^"W^ lJA., ^, k>A>t-~ '^-^w #£c> ^ -<^^-^^ AN r ESSAY ON THE IMPORTANCE OF THE OBSTETRICK ART; SUBMITTED TO THE EXAMINATION OP Charles Alexander Warfield, M. D. President, And the Medical Faculty OF THE COLLEGE OF MEDICINE OF MARYLAND, FOR THE DEGREE OF DOCTOR OF PHYSICK, By Thomas DashieU~Jones....of ^Somerset, Maryland, MEMBER OF TH.W^.^IA^OA^oa.TV *«> OF THE BALTIMORE *. PRINTED BY BENJAMIN EDES. May, 1812. \ TO JOHN B. DAVIDGE, A. M. M. D Professor of Anatomy, Surgery, Sfc. OF THE COLLEGE OF MEDICINE OF MARYLAND, Whose diligence in cultivating, and ingenuity in improving science, merit the greatest praise: this is respectfully inscribed as a mark of res- pect, for his talents and virtues, by his pupil, THE -AUTHOR. «< I ESSAY. ▼ ? ITH regard to the rank which midwifery ought to hold, and to its intrinsic importance, much discifs- sion has taken place. By some, who have been zea- lously attached to the obstetrick art by taste, or who have had sinister motives for their commendation, it has been advocated as being more indispensably ne- cessary than, I believe, it will be found to be on a so- ber and candid examination of the subject. Others who have never engaged in the practice, and conse- quently could not have understood the different situa- tions in which an acquaintance with it is necessary to the safety of parturient women, nor have duly appre- ciated its resources, have decried the practice of mid- wifery altogether, and have asserted it to be a trifling, an useless, and sometimes a dangerous art. A few individuals, either from an ill-directed zeal, or from palpable knavery, have gone still further, and have advocated the practice of performing most horrid and dangerous operations, as substitutes for the estab lished and generally successful means of relief in diffi- cult labours, unequivocally discountenancing the cul- tivation of this branch of our profession by men of science. These strikingly different views of this subject, by men highly respectable for their talents and candour, appeared to me to render it worthy of investigation. 6 I shall therefore attempt to take a cursory view of the probable origin of the practice of widwifery, of the circumstances which have caused it to be confined chiefly to female practitioners, of those considerations which render it necessary for men, or at least persons regularly and well instructed in the principles of the art, to engage in the practice of it, especially where the habits and modes of living are indolent and luxu- rious: I shall also state the circumstances which cause the greater demand for skilful obstetrick practitioners in large and populous cities, than in other places: To which I will take occasion to add an account of the proportion of dangerous cases as well as of the mor- tality, among puerperal women. I will moreover point out the plan by which, according to my view of the subject, the obstetrick practitioner should be gov- erned. I shall not undertake to explain the reason why man, at his birth, is more completely, and for a longer time, helpless than any other animal of creation: the fact is obvious to all. The young partridge flees with a portion of the shell of the egg which produced it, on its head: the calf and the colt rise and follow their dams almost in the moment of their birth; while at this stage the infant is helpless and liable to be des- troyed by the untoward positions into which women sometimes throw themselves at the instant of bringing forth; and also by other attending circumstances, es- pecially if the mother, as not unfrequently happens, be too much exhausted to give proper attention: which must have suggested, at a very early period, the neces- sity of having one or more attendants to assist women in labour. 7 .............^. We do not know when aid was first given to wo- men suffering the pains and in,the perils of child-birth; nor is it material to trace the practice to the earliest periods of human existence. If, however, stress. should be laid on the antiquity of it, we learn from the highest authority that Rachel, wife of Jacob, and Ta- mar were assisted by mid wives during their labours. The Egyptian midwives were employed by Pharaoh for the destruction of the Hebrew children. We are informed that the mother of Socrates officiated in the capacity of a midwife: And in the works of Pla- to, an account is given of the functions and privileges of midwives. JEtius speaks of a person of the name of Aspasia, as a midwife; and persons of the same description are spoken of by Plautus, Pliny, Terence, and several other old writers. It appears however that, in all the ancient languages, the names by which they were called are feminine. Though some au- thors speak of men who were supposed to be skilled in this branch, and employed in those cases which were found unmanageable by the female practition- ers, especially in large cities. Paulus, who was born in the island of YEgena, in the seventh century, ap- pears to have been the first person who was called a man-midwife. He wrote a book in which he partic- ularly noticed women's complaints:—his practice how- ever in this branch, was probably altogether confined to difficult cases. In earlier stages of society, before the medical pro- fession was