Obstetrics and Gynecology

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OBSTETRICS AND GYNECOLOGY

OBSTETRICS AND GYNECOLOGY. Obstetrics and gynecology were marked by technical, intellectual, and social innovation in the early modern period. While female midwives continued to deliver almost all babies, both male and female writers sought to improve obstetrical practice, and anatomists strove to understand the workings of the human body, including the female sexual and reproductive systems. Although historians argue about the actual extent of maternal mortality, it is clear from sources that women feared losing their lives in childbirth and that most women knew personally another woman who died in childbirth or shortly thereafter. Similarly, while the full extent of neonatal death in early modern Europe will remain unknown, it is clear that birth was far more hazardous for babies than for their mothers.

Obstetrics and gynecology were grounded in classical and medieval precedent. The first European vernacular work on obstetrics, Eucharius Roeslin's Rosegarten, was published in German in 1513 and was reprinted at least another twenty-four times up to 1608. Addressed to midwives and married women, it describes the mechanics of labor and delivery, care of the newborn, and common complaints in pregnancy. Roeslin's son translated the work into Latin, and the book subsequently became a European best-seller, translated into French, Dutch, Spanish, Danish, English, and Czech and republished into the eighteenth century.

Although Roeslin's work proclaimed itself to be for a popular or lay audience, it owed much to learned authorities. Scholarship suggests that the work was not originally written for midwives but for medical men. In his preface, Roeslin describes how Galen (129c. 199 C.E.), Rhazes (Rāzī, c. 865between 923 and 935), Avicenna (Ibn Sīnā, 9801037), and Averroës (Ibn Rushd, 11261198) struggled to understand the human body, and then places his own work within this learned masculine lineage. Much of the book, including the illustrations, ultimately derives from classical antiquity, specifically from Gynecology by Soranus (c. 100 C.E.). Indeed some historians have argued that contemporary midwifery practice was more sophisticated than Roeslin's classically based text might suggest. Roeslin after all was working from texts, not from experience delivering healthy babies, and his preface suggests a scorn for the manual knowledge and skill midwives possessed.

INNOVATIONS

Four technical innovations characterized early modern obstetrics. Until the eighteenth century babies were delivered by female midwives; male surgeons only entered the birthing room when the midwife and the attendant women judged that the infant's life was already lost. The task of the surgeon was to extract the body of the infant, often by the bloody means of perforating the infant's cranium to reduce the size of the skull or otherwise mutilating the infant's body. In 1549 the French surgeon Ambroise Paré (15101590) published directions for the technique of podalic version, that is, turning the baby in the womb so the feet present first, allowing application of traction to the feet and legs to induce delivery. It is not clear how extensively the technique spread or was employed by midwives, but it was an effective and lifesaving technique.

The second set of innovations centered on new devices. An obscure array of tools was in use by the late seventeenth century to apply traction to the head of the baby in the birth canal to promote delivery. The vectis, a sort of spoon-shaped device, and the fillet, a circle of leather or fabric put around the infant's head, seem to have been employed by some practitioners. The most successful of these devices, however, was that developed by the Chamberlen family, the obstetrical forceps, similar in design to modern forceps. For about a century this London family of Huguenot immigrants kept their device a secret. The use of forceps was demonstrated in Paris in 1720, and the first printed description of their design and use dates from 1733.

While the forceps offered surgeons a new technique that promised to preserve the lives of mother and baby, it was not uncontroversial. First, as seen in the writings of some practitioners, the instrument was not easy to use, and usually a surgeon had to be shown the technique in detail. Not all surgeons were convinced of their utility. William Smellie (16971763), the first British superstar male midwife, wrote that forceps were only necessary in ten of ten thousand cases. William Hunter (17181783), his successor, said of forceps "where they save one, they murder twenty" (cited in Spencer, pp. 7273). However, for women afflicted with malformed pelvises (often caused by rickets), the forceps offered new hope of giving birth to a living child.

