Four thousand years of obstetrics

[From Fernehs’

Universa

Medicina,

BOOKSHELF

Geneva,

1679.1

BROWSING

FOUR THOUSAND

YEARS OF OBSTETRICS*

J. WILLIAM WHITE, SCRANTON,

0

BSTETRICS is that part of the science and art of medicine most intimately reIated to the function of reproduction, the foremost of the four primary, instinctive bases of nature. The word obstetrics comes from the Latin ob and stare, “to stand before,” “to protect.” WhiIe, in the strict sense, it shouId be apphed to chiIdbirth or parturition, usage justifies its appIication to a11 phases of human reproduction, with midwifery and tocoIogy as synonyms. The function of reproduction is a cIosed cycIe of events interposed in the Iife of woman, and comprised of five periods: conception, pregnancy, Iabor, Iactation and invoIution, with possibIy a sixth, menses, a prerequisite. The history of obstetrics possesses a peculiar interest, and one by far more genera1 than that of any other branch of medicine as its status and its progress are most intimateIy bIended with the condition of peopIes and the extent of their CiviIization. The obstetric art, the assistance rendered during parturition, the care of the mother and chiId, is a necessity at a11 times. This branch of medicine appIies to the physioIogicaI as we11 as the pathoIogica1 state,

M.D.

PA.

and thus differs from a11others the exercise of which is confined to morbid conditions. However remote the period, however crude or primitive the peopIe, in ancient or modern times, aid was aIways given chiId-bearing women. Long before medicine was conceived as an art, women who bore chiIdren received attention from the most primitive peoples who, taught by experience, assisted their neighbors as a warrior or hunter renders primary surgica1 aid to his wounded feIIow. Much information reIative to the parturient of the dark age remains conjectura1 and obscured by mists onIy dispersed with the advent of the earIiest records. It is quite natura1 to assume, however, that obstetrics was the art first and most frequentIy caIIed for and that it attained a certain degree of perfection at reIativeIy an earIy day. It is aImost inconceivabIe that not a step forward was taken for two thousand years, from the time of Hippocrates unti1 Part: and VesaIius Iaid the foundation for the modern scientific schoo1. In earIy days it w’as woman who gave aid to her sister in child-birth; the art was in the hands of women, usuaIIy of Iow caste. It was Iooked upon as woman’s work, and progress was thus impeded, if

* Read before the P. Brooke BIand (Jefferson MedicaI CoIIege), and the Barton Cooke Hirst (University of Pennsylvania) Undergraduate Obstetrica Societies in Joint Meeting, February 25, 1926. Submitted for pubIication December 22. 1930.

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not impossibIe. WhiIe the aid of priests or men thought possessed of mystic powers was sought in diffIcuIt cases, they were at other times carefuIIy excIuded from the Iying-in room, and thus prevented from gathering the experience necessary to progressive innovation. It was eminentIy the sphere of woman, and so considered unti1 the era of modern scientific medicine. We need but recaI1 the experience of Dr. Wertt, of Hamburgh, Germany, who in 1522, attired as a woman, sought to attend and study a case of Iabor and was burned aIive for his endeavor. We may aIso recaI1 the experience of Dr. WiIIoughby one hundred years Iater, who, whiIe assisting his midwife daughter, was obIiged to craw1 on his hands and knees into the darkened room. The titIe of maeuti, man-grandmother, was given by the Greeks in the time of Hippocrates (400 B.C.) to men caIIed in difhcuIt cases and this spirit prevaiIed to the scientific period, as indicated by the appeIIation given ChamberIen, “the manmidwife,” who devised the forceps in the middIe of the sixteenth century. We may Iook to the obstetric practice of a peopIe as indicative of their civiIization, cuIture, and moraIe. In America the practice of obstetrics is considered not aIone as worthy of the physician, but as one of the most important branches of his art, and in this country confinements among native-born women are, as a rule, conducted by physicians. In striking contrast to this in oIder countries, unti1 fairIy recentIy, even among the higher cIasses, the treatment of women in Iabor was IargeIy the province of the midwife. With the growing importance of anatomica and physioIogica1 knowIedge, with the supremacy of the maIe scientific obstetrician, IocaI and nationa pecuharities graduaIIy fade away and the obstetric art assumes a more important position among the various branches of medica science. Not unti1 recentIy, however, has obstetrics come to occupy the position it deserves by priority and importance. Side

