The Fillet is the oldest of obstetric instruments, having been frequently employed before the invention of the forceps, and even in the time of Smellie it was much used in the metropolis. It has since com

pletely fallen out of favor as a scientific instrument, although its use is every now and again advocated, and it is certainly a favorite instrument with some practitioners. This is to be explained by the apparent simplicity of the operation, and the fact that it can generally be performed without the knowledge of the patient. The latter, however, is one strong reason why it should not be used.

Nature of the Instrument. The fillet consists, in its most improved form (that which is recommended by Dr. Eardley Wilmot1) (Fig. 186), of a slip of whalebone fixed into a handle composed of two separate halves which join into one. The whalebone loop is slipped over either the occiput or face, and traction used at the handle.[2]

When applied over the face, after the head has rotated, it would probably do no harm; but if it were so placed when the head was high in the pelvis, traction would necessarily produce extension of the chin before the proper time, and would thus interfere with the natural mechanism of delivery. If placed over the occiput, it is impossible to make traction in the direction of the pelvic axes, as the instrument will then infallibly slip. If traction be made in any other direction, there must be a risk of injuring the maternal structures, or of changing the position of the head. Hence there is every reason for discarding the fillet as a tractor, or as a substitute for the forceps, even in the simplest cases.

It is quite possible that it may find a useful application in certain cases in which the vectis may also be used, viz., as a rectifier of malposition; and, from the comparative facility of its introduction, it would probably be the preferable instrument of the two.

CHAPTER V.

OPERATIONS INVOLVING DESTRUCTION OF THE FETUS.

Operations involving the destruction and mutilation of the child were among the first practised in midwifery. Craniotomy was evidently known in the time of Hippocrates, as he mentions a mode of extracting the head by means of hooks. Celsus describes a similar operation, and was acquainted with the manner of extracting the fœtus in transverse presentations by decapitation. Similar procedures were

1 Obst. Trans., 1874, vol. xv. p. 172.

[The whalebone fillet originated with the Japanese, and was a fearfully destructive instrument with them, traction being made with a windlass.-ED.]

also practised and described by Aetius and others among the ancient writers. The physicians of the Arabian school not only employed perforators for opening the head, but were acquainted with instruments for compressing and extracting it.

Religious Objections to Craniotomy.-Until the end of the seventeenth century this class of operation was not considered justifiable in the case of living children; it then came to be discussed whether the life of the child might not be sacrificed to save that of the mother. It was authoritatively ruled by the Theological Faculty of Paris that the destruction of the child in any case was mortal sin. "Si l'on ne peut tirer l'enfant sans le tuer, on ne peut sans péché mortel le tirer." This dictum of the Roman Church had great influence on Continental midwifery, more especially in France, where, up to a recent date, the leading obstetricians considered craniotomy to be only justifiable when the death of the foetus had been positively ascertained. Even at the present day there are not wanting practitioners who, in their praiseworthy objection to the destruction of a living child, counsel delay until the child has died-a practice thoroughly illogical, and only sparing the operator's feelings at the cost of greatly increased risk to the mother. In England the safety of the child has always been considered subservient to that of the mother; and it has been admitted that, in every case in which the extraction of a living foetus by any of the ordinary means is impossible, its mutilation is perfectly justi

fiable.

Formerly Performed with Unjustifiable Frequency.-It must be admitted that the frequency with which craniotomy has been performed in England constitutes a great blot on British midwifery. During the mastership of Dr. Labbat, at the Rotunda Hospital, the forceps was never once applied in 21,867 labors. Even in the time of Clarke and Collins, when its frequency was much diminished, craniotomy was performed three or four times as often as forceps delivery. These figures indicate a destruction of fœtal life which we cannot look back to without a shudder, and which, it is to be feared, justify the reproaches which our Continental brethren have cast upon our practice. Fortunately, professional opinion has now completely recognized the sacred duty of saving the infant's life whenever it is practicable to do so; and British obstetricians now teach as carefully as those of any other nation the imperative necessity of using every endeavor to avoid the destruction of the foetus.

Divisions of the Subject.-The operation now under consideration may be necessary: 1st, when the head requires either to be simply perforated, or afterward more completely broken up and extractedan operation which has received various names, but is generally known in England as craniotomy, and which may or may not require to be followed by further diminution of the trunk; 2d, when the arm presents, and turning is impossible. This necessitates one of two procedures-decapitation, with the separate extraction of the body and head, or evisceration. In both classes of cases similar instruments are employed, and those generally in use at the present time may be first briefly described.

Instruments Employed.-The object of the perforator is to pierce the skull of the child, so as to admit of the brain being broken up and the consequent collapse and diminution in size of the cranium. The perforator invented by Denman, or some modification of it, has been principally employed. It requires the handles to be separated in order to open the blades, and this cannot be done by the operator himself. This difficulty is overcome in the modification of Naegele's perforator used in Edinburgh, in which the handles are so constructed that they open the points when pressed together, and are separated by a steel rod with a joint at its centre to prevent their opening too soon. By this arrangement the instrument can be manipulated by one hand only. The sharp-pointed portion has an external cutting edge, with projecting shoulders at its base to prevent its penetrating too far

FIG. 187.