The third technical innovation was almost never performed; in fact it was judged a failure for most of the period. Learned men knew that Julius Caesar had been born by cutting open his dead mother's belly, but in the sixteenth century surgeons began to discuss the possibility of performing the operation to save the life of the mother as well as the child. Supposedly a Swiss gelder performed the operation on his own wife at the beginning of the sixteenth century. Paré had authorized the use of the operation five times at the Hôtel-Dieu in Paris, but none of the women survived. Paré forbade other surgeons to perform it. Only in the 1790s did surgeons begin again to perform cesarean sections on living women.

The fourth innovation was pioneered by the French midwife Madame Angélique Marguerite le Boursier du Coudray (c. 17141794). She invented mannequins that modeled various presentations in childbirth and employed these new devices in a system of royally sponsored midwifery courses. From 1760 to 1783 Coudray taught in over forty French cities and towns. She understood that midwives learned their techniques from other midwives through touch, not sight. Consequently she structured her teaching with posters and with the life-size mannequins that she constructed herself from leather, bone, and fabric.

CIRCULATION OF KNOWLEDGE

Reproduction was a mysterious, even magical, property of the female body, often compared to alchemical or agricultural processes. The Renaissance rebirth of human dissection offered male surgeons the possibility of knowing about the hidden interiors of women's bodies in a new and powerful way not available to female midwives. Renaldus Columbus (15161559) famously "discovered" the clitoris in 1559. His successor at the University of Padua, Gabriele Falloppio (15231562), argued that he had first identified the clitoris as well as the tubes that still bear his name. In 1611 the Copenhagen anatomist Caspar Bartholin (15851629) scorned both of their claims and pointed out that everyone had known about this body part since the second century. Other anatomists scoffed at their medieval predecessors, who claimed that the human uterus had seven cells or chambers.

The knowledge and practices of obstetrics and gynecology circulated among and between learned and lay cultures to a greater extent than many other areas of medicine. Obstetrics was almost entirely practiced by midwives and women, and the dynamics of the birthing room ensured that any male practitioner called in would have to temper his plans to fit with the wishes of the birth mother's attendants. Alexander Read (15861641), for example, reminded his readers of what had become accepted wisdom, namely that the unborn baby only respired via the blood in the umbilical cord. Nonetheless Read advised surgeons to keep the mother's mouth and genitals open even after she died if a postmortem delivery of any kind was contemplated. Although the practice was useless, women believed that the unborn baby would suffocate unless the passages for air were kept open, and would blame the surgeon for negligence. Coudray's teaching similarly illustrates that obstetrics was poised between the female world of the birthing room and the male anatomical theater but that neither was isolated from the other. Coudray's brilliance lay in translating the realm of anatomy from sight to touch and from surgeon to midwife.

These intersections between learned academic medicine and practices of midwives and other women emphasize that birth was a social and cultural process far more than it was a medical one. The great conundrum of early modern obstetrics, namely why well-to-do women in England and North America came to employ male midwives, cannot be addressed without understanding social and cultural processes. In many places in Europe obstetrics and gynecology were shaped by larger shifts in the valuation of infants and the roles of mothers as much or more than they were by developments internal to medicine.

Historians have struggled to explain why and how women in England came to accept men as midwivesas the attendants for normal deliveriesin the first half of the eighteenth century. It was once thought that the technological determinism provided the answer: men midwives had forceps, which their female counterparts lacked. However, some of the most popular male midwives did not use forceps or only employed them rarely. Hunter is quoted above scorning the forceps, and yet he was the most successful male midwife in mid-eighteenth-century London. Hunter taught anatomy and male midwifery to male pupils at his own private school, in the process creating a public reputation as a skilled and knowledgeable man. He also cultivated politeness, advising his students, for instance, to avoid performing rectal exams to determine pregnancy in order to preserve the dignity of his female patients. Supposedly he helped a few aristocratic women conceal illegitimate births, and his name was madehe was seen as genteel and courteous. Undoubtedly the rise of male midwifery owed something to the perception that men might offer a technology that women did not (the forceps), something to the whims of fashion, something to changing patterns of women's work, and something to the recasting of vernacular practices as "superstition." By the end of the eighteenth century a number of medical men in Britain specialized in obstetrics and delivered thousands of babies over the course of their careers. Nonetheless midwives continued to deliver most infants.

