Obstetrics in the 1700s

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Obstetrics in the 1700s

Overview

Obstetrics, the medical specialty of caring for women and their babies during childbirth, arose in the mid-eighteenth century. Ordinarily, women in childbirth were attended by other women—mostly relatives, friends, or neighbors who offered support and practical aid. In addition, a midwife ( meaning "with woman") was often employed to bring skilled assistance and the assurance of someone who had attended many births. The nearest surgeon was summoned only in the midst of dire complications. By 1750, physicians and surgeons sought opportunities to attend births and incorporate pregnancy and childbirth into the medical forum. Almost universally male, these man-midwives gained acceptance throughout the latter half of the eighteenth century. The increasing status of surgeons, advances in technology such as the invention of the obstetrical forceps, and the growing number of institutes and universities dedicated to medical knowledge and training of physicians enabled the birth of obstetrics as a medical specialty.

Background

Before the eighteenth century, childbirth was a women-only affair. Midwives received no formal training, and learned their skills mostly through informal apprenticeship or direct experience. Especially in English and European society, midwives were not viewed as part of the medical community. Instead, the role of the midwife was seen as a benevolent and seemingly religious one. Superstitions regarding childbirth lingered from the Middle Ages. Attempting to prevent witchcraft associated with childbirth, bishops in the Church of England required midwives to obtain an Episcopal license which prohibited them from practicing magic, coercing fees, or concealing information about a birth. Midwives were obligated to treat the poor, and were able to perform baptism in emergencies. In the early 1700s, midwives in some American colonies were required to obtain a license similar in content to the Episcopal licenses of England. These rules of licensure kept the midwife's primary function a social one, and minimized her importance medically.

The first physician to place midwifery on sound scientific ground was William Smellie (1697-1763). British-born, Smellie practiced general medicine in Scotland and studied surgery in Paris before settling in London in 1739. Smellie, interested in obstetrics, conceived the idea of teaching the subject at his apothecary shop residence. He used a leather-covered mannequin of bones, and charged three guineas for the course. Smellie offered free care to London's poor women, thus providing him with clinical teaching material. As Smellie's patients allowed students to attend their deliveries, the trend toward medically trained persons attending childbirth was established. Smellie was also the first to teach obstetrics and midwifery on a scientific basis.

Smellie published his lectures, along with his Treatise on the Theory and Practice of Midwifery in 1752. Further advancing the practice of obstetrics, Smellie introduced obstetrical forceps that were properly designed and properly used. Made of wood or steel and padded with leather, the forceps were correctly curved, and had a simple lock design. Smellie's forceps were the length necessary to deliver the head of the baby only after it had descended into the pelvis, a standard for safety defined by Smellie and published in his works. Careful systematic measurements of pelvic capacity were taken by Smellie and his students, which led to standards of differentiating normal pelvic structure from the abnormal.

Smellie acquired a large practice, and among his pupils was English surgeon William Hunter (1718-1783). Hunter, per Smellie's example, also eventually gave private lecture courses on surgery, dissection, and obstetrics. Hunter trained many of London's man-midwives, and, due to his skill and courtly disposition, Hunter was also in demand as a man-midwife to London's social elite. Hunter's further contributions to obstetrics include a famous atlas of the pregnant uterus, praised in both scientific and artistic circles, and the discovery of a separate maternal and fetal circulation. Hunter also built the celebrated anatomical theater in London, which served as the training ground for the best surgeons of the day. Among these was John Hunter (1728-1793), brother to William Hunter. John Hunter, an enthusiastic experimentalist, became the leading surgeon-physiologist of his day, elevating surgery from a manual trade into a scientific discipline. As obstetricians trained as surgeons, the practice of obstetrics was elevated as well.