cultivated by men set apart for that pur- pose, from early life, and educated with a view to the practice of it, we may very naturally conclude, that s the little medical aid which was given, was in the first instances afforded by the oldest members of families, or those who had had the greatest opportunities of making observations on diseases: Some among these, from a natural sagacity, or from having accidentally been more engaged in such "business, must have be- come more skilful than others, and would be called on to assist their less successful neighbours: these would of course become a sort of regular practitioners of physic. Under circumstances such as those of which I have just spoken, we should naturally suppose that the as- sistance which might be rendered to women in labour would be afforded by those of their own sex; because, in a simple state of society, in which alone such cir- cumstances could have existed, the habits of industry and activity to which women are subjected, would, in the general, prepare them for going successfully through the process. In that state of society more- over women are generally looked on by their rugged lords as unworthy any particular attention: and in countries where polygamy was allowed, the death, or irremediable injury of a few women from the difficul- ties and dangers of parturition, was not deemed a mat- ter of any importance; and therefore it was not re- quired that persons should be regularly instructed be- fore they undertook to officiate as midwives. There is yet another very satisfactory reason why male prac- titioners were not engaged in that branch of business, viz. That until very lately the extent of their obstetrick knowledge and skill was so limited, that the women could derive no considerable benefit from their inter- 9 ference: For even when society had improved to such a degree that particular men applied them- selves exclusively to the practice of midwifery, meth- ods of affording relief,recommended by them in cases of difficult labour, argued the most entire ignorance of the structure and actions of the parts concerned in parturition. So unenlightened on this point was the great Hippocrates that, when any other part than the head of the child presented, he directed the attendants to raise the lower extremeties and pelvis of the wo- man, that the child might fall back into the womb, where he supposed it would have room to turn itself, and that it might present aright when it should return to the passage. When this plan did not succeed (and we easily under- stand that there was a very slender chance of its suc- cess) another was proposed: several strong persons were employed in shaking the patient violently in dif- ferent directions, intending thereby to effect a more speedy delivery; the assistant was directed to push up the presenting part, and at the same time to bring down the head if possible: After all these efforts, if the object could not be accomplished, the assistant was advised to have recourse to embryotomy. It is not difficult to determine readily on the proportion of un- successful cases of this operation; when we consider that it was performed on patients who had been sub- jected to such discipline, during labour, as that which I have described, with ill adapted instruments in the hands of persons unacquainted with the structure of the parts concerned. Even when there was no unfavorable presentation, 2 10 if labours proceeded slowly either from a bad forma- tion of the pelvis, from a casual rigidity of the soft parts, or from the proper space of time not having elapsed, and consequently these parts not being sub- servient to the peculiar laws of the animal economy which influence their evolution, it was the practice to bind women to ladders, or other bodies, and thus to suspend them that the child might drop out by the operation of gravity: In other cases they were com- pelled to walk or leap about, or by other means well shaken, that the child might thus be jostled from the womb as any mass from a common bag. When such rough and preposterous means were the best that the most skilful men had to propose for the alleviation of the sufferings of parturient women, it is not surprising that the women rarely had recourse to them. If women obtained so little assistance from male practitioners in the difficulties of which I have just spoken, they could not reasonably have looked to them for safety in the perilous conditions to which they are often reduced by the sudden and dangerous uterine hemorrhages and other accidents, which are so often fatal to women in a few hours, and which re- quire the utmost promptness and energy in the prac- titioner. In the earlier periods, and in the more simple states of society, when probably the hardy mode of rearing children destroyed those who had not good original stamina, and matured and strengthened those of good constitutions, defective forms, and consequently cases of difficult and dangerous parturition, certainly occur- red much more rarely, than at the present time under existing circumstances. 11 I have already intimated that the "methods of treat- ing children practised by some of the nations of an- tiquity, as well as by some uncivilized nations of the present time, destroyed the children who were defec- tive in original stamina, and at the same time had the effect of securing to those of good constitutions,healthy habits and perfect forms.