Book of the month: The Obstetrician's Armamentarium: Historical Obstetric Instruments and their Inventors
Authors: Elliot E Philipp
Journal: Journal of the Royal Society of Medicine (2001)

Some years ago a Fellow of the Royal College of Obstetricians and Gynaecologists started a small collection of antique obstetric forceps and other early obstetric instruments. Before he died he set up the collection, beautifully labelled, in two showcases and it was exhibited in the Royal College of Obstetricians and Gynaecologists. The College Council one day decided that the space was needed for other purposes and a porter was told to put the instruments into cardboard boxes. He disarticulated the forceps, muddled them up, and separated them completely from their labels. The lay-secretary of the College, horrified by what had happened, telephoned me to come urgently and repair the damage. It was worse than trying to do a jigsaw puzzle without any picture to go by. After several hours I had managed to reassemble only one pair of forceps; but did not know which label should be attached. I did not even know for certain to which century the forceps belonged. So a curator from the instrument department of the Science Museum came, and after some days she and a colleague had put together several but not all the pieces of the puzzle. The lesson is that it is very difficult to assemble and authenticate even a small collection of these instruments.

Bryan Hibbard has done much more, and on a grander scale. In 1960 or thereabouts, he retrieved from storage a collection of obstetric instruments from the Department of Obstetrics and Gynaecology in the University of Liverpool, where he worked for some time. He then did the same at the Royal College of Obstetricians and Gynaecologists, completing the task not quite finished by the curators from the Science Museum; and he was soon able to add greatly to it by acquiring from the College a collection which had resided in a Manchester Cellar. He later obtained a collection from University College London, similarly neglected.

Bryan Hibbard's book The Obstetrician's Armamentarium1 is not the first authoritative catalogue of obstetric instruments. There are two older ones. The second and more important is by an Indian obstetrician, Sir Kedarnath Das, first published in 1929. A facsimile edition of this illustrated catalogue was produced in 1993 under the supervision of Professor Hibbard, who made no alterations or additions to the text. An earlier one in 1887 was by A Meadows, who catalogued the collection of obstetric instruments then in the Royal College of Surgeons of England. This collection, was largely destroyed by bombing during the Second World War. Meadows' catalogue fortunately still existed, though it was not illustrated.

Hibbard's new book is fully illustrated. Some of the illustrations are the original inventors' together with their instructions on how to use the instruments. Others are photographs taken by Hibbard with the help of his wife, occasionally of a model rigged up to show the forceps in action. But the book is much more than a catalogue of instruments, because it details the history of obstetrics through the centuries. The inventors come from many countries and go back a long way. They are in many cases the important founders of our present subject. A key figure is William Smellie (1697-1763). In Smellie's day, obstructed labour was often completed by performing an internal version through the vagina, to turn the head in to the upper part of the uterus and bring the breech down. The baby was then extracted by pulling on a leg or by using breech hooks. This method caused great infant mortality, so in 1737 Smellie tried a pair of French forceps (Dusee's), that had been recommended to him by a Scottish obstetrician, Alexander Butter. Smellie not only designed several better forceps which enabled him to avoid the internal version; he also wrote textbooks and produced a very important atlas, which contains among other things illustrations and descriptions of how to apply forceps and deliver the baby (Figure 1). Like his contemporary William Hunter, he was a Scot who migrated to London. But while Hunter was a very dapper well-dressed man who attended the aristocracy, Smellie was down to earth and attended the poor. In this book, we find details of Smellie's methods of teaching and how he himself had learnt from the great obstetricians of Paris.



Figure 1

Smellie's straight forceps. Changeable leather thronging covered the blades, lubricated with lard



The illustrations, taken from Smellie's atlas and supplemented by Hibbard's photographs, include Smellie's wooden forceps, now in the museum at the Royal College of Obstetricians and Gynaecologists. Andre Levret in Paris (1703-1780) was Smellie's contemporary. He became the French Royal accoucheur; but he also found time to design several types of forceps and other instruments, some of a destructive nature, such as the tire tete which was used to extract the baby's head after decapitation when the child had died.

Hibbard's arrangement of the chapters overcomes some of the difficulties of putting such diverse material in order, because he first describes chronological developments and then geographical variations. A whole chapter is given to the development of forceps in America. We learn about Deacon Samuel Fuller, a serge-maker by trade who became the first medical practitioner in America. He travelled to the new continent in the Mayflower, arriving in 1620 with his third wife, who was a midwife. Her name was Bridget Lee Fuller and she probably delivered three babies during their journey. The training of man-midwives was started in Philadelphia by William Shippen Jr, who was a pupil of Smellie and Hunter. He later worked in New York. Hibbard discovered this by going back to primary sources. Misuse of a pair of forceps led to one of the earliest malpractice legal suits to be brought in America.

Unfortunately not all babies could be delivered alive, particularly before the popularity of today's caesarean section. So there were instruments to destroy and then to extract dead babies. These instruments are accorded separate descriptions. Comminutors and communitor-extractors have their chapter. A communitor is a crushing instrument. This chapter, like all the others, is profusely illustrated. Other chapters describe axis-traction forceps, which are often still used today. There are also illustrations of fillets, levers and other extractors (Figure 2) which did not have to destroy the baby to effect delivery. An important chapter is that on symphysiotomy and pubiotomy. It is relevant still today because, by division of the symphysis pubis, the diameters of the pelvis can be greatly increased. This procedure was used before caesarean section became popular in the western world. Today a caesarean section may be very difficult to organize in resource-poor countries.



Figure 2

Delore's cord and pulling tractor. A dynamometer is interposed in the pulling system



The Obstetrician's Armamentarium is a special work. To read and review it has been a great joy.