As important as the curious rise of male midwifery are two other social phenomena: an increased value placed on infant life and a reconfiguration of motherhood. In part due to the rise of mercantilism and its attendant belief that the wealth of the nation depended on the health of the nation and in part due to patterns of post-Tridentine Catholic charity, infant life became more highly valued in the seventeenth and eighteenth centuries. Although the dead bodies of newborns could still be found abandoned on dung heaps, initiatives such as foundling hospitals and lying-in hospitals presented the possibility that unwanted babies might be supported by the church or the state. The Ospedale degli Innocenti was founded in Florence in 1419; other Italian cities followed suit in the sixteenth century; Paris and Lyon in the seventeenth century; and London in the eighteenth century. Such hospitals afforded medical men clinical training and poor mothers a roof over their heads, bed rest, and nourishing food.

Related to the new value placed on infant life was a gradual shift in the meanings of motherhood. From the late seventeenth century medical men echoed churchmen and philosophers in emphasizing the importance of maternal care for babies. The archbishop of Canterbury gave a sermon extolling the virtues of breast-feeding in the 1690s; medical men chimed in, arguing against the widespread practice of employing wet nurses. Increasingly middling women were instructed that their place was in the home, not at their husbands' workshops, and that their task was to nurture their children. By the late eighteenth century this reconstruction of the meanings of maternity was used quite consciously by Jean-Jacques Rousseau in Émile (1762) to claim that women could take no public roles. Medical men played an important part in these changing definitions of motherhood. In 1747 William Cadogan (17111797) denigrated much of traditional baby care as superstition and ordered mothers to ignore the advice of other women and to be under the supervision of "men of sense," namely husbands and doctors.

The histories of early modern obstetrics and gynecology began as the prehistory of a medical specialty, highlighting a few forward-looking innovations and denigrating the rest as ignorant or worse. Since then feminist historians have broadened views of midwifery, and historians of the body have explored the construction of sexual anatomies. Like much of the history of medicine, however, learned obstetrics and gynecology remain understudied and poorly connected to the larger stories of scientific revolutions and changes in gender ideologies.

See also Family ; Medicine ; Midwives ; Motherhood and Childbearing ; Public Health ; Sexual Difference, Theories of .

BIBLIOGRAPHY

Primary Sources

Rendle-Short, Morwenna, and John Rendle-Short. The Father of Child Care: Life of William Cadogan (17111797). Bristol, 1966. Includes the complete text of Cadogan's "Essay upon Nursing and the Management of Children," 1748.

Roeslin, Eucharius. When Midwifery Became the Male Physician's Province: The Sixteenth Century Handbook: The Rose Garden for Pregnant Women and Midwives. Translated by Wendy Arons. Jefferson, N.C., 1994.

Secondary Sources

Bowers, Toni. The Politics of Motherhood: British Writing and Culture, 16801760. Cambridge, U.K., 1996.

Bynum, W. F., and Roy Porter, eds. William Hunter and the Eighteenth-Century Medical World. Cambridge, U.K., 1985.

Gélis, Jacques. History of Childbirth: Fertility, Pregnancy, and Birth in Early Modern Europe. Translated by Rosemary Morris. Boston, 1991. Translation of L'arbre et le fruit.

Laqueur, Thomas. Making Sex: Body and Gender from the Greeks to Freud. Cambridge, Mass., 1990.

Spencer, H. R. The History of British Midwifery from 1650 to 1800. London, 1927.

Wilson, Adrian. The Making of Man-Midwifery: Childbirth in England, 16601770. Cambridge, Mass., 1995.

Mary E. Fissell