* We should not therefore expect frequent instances of perilous or difficult par- turition, with the women of such nations, and under such circumstances, the calls for great skill were not very frequent, the business was permitted to remain for many ages, exclusively in the hands of uneducated females. Therefore to the variety of cases requiring great obstetrick knowledge, attributable to the healthy habits, and good forms of females raised in a hardy manner, with ample exercise, and to the unskilfulness of the men, do I, in a great measure, impute the long continuance of the habit of confiding the manage- ment of this department of practice so entirely to women. For in a direct ratio with the progress of the refined, luxurious, and indolent modes of living among women, and with the cultivation of this branch of science by physicians, we find men engaged in the practice of midwifery. We know that there exists almost universally in the female feeling a repugnance to accept the assist- ance of persons of the other sex in time of labour; * Such are supposed have been the effects of the Spartan education, as well as of the severe discipline to which chil- dren are subjected in some of the tribes of North American. Indians. 12 whether this disposition be innate, or the effect of ed- ucation, it is not material to determine; but it certain- ly is a cause to which we may ascribe the continua- tion of this practice with the women, and will no doubt contribute very much to retain it in the hands of female practitioners throughout time to come. The effect of it was shown in an eminent degree in Athens, when a law was made prohibiting women and slaves from practising midwifery. We are informed that the women who fell in labour at that time, preferred bringing forth without any aid rather than permit men to officiate. In this time of peril with her coun- try-women, a young wonlan named Agnodice, cut off her hair, and disguised herself in the dress of a man, after which she prepared herself for the practice of midwifery, and offered her services to her country-women, at the same time apprizing them of her sex: the demand for her attention soon became so extensive as to excite suspicion, upon which the craft was detected, and its agent brought to trial. The continuance of the practice of midwifery in the hands of persons uninstructed even in the rudi- ments of the knowledge necessary for the successful exercise of the obstetrick art, has been in a considera- ble degree attributable to the doctrines of some very respectable philosophers and physicians, who believ- ing in the perfect facility and safety with which the lower orders of animals are said to bring forth their young, have concluded that human parturition is ex- actly the same, in regard to the relative circumstances of the operation; and from analogy, that it would al- so if, left to nature, be accomplished with ease and 13 safety. In this case, not only the conclusion is incor- rect, but the position also upon which it is founded. It is said that the lower order of animals are not sub- ject to tedious, dangerous or difficult labours. We may indeed take the liberty of saying that when wild, or in a state of nature, they do not die in the act of parturition: but who shall prove this? It is true that we do not find bears, wolves, or deer, dead in such situations as to warrant the conclusion that they died in labour: but the same argument would prove with equal conclusiveness that they seldom or never die of diseases or of old age, as they are so rarely found in forests frequented by them. All animals when dis- eased, seek retirement, and when the time of labour approaches we observe the same propensity to pre- vail. As however we have not an opportunity of de- ciding on this point as it regards animals in a wild state, we may perhaps satisfy ourselves as to the dif- ficulty and danger of brute parturition by the obser- vations of persons who have attended particularly to herds of domesticated animals, especially cows. We are assured on the testimony of a man, very exten- sively engaged in the management of these animals, near London, that they sometimes suffer very severely during labour, which is evinced by the evident distor- tion of their countenances which are suffused with tears, and by their groans which may be heard at a considerable distance. He says that the process of labour with these animals is sometimes over in half an hour, but that it is oftenerAthe duration of two hours; and that it is frequently protracted to eight or ten hours, or even to two or three days; and that this 14 delay occurs not only in consequence of an unfavor- able position, but even in cases of natural presenta- tion. He also adds that the difficulties in these cases is sometimes so great as to require the dexterity and strength of six or eight men, or even the agency of horses to^extract the young animal. He moreover informs us that these animals sometimes lose large quantities of blood in parting with their young. And although he admits that he never knew one to bleed to death in such