Impact

Like most of the medical advances of the eighteenth century, advances associated with childbirth and obstetrics were linked to the prevailing philosophy of the Enlightenment. A rational approach to the events surrounding childbirth was advocated by the new man-midwives. Previous superstitions and interventions labeled by physicians as unnecessary "midwife meddling" (binding breasts, for example) were abandoned in favor of allowing nature to accomplish much of the process. Ladies were encouraged to give birth in rooms with fresh air and sunlight. Newborn infants were no longer swaddled in restrictive linens as it was felt that allowing freedom of movement would promote muscle and bone development. The importance of breastfeeding was championed as women were urged to dismiss their wet-nurses and bond with their infants. Women were admonished of the potential risks to their reproductivity brought about by wearing corsets, and one anatomist carried out a public campaign for women to abandon them. Not all Enlightenment-related opinions regarding obstetrics and child care were well received. In France, wet-nursing prevailed, and in Catholic Spain and Italy, male obstetricians made little progress as the Church demanded female modesty. Throughout the western world, most women kept their corsets.

By 1775, most women of the upper socioeconomic class in Europe and America chose the accoucheur, or male midwife, to attend them in childbirth. His confidence in allowing a natural approach to birthing was backed by a solid base in anatomy and the known physiology of the day. In addition, he had instrumentation to hasten emergency or difficult deliveries, and some advance knowledge of when he might need to use them. For instance, obstetricians were taught to identify pelvic deformities brought about by the fashionable low protein diet of wealthy women, as well as those caused by rickets in malnourished poorer women, and to anticipate a forceps delivery, or at worst, surgically dismember the fetus and deliver it in pieces to save the life of the mother. Maternal death from such complications was no longer a foregone conclusion. Fetal lives were also saved when birthing complications arose. Smellie was the first physician documented to successfully resuscitate an asphyxiated infant by inflating the lungs with a silver catheter.

Although the services of medically trained man-midwives were accepted and often preferred by childbearing women in the last half of the eighteenth century, the majority of babies were still delivered by traditional female midwives. Universities and institutions of medicine had simply not yet produced enough physicians and surgeons to meet the needs of the population. By the end of the century, university medical schools and private institutions of medicine that included obstetrics in the curriculum flourished across Europe. In colonial America, the Medical College of Philadelphia was founded in 1765, King's College (later Columbia) Medical School in 1767, and Harvard in 1782. No longer was it necessary for an aspiring American physician to travel to Europe to receive an excellent medical education. Obstetrics was the first medical specialty taught at these schools. Midwifery was assumed to be a cornerstone of American medical practice, since every physician would encounter childbearing patients after graduation. In America, physicians would essentially replace midwives in attending childbirth, although the transition would take more than another century, due to westward expansion and the enlarging frontier.

In other countries, notably Britain, there was sometimes considerable strife between midwives and their male physician counterparts. Besides competition for the financial reward (meager at times, and often settled in trade), midwives often felt male physicians should not be involved in such an intimate female process. One eighteenth-century midwife, Elizabeth Nihell, accused Smellie of insufficiently training midwives, so that physicians would have to be called in to birthing situations more often. Nevertheless, in Britain the practice of obstetrics flourished, but did not completely take the place of midwifery. The two professions often collaborated, as midwives received better training and the number of obstetricians increased.

Obstetrics in the eighteenth century made few advances profound enough to dramatically impact the health of the childbearing population as a whole. Childbirth, although now appreciated as a natural process, could still be a risky business. Puerperal fever (infection after childbirth) still afflicted women of all classes. In one epidemic year of 1772, mortality in Paris, Vienna, and other European centers rose as high as 20% of all new mothers. Few cesarean sections were attempted, and fewer were successful before anesthesia and Listerian antisepsis. Infections and other causes of maternal and infant mortality occurred at rates significant enough to lower the average life expectancy in Europe and America to well below 40 years. The most important accomplishment of obstetrics in the 1700s was that it began to transform perceptions of medicine's place in society. With Enlightenment thinking, the stage was set for future obstetrical and medical advances based on sound scientific reasoning and experimentation, rather than on religion or tradition.

BRENDA WILMOTH LERNER