FIG. 188.

FIG. 189.

Various forms of perforators.

into the cranium. Many modifications of these arrangements have since been contrived (Figs. 187, 188, 189). In some parts of the Continent a perforator is used constructed on the principle of the trephine; but this is vastly more difficult to work and has the great disadvantage of simply boring a hole in the skull, instead of splitting it up, as is done by the sharp-pointed instrument.

The instruments for extraction are the crotchet and craniotomy forceps.

Crochets and Craniotomy Forceps.-The crotchet is a sharppointed hook of highly tempered steel, which can be fixed on some portion of the skull, either internal or external, traction being made by the handle. The shank of the instrument is either straight or curved (Figs. 190 and 191), the latter being preferable, and it is either attached to a wooden handle or forged in a single piece of metal. A modification of this instrument is known as Oldham's vertebral hook. It consists of a slender hook, measuring with its handle thirteen

inches in length, which is passed through the foramen magnum and fixed in the vertebral canal, so as to secure a firm hold for traction. All forms of crotchets are open to the serious objection of being liable

FIGS. 190, 191.

to slip, or break through the bone to which they are fixed, so wounding either the soft parts of the mother, or the fingers of the operator placed as a guard. Hence they are discountenanced by most recent writers, and may with propriety be regarded as obsolete instruments.

Their place as tractors is well supplied by the more modern craniotomy forceps (Fig. 192). These are intended to lay hold of the skull, one blade being introduced within the cranium, the other externally, and, when a firm grasp has been obtained, downward traction is made. A second object it fulfils is to break away and remove portions of the skull when perforation and traction alone are insufficient to effect delivery. Many forms of craniotomy forceps are in use-some armed with formidable teeth; others, of simpler construction, depending on their roughened and serrated internal surfaces for firmness of grasp. For general use, there is no better instrument than the cranioclast of Sir James Y. Simpson (Fig. 193), which admirably fulfils both these indications. It consists of two separate blades fastened by a button joint. The extremities of the blades are of a duck-billed shape, and are sufficiently curved to allow of a firm grasp of the skull being taken: the upper blade is deeply grooved to allow the lower to sink into it, and this gives the instru ment great power in fracturing the cranial bones, when that is found to be necessary. It need not, however, be employed for the latter purpose; and the blades, being serrated on their under surface, form as perfect a pair of craniotomy forceps as any in ordinary use. vided with it, we are spared the necessity of procuring a number of instruments for extraction.

Crotchets.

Pro

Cephalotribe.-Amongst modern improvements in midwifery there are few which have led to more discussion than the use of the cephalotribe. This instrument, originally invented by Baudelocque, was long employed on the Continent before it was used in England, the prejudice against it being no doubt due to its formidable size and appearance.[] Of late years many of our leading obstetricians have used it in preference to either the crotchet or craniotomy forceps, and have materially modified and improved its construction, so that the most objectionable features of the older instruments are now entirely removed.

The cephalotribe consists of two powerful solid blades, which are applied to the head after perforation, and approximated by means of a screw so as to crush the cranial bones, and after this it may also be

[1 It was introduced into our country in 1843, under the name of brise-tite.-ED.]

used for extraction. The peculiar value of the instrument is that, when properly applied, it crushes the firm base of the skull, which is left untouched by craniotomy; or, if it does not, it at least causes the base to turn edgewise within the blades, so as to be in a more favorable position for extraction. Another and specially valuable property is that it crushes the bones within the scalp, which forms a most efficient protective covering to their sharp edges. In this way one of the principal dangers of craniotomy-the wounding of the maternal passages by spicule of bone--is entirely avoided.

The cephalotribe, therefore, acts in two ways-as a crusher and as a tractor. Some obstetricians believe the former to be its more important use, and even maintain that the cephalotribe is unsuited for traction. This view is specially maintained by Pajot, who teaches that, after the size of the skull has been diminished by repeated crushings, its expulsion should be left to the natural powers. There are some grounds for believing that in the greater degrees of obstruction the tractile power of the instrument should not be called into use; but, in the large majority of cases, the facility with which the crushed head may be withdrawn by it constitutes one of its chief claims to the attention of the obstetrician. No one who has used it in this way, and experienced the rapid and easy manner in which it accomplishes delivery, can have any doubt on this point.

There is every reason to believe that cephalotripsy will be much extended in Great Britain, and that it will be considered, as I believe it unquestionably deserves to be, the ordinary operation in cases requiring destruction of the foetus.['] The comparative merits of cephalotripsy and craniotomy will be subsequently considered.

[This is certainly not its future in the United States, where foetal destruction is being avoided, under the largely diminished fatality of the Cæsarean section and symphyseotomy.-ED.]