cases, he says, that he has seen many instances in which they have been reduced so low that for a long time they have not, and in some cases they have never recovered their former health. The same person assured Dr. Bland that they are sometimes subject during labour, but much more so immediately after, to convulsions, of which they expire in a very short time. We learn from the same authority that they are liable to a laceration of the perineum to a great extent; to prolapsus uteri; and to a retention of the membranes called cotyledons, which are analogous to the placenta in the human subject. The retention of the membranes subjects the animal, thus suffering, to bad health and emaciation, until the substance be gradually discharged in consequence of putrefaction. We have in this herdsman a candid and dispassion- ate testimony of the tediousness, difficulties and dan- gers of brute parturition. We cannot conceive of any temptations which could have induced him to mistate* the facts; moreover his representations bear internal evidence of their having been founded on observation. I am justified by very respectable authority in assert- ing that a gentleman near Baltimore, lost three cows 15 in one year, all which died in the act of parturition; and I am informed by a medical friend of mine, that he has seen one case in which the cow died in the act of parturition, with the calf half extruded from the os externum. These cases of difficult and dangerous labours, of which many others might be adduced, are sufficient to shew that brutes; do not always go through the parturient act with ease and safety, and conse quently that no analogical argument can be advanced to support the practice of leaving women in labour entirely to nature. If we were influenced by the representations of travellers, respecting the facility with which children are brought forth in different parts of the world, we should conclude that no aid is requisite to a woman while bringing forth her young. Independently of the objections which might be urged against those representations on the probable ground that these travellers could not have had con- venient opportunities of making accurate observations on women in labour, it may be remarked that they were made principally on women in that state of so- ciety in which we find, what I have before mentioned, but few delicate habits or defective forms. Bruce, as well as Pettivilius made observations on this subject among the women of Abysinia: other writers make similar reports with respect to the wo- men of different parts of Africa, Asia and America, and in all these instances they may be said to have been made on women nearly in a state of nature. It is reported that among the rude inhabitants of South America, some of the men act the part of an accou 16 cheur with their wives; and that the women when de- livered, forthwith proceed to wash themselves, and immediately afterwards engage in their ordinary avo- cations. Brisson and other travellers, tell us that the Moor- ish women bring forth almost entirely without pain or difficulty. Diodorus jBgculus gives an account of a most singular practice of the husbands in Corsica, who, as soon as their wives were delivered, took their places in bed and received the indulgences which were deemed necessary to the puerperal state. But in the time of this writer, Corsica might be considered, as it regarded the treatment of women, to be in a state of barbarism. After all, it is not difficult to account for the easy labours of the women of the nations which I have mentioned; nor do I hesitate in ascribing it to their healthful habits and perfect forms: they being either laborious or accustomed to free and full exercise in the open air, which, I will take occasion to repeat, greatly contributes to establish an accurate proportion of form. Mr. Brydone would however induce us to believe, that the process of parturition is by no means a seri- ous affair, and that lying in, is nothing more than a party of pleasure in Sicily, where the habits of living are both indolent and luxurious: In support of which positions, he tells us that he was invited in conformity with the custom of the place, to visit a lady who had been delivered the night before, whom he found sit- ting up in bed conversing with great cheerfulness. Many ladies of our own country might also receive 17 and enjoy company on the day succeeding their de- livery, if it were not forbidden by custom, by pru- dence, and by decency. I therefore think that the practice of the Sicilians may rather be considered as a proof of the easy and social intercourse of that island, than as an evidence that parturition there is un- attended by pain, difficulty, or danger. Having conceded the point, to those who rely on the powers of nature in parturition, that under cir- cumstances the most favourable to the perfection of the female form and constitution, there will rarely be difficulties from any irregularity or deficiency in the dimensions of the pelvis, I must insist, notwith- standing, that even under such circumstances as these, many accidents occur which, when the cases are left to nature, terminate fatally: of these cases I shall take some notice presently. The number of such cases which take place