risk of damaging the uterus. Many avoided it altogether, as they have avoided using instruments such as forceps, hoping that difficult deliveries could be resolved without interventions as labour proceeded. However, for those who belonged to the non-intervention school, the outcome could be disastrous. Sir Richard Croft was the obstetrician attending Princess Charlotte, whose son would have been in line to the throne after King George IV. The Princess had a complicated delivery, but Croft allowed her to go for two whole days of labour without assistance or sustenance. When the fetus was delivered stillborn, it was found to be large and weighed 9 pounds. The exhausted Princess died the following morning. Sir Richard came under such heavy criticism for handling this case that he committed suicide.

Despite the developments in anaesthetics during the 19th century, surgeons could not venture into the inside of the patient’s body without considering the extremely high death rate following operations. Therefore, caesarean sections were only performed if the fetus could not be extracted via the birth canal, as a gamble at saving the mother from inevitable infection and death. Following the advent of anaesthetics and antiseptic techniques, caesarean sections became safer and preferred to tackle obstructive births. Caesarean sections prevented fetal death by asphyxiation, thus reducing the instances in which the doctor must extract a dead fetus from the mother. As a result, the practical use of cranioclasts has largely diminished in the developed world. However, their modern variations remain available from many suppliers of surgical instruments today.

References

About the author

Zhǐyù Chén is a digital content volunteer at the Old Operating Theatre Museum and Herb Garret and an undergraduate at Newnham College, Cambridge. Following two years studying Biology and Physics, she is looking forward to spending her final year reading History of Science and Medicine with a dissertation on the British reception of non-Western natural knowledge from mid 19th-century to the present. Find her on Instagram @chenzhiyudisagrees.

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