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by side with higher deveIopment of the art in our present civiIization, the various epochs of the empirical stage through which it has passed stiI1 persist. Obstetrics, as it existed before the time of the Pharaohs, and previous to the time of Greek civiIization, is faithfuIIy preserved among races and peopIes who remain primitive. Side by side with the axis-traction forceps, the perfected cesarean section, aseptic techIegislative edicts, nique, strict teaching, and most modernIy equipped Iying-in hospitaIs, a11 epochs of empiricism are represented, even to the very earIiest intuitive practices, as they must have existed in Egypt or in Greece before the time of Homer. Among the Mexican Indians and certain negro tribes of Africa, obstetrics persists unadorned by modernization. These simple peopIe with their primitive resources, however, before the taint of present miscegenation of races, were by no means as heIpIess as might appear at first sight. Labor was more natura1, the parturient exposed to fewer dangers, for it is now known that diffIcuIties of chiIdbirth increase proportionateIy with progress civiIIy and economicaIIy. This is not due so much to degeneracy of humanity, brought about through Iives of reIative ease and Iuxury as it is to the danger of infection in crowded IocaIities, and the increasing disproportion between passage and passenger, a change in reIationship between the head and peIvis, fostered perhaps by an admixture of races, resulting in hybrids, progenitors of future mutations. These eIements of danger are wanting in the primitive peopIes, where intermarriage of nations, or even tribes, is aImost unknown. Guided by natura1 instinct, the expectant mother prepares for her sufferings in secIusion, usuaIIy near a stream into which she may pIunge immediateIy after deIivery. There her tent is pitched and onIy those who have had easy, uncompIicated Iabors resuIting in heaIthy offspring are granted access. OnIy aIong the borders of civiIization, where natives

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are confined IegitimateIy or otherwise, by foreign breeds, is labor Iooked upon with any degree of apprehension. MereIy as a matter of interest, let us review some of the principa1 characteristics of intuitive practices, much, though not entireIy, like those carried out by our more recentIy civiIized North American Indians, chiefly, the Comanches, Sioux, Kiawas, FIatheads, Creeks and Crows. First, Iabor was thought due to a feta1 desire to change its environment, its mode of Iife, as expressed in movements. Second, the character of the Iabor was referabIe to the chiId, or to its disposition, and a fetus so perverse as to cause difficuIty merited death, together with the one who was so evi1 and cursed as to bear such an one. Third, in the main, aid was given by varying the posture. The parturient usuaIIy assumed a squatting position and thus caIIed into use accessary muscIes ordinariIy concerned with defecation. Fourth, the uterus was secondariry stimuIated by pressure with the hands, kneading and shampooing, or by compression of the abdomen with the end of a poIe or, in some instances, by the appIication of a beIt. Fifth, a sIowIy diIating OS was stimuIated, never diIated manuaIIy. Sixth,. as a ruIe, the funis was not severed unti1 the secundines were extruded. BIunt instruments, a finger nai1, or the teeth served the purpose of scissors and the cord was cut usuaIIy within a few inches of the umbiIicus and then dried as quickIy as possibIe, sometimes by roIIing it between the fingers before an open fire for twentyfour hours. The pIacenta was deIivered by various expectant methods, one of which was tying the cord to the great toe, where, upon involuntary extension, miId and Iimited traction was exerted. Seventh, post-partum uterine contractractions were procured by kneading, by a carefuIIy directed spray of water between the teeth or a pIunge into the neighboring stream.