over an extensive country, where the women are accus- tomed to plain living and ample exercise, is indeed not sufficiently great to require the service of a skilful obstetrick practitioner in every vicinity. The aggre- gate however is not inconsiderable. But in large and populous cities, difficulties and dangers so frequently occur in parturition as to demand of the practitioner very particular attention to this subject. Of these evils of labour, some arise from the mismanagement of children in early life, while others are acquired from indulging in bad habits at mature age. In all populous and wealthy cities there are two classes which chiefly furnish troublesome cases to the accoucheur, these are the affluent and the indigent. The first error of which I shall speak as productive 3 18 of the more serious evils of parturition in these cities than in dissimilar situations, is the injudicious delica- cy with which children are treated; the confinement which a residence in towns almost necessarily impos- es on them, and consequently the want of exercise and fresh air, which evils are augmented by sending children prematurely to school, where they are often kept perfectly still in the contaminated air of a crowd- ed room, in a sitting posture, for several hours togeth- er: moreover, children of cities subsist on diet too stimulating, as tea and coffee, and other food by far too highly seasoned for their stomachs. By this im- proper mode of living the constitution cannot fail to sustain considerable injury: whereas on the contrary, the children of the indigent order of populous cities fre- quently suffer from a penury of food both as to quan- tity and quality. They are besides in many instances confined in narrow unventilated lanes and allies, and in damp cellar-rooms, often very imperfectly protected from the inclemency of the weather either by clothing or even a competent supply of fire; and in manufac- turing towns they are often engaged in some mechan- ical business almost as soon as they can walk. These causes are the source whence arise the fee- ble and sickly appearance of the children of the rich, and the meagre and squalid looks of those of the *poor; in both of whom we often observe rachitis or scrophida making formidable ravages, which consum- mates the unhappy condition of these unfortunate subjects. It is at this early period of life that the >pelvts of females are often irremediably injured, and a foundation laid for the most perplexing cases that fall within the province of the accoucheur. The 19 chief weight of the body either in an erect or sitting posture rests on the sacrum which in many cases yields, and approaches the pubis; in others the aceta- bula approximate the sacro-iliac junctions in conse- quence of the counteraction between the weight of the body and the supporting qssa femorum; and when a child labours under rachitis the sitting posture gives the tuberosities of the ischia a tendency towards each other. From all or any of these defects in the pelvis, more or less difficulty will be experienced in parturition according to the degree of deformity. Although it must be admitted that notable deform- ities of the pelvis, are not very common as conse- quences of these modes of living, still such habits very frequently prevent the body from acquiring its proper firmness and vigour, and from this results a feeble and infirm constitution, the evil of which is in- creased by the irregularities and dissipated habits, which are in the general connected with wealth and fashion in large cities. Thus under these circumstan- ces the constitution is often so much enervated as to be unable to go through the regular period of gesta tion, and abortion is the issue; or if the time of ges^ tation be of sufficient duration for the maturity of the foetus, such delicate and nervous habits are liable to tedious, difficult, and sometimes dangerous labours. I have pointed out the material circumstances which certainly have the effect of producing a greater pro- portion of afflictive labours in large towns than is ob- served in the same number of cases scattered over an extensive country, and this consideration independent- ly of the density of population, suggests the greater necessity of well informed obstetrick practitioners in large cities than in country places. 20 There are however other casualties which, although they may occur more frequently in towns, also hap- pen in all other places. Uterine hemorrhage may at- tack pregnant women in any situation, and at almost any period of gestation: they may arise from a par- tial separation of the placenta from the womb, or from the breaking up of the attachment of the pla- centa over the os uteri by the natural evolution of the parts. The former species is checked by rest, hori- zontal posture, and other general means : the latter requires that the attendant should be fully apprised of its nature that he may accomplish the delivery promt- ly at the proper time, as in this way only can the pa- tient in many cases be rescued. Violent hemorrhages supervene very often after the expulsion of the child, which sometimes can only be arrested by introducing the hand into the uterus and extracting the placenta. Recondite hemorrhage occasionally takes place du- ring the progress of labour, which is constituted of an effusion of blood into the cavity of the uterus by rea- son of which the abdomen is rapidly distended, and becomes turged and tense; the throes are enfeebled or cease altogether; the circulation becomes languid; the expelling force is exhausted; nature yields and the pa- tient is left in a sinking condition, for which we have no remedy but from the intervention of skill. Wrong presentations which are insurmountable by the powers of nature are often obstacles to delivery. When an arm, a shoulder, an ear, the back, or the breast of the child presents, unaided nature is almost always incompetent to the task of effecting delivery, and without judicious assistance the patient becomes exhausted by the long continuance of the pains and exertions of labour and dies undelivered. 21 I consider it unnecessary to enter more minutely in-' to an enumeration of the cases in which an intimate acquaintance with midwifery, as well as intrepidity in the attendant, are indispensably necessary to the safety of parturient women I readily admit that in a vast majority of cases na- ture-would and does complete the process of parturi- tion without the interposition of art; but I as readily contend that there are many instances in which from the circumstances enumerated, not only nature is inad- equate to the business, but the greatest skill and dexteri- ty that can be acquired from a regular course of study in regard to the structure and actions of the parts con- cerned, and a familiar acquaintance with the means of relief, are necessary to the preservation of the patient. Nor is the relief of women in labour from the difficul- ties which I have mentioned, the only consideration, that excites my anxiety to see the practice of midwife- ry entirely in the hands of persons thoroughly instruct- ed in the obstetrick art: an advantage of no trifling im portance, which would arise from such a change, is, that it would secure women from the injurious treat- ment of common midwives which has now become so inveterate that no persuasion can alter, nor energy sup- press it. Their violent efforts to help the women and to accelerate the birth of the child are productive of very great mischief, and are evidently the source of many sad calamities, which occur in common practice. As it has been suggested that the cases requiring aid, are too small a proportion of the whole to warrant the engagement of men in this pursuit, it may not be un- interesting to state the estimates of the number and 22 kinds of difficult cases, as found in different obstet- rick records. Dr. Smellie supposes that of one thousand cases, eight will require instruments, or, that the foetus be turned to supersede the necessity of their use. Dr. Bland, who made his report from an hospital register, says, that out of one thousand eight hundred and nine- ty-seven cases, there were eight in which the arm pre- sented; in one the funis; in eight others the head was opened, and in four the forceps were used. Notwith- standing reports on this subject vary very much, we shall perceive by all which are honestly made, that the num- ber of cases requiring aid, though comparatively small, is far too great to be sacrificed to ignorance and preju- dice. Our views of the importance of the duties of the obstetrick practitioner, may perhaps be rendered more satisfactory by noticing, on an extensive scale, the pro- portion of deaths occurring in the puerperal state; the mortality of which has been ascertained to constitute- in London, nearly one eightieth of the whole funeral catalogue. From an examination of several country registers in England and Germany, Dr. Short calcu- lated one in every sixty puerperal women to die in child-bed: Others have fixed the proportion at one in sixty-six. On a computation made from the London registers of seventy six years, it was found that one in seventy-four died in child-bed in that city during the period above mentioned. If the province of the accoucheur extended no far- ther than to the exercise of his art, in obviating the above mentioned difficulties and dangers, at the time 23 of parturition exclusively, 1 presume that it would even then be admitted to be highly useful. But if all the indispositions incident to women from the com- mencement of pregnancy, to the termination of lacta- tion, which are attributable either to the one or to the other of these conditions of the body, or to the act of parturition, be deemed objects of attention in an es pecial manner to the obstetrick practitioner, it must be allowed that midwifery ranks among the most im portant branches of medical science. The affections of this class are various and extremely distressing, and sometimes dangerous; and the subjects of them more- over claim our highest concern from the influence which they have on the comfort and happiness and even the existence of mankind,* I cannot resign my pen without committing to this paper, a memorial of the warm emotions of my breast which I publicly tender as a tribute of liberal grati- tude and respect to the Professors of the College of Medicine of Maryland, for their social politeness and instructive attention, exercised towards their friend the Author. FINIS I