Eighth, the puerperium ended either immediateIy after the pIunge or after an interva1 of rest, the Iatter extending over a period of not more than seven days. The period of comparative isoIation, during which the parturient and her surroundings were “uncIean” varied, but it was the usua1 custom to smoke or burn eIements of contact before she assumed her natura1, triba1 duties. Supporting beIts or binders were wbrn by some for successive days or months, according to the custom. Do not these facts impress one that our naive sister had some idea, instinctive if you desire, but none the Iess comprehensive, of hygiene, of assisting nature, and Iast but not Ieast, of protecting herseIf against infection? Through how many years or at what price she gained this knowIedge is by its obscurity mysterious. We can think only within Iimits of the finite, in terms of our own enlightenment. For much we must revert to historical records. From these knowIedge is amassed, and it is desirabIe in an effort at Iearning to pay strict regard to chronoIogica1 sequence. Therefore, this important subject may be divided, according to Courier, into seven periods as foIIows: I. AI1 that precedes the time of Hippocwhen observations were recorded rates, and deductions made therefrom. 2. From the time of Hippocrates, the fifth century B.C., to the Arabian physicians of the ninth century. 3. From the Arabians of the ninth century to their disappearance in the tweIfth century. 4. The period of reIative darkness, from the thirteenth century to the time of Ambroise Par&, 1550. 5. From Pari: to the genera1 knowIedge of the obsetetrica1 forceps in the seventeenth century. 6. From the genera1 knowIedge of forceps to the use of chIoroform during Iabor in the middIe of the nineteenth century. 7. From the use of chloroform to the present time, incIuding the deveIopment and use of antiseptics in obstetrics.

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VOL. XI, No. 3

FIRST

PERIOD

When obstetrics became an art and was practiced as such we have no means of knowing. It is sufficient to note that in that ancient book, the BibIe, abnormahties in parturition were observed, and that the function of the midwife was recognized more than 4000 years ago. Thus the birth of twins, Pharez and Zarah, is noted in Genesis, and the first recorded instance of spontaneous version is given. And it came to pass in the time of her travait that twins were in her womb. One put

out his hand and the midwife took and bound upon his hand a scarret thread saying--this came first. And it came to pass as he drew back his hand that his brother came out, and she said how hast thou broken forth? This breach be upon thee; therefore, his name was caIIed Pharez and after came out his brother that had the scarlet thread upon his hand, and his name was caIIed Zarah.’ The Egyptians of 4000 or more years ago, a highIy cuItured race, Iived in cities. The change from a natura1 or nomadic Iife meant more or Iess change in structura1 anatomy and, consequentIy, more or Iess change in the structure of the peIvis, and this was the occasion for the deveIopment of the midwife. The BibIe decIares that the Hebrew women in Egypt had easier Iabors than the Egyptians and ConsequentIy, the midwives had Iess occasion to render them assistance. And the King of Egypt caIIed for the midwives and said unto them, Why have ye done this thing and have saved the men-children

aIive? And the midwives said unto Pharaoh, Because the Hebrew women are not as the Egyptian women, for they are IiveIy and are deIivered e’er the midwives come in unto them.’ DificuIt Iabor is recorded in the twinbirth of Esau and Jacob, when the Iatter conpresented an arm, an indiscretion stituting an earIy recorded instance of shouIder presentation. 1Genesis: xx&ii, 2

27-30.

Exodus: I, 18-19.

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And when her days to be derivered were fuIfiIIed, behoId, there were twins in her womb; and the first came out red a11 over Iike an hairy garment, and they caIIed his name Esau. And after that came his brother out and his hand took hold on Esau’s hee1, and his name was caIIed Jacob.3

The diffrcuIt Iabor of RacheI is aIso mentioned, which, though encouraged by surrounding attendants or midwives, she was unabIe to withstand and succumbed. And it came to pass when she was in hard Iabor that the midwife said unto her-Fear not for thou shaIt have this son aIso. And it came to pass as her sour was in departing (for she died) that she caIIed his name Ben-oni, but his father caIIed him Benjamin.4 Other interesting facts in the BibIicaI account are that the parturient was deIivered upon a stoo1 or obstetric chair and the women were accustomed to heIp themseIves when in Iabor, probabIy by pressing and puIIing on some resisting object. “And he said when ye do the offIce of a midwife to the Hebrew women and see them upon the stooIs, if it be a son then ye shaI1 kiII him, but if it shaI1 be a daughter then she shaI1 Iive.“” The Iaw of Moses prescribed the purification of women after Iabor. It demanded a period for her recuperation, and the return of her genitaIs to the norma or unimpregnated condition. The TaImud recognized the period of pregnancy as two hundred and seventy to two hundred and seventy-three days and stated that pregnancy couId not be determined prior to the fourth month. It anticipated the error of Hippocrates, that an eighth months’ fetus was not viabIe, and decIared that the chiId floated in the amniotic sac foIded up Iike a scroI1. In Egypt in addition to the midwives, mystics and priests, the Iatter repositories of much of the knowledge of earIy times, 3Genesis: xxv, 24-26. * Exodus: I, 16. 5 Exodus: I, 16.

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rendered assistance in diffIcuIt Iabors. Their experiences with the dead supposedIy permitted of some knowIedge of anatomy however vague. Obstetrics of ancient India leaves IittIe to posterity in the records. They thought the embryo fastened itseIf to the womb in the first month, was egg-shaped in the second, that the head and extremities began to grow in the third, that the head and trunk took distinct form in the fifth month and that these became more definite in the sixth and seventh months; in the eighth month the chiId became uneasy, and was born from the ninth to the tweIfth month. The head shouId aIways come first, the face turned toward the materna1 spine in prayer and looking to earth just before birth took place. It is thought also they possessed some knowIedge of extraction by podaIic version, cesarean section upon the dead, embryotomy and craniotomy upon the IikeIy stiII-born, and that they advanced so as to recognize various presentations and abnorma1itie.s and possibIy devised artificia1 means in their efforts to remedy the Iatter. The ancient Japanese practiced friction of the abdomen to faciIitate Iabor, performed externa1 version, and determined the existence of pregnancy by certain signs in connection with the puIse, abdomen and breasts. When we come to the Greeks we reach the fountain of recorded observation in arts and science. NaturaIIy we Iike to invoke Hippocrates who Iived in the fifth century B.C. and whom we affectionateIy revere as the Father of Medicine. The midwives of his day attended a11 wants of the parturient, encouraging Iabor pains by massage, sternutatories, and emetics, making the patient waIk about and even shaking her if Iabor was too Iong deIayed. If she died undeIivered, the recognized practice was the immediate performance of cesarean section, and when the chiId was born aIive they sang hoIy songs to greet it. Midwives aIso induced abortions,

which were thought Iegitimate if in accordance with the desire of the impregnated. It was in this period that private Iying-in asyIums were estabIished. In punishment for the mistakes of midwives, which certainIy were not few, AristotIe forbade midwifery practice in Athens by a Iaw which was not repeaIed unti1 285 B.C. Hippocrates was a teacher, and it was his beIief that a seven months’ fetus was viabIe, whiIe one of eight months was not, a faIIacious observation handed down aImost to our own time. He and his foIIowers advised the manua1 separation of the pIacenta when expuIsion was deIayed, and Iaid down ruIes for destructive operations such as embryotomy, craniotomy, perforation, hook extraction and amputation of the Iimbs. The Roman custom of caIIing upon their goddesses, Lucina, Juno and Diana for assistance obscured Latin scientific contribution. SECOND PERIOD: 500, B.C. TO 800, A.D. From the fourth century B.C. to the time of GaIen, the first century A.D., IittIe was added to the art. GaIen, neither an obstetrician nor surgeon, taught that miIk appeared in the breasts as the resuIt of pressure upon the viscera1 bIood vesseIs; and it was he who advocated what Iater became particuIarIy noteworthy of the period, that destructive obstetrics was eminentIy man’s domain. FoIIowing GaIen there appeared obstetricians of merit. In this group were CeIsus, Soranus of Ephesus, Moschion and AEtius. CeIsus (25 B.C. to 50 A.D.) recognized head, thigh, foot and transverse presentations in his practice. Soranus of Ephesus (IOO A.D.) remains the most distinguished obstetrica writer of antiquity. He taught that inversion of the uterus might foIIow hasty or fauIty deIivery of the pIacenta, and that premature rupture of the membranes deIayed and made diffIcuIt Iabor. He was the first to divert from the beIief that the one and onIy norma presentation was vertex. He devised the knee-eIbow

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position and did both cephalic and podalic versions in the delivery of Iiving children. One of his pupils, Rufus, was the first to describe the FaIIopian tubes. Moschion described the feta1 membranes and taught that the menstrua1 blood nourished the fetus, that the period of lactation was of eighteen months’ duration, that the OS might be diIated manuahy, that the membranes might be artificiaIIy ruptured, that the pIacenta might be extracted manuaI1y and that the cord should be tied with two ligatures and cut between them. With the coming of Aetius (501-575 x.D.) there appeared a new Iight in the literary gIoom which had persisted for two hundred years. He industriously coIIected and submitted previousIy inaccessible writings. He discussed puberty, menstruation, the signs of pregnancy, embryology, the cord, and obstacIes of labor. His articIes considered the narrow peIvis, the obliquity of the peIvis, the hygiene of pregnancy, the use of pessaries for proIapse of the uterus, ankylosis of the pubis, poIyps and other obstructive eIements to labor, incIuding distention of the rectum and bladder, as we11 as the role pIayed by- the fetus. His originality is further expressed in the use of a vagina1 specuIum and a pre-forceps device, the two-bIaded crochet. The period cIoses with Aetius supreme, his foIIowers, amongst whom was Paul of Aegina, carrying on as imitators. THIRD

PERIOD

After Paul of Aegina came a period of sterility and darkness unti1 the Arabs picked up the torch in the ninth century. Arabian medicine found its principa1 disciple in Avicenna of Ispahan, an adherent of the Greeks, who dignified their mistakes by repetition. With his name, appearing between the ninth and tweIfth centuries, are those of Albucasis, Misdrach and AImisdrach, a11 advocates of the destructive forceps. With the downfar of the Arabs at the end of the twelfth century, came another

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Iong period of obstetrical gloom, though iIIumined before and afterward by an occasional- g1eam. of light. But before this downfar there was founded the school of SaIerno, in the eleventh century, folIowed by those of BoIogna and Paris, with the transIation of the Arabic writers into Latin of the MiddIe Ages. FOURTH

PERIOD

The thirteenth and fourteenth centuries are mostly a bIank, except for the appearance of an unimportant work on “Reproduction and Birth” by AIbertus Magnus, a Dominican priest of the thirteenth century (I 193-1282). In the fifteenth century the Renaissance had already appeared, printing had been discovered, the universities of Prague, Restock, Leipzig and GriefswaId had been founded, and ItaIian gynecoIogists were at work. In 1513 RijssIin pubIished “A Garden of Roses for Pregnant Women and Midwives,” a compilation of what had been written since the time of Hippocrates, and in 1554 Rueff, of Zurich, pubIished a book for midwives, foIIowing cIoseIy the principIes found in RijssIin to which he added descriptions of manua1 diIatations, extractions of pIacenta, aIterations of position in deIay, and a Iong, smooth, duckbiI1 forceps for extraction of the head, for which Iatter he is therefore accredited by Crantz, Stein and others, as inventor of the forceps. Rueff, however, made onIy a forward step in advance of AEtius, for his forceps were tru1y destructive. The sixteenth century opened the first cIinic for the instruction of midwives at Padua. In EngIand in 15 18, Lanfranc, the court physician to Henry VIII, obtained a “patent” for the RoyaI CoIIege of Physicians from which time obstetrics assumed importance in that country. The first English work of merit was pubIished by Raynolds in 1565, “The Byrthe of Mankind.” This effort, though translated into Dutch, French, Spanish, Latin and other Ianguages, bore two mistakes of note; that

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vertex presentation was the onIy naturaI position and that the face and foreparts of the chiId faced the foreparts of the parent. FIFTH

PERIOD

There was every reason why a11 departments of medicine shouId now make great progress. Letters had revived, the art of printing diffused with great rapidity, Vesalius, Columbus and their foIIowers had developed the anatomy and physioIogy of the pelvis as never done before, and the mistakes of 2000 years, dating from GaIen and Hippocrates were rectified. To this period belong Fallopius and Eustachius. The rear genius in obstetrics next appeared in France in the person of Ambrose Par& whom Smellie honored in the expression, “The famous restorer and imPari: was in prover of midwifery.” association with the schoo1 of Paris, at this period the foremost in the worId, and surgeons of his folIowing thought it not beneath their dignity to emuIate Park even in the reaIm of obstetrics. For the first time men began to encroach upon the domain and prerogative of midwives, to dispe1 the inherent modesties of woman. It was Par& who instituted cesarean section on the Iiving, imitating Jacob Nufer, a sow geIder, who thus successfuIIy dehvered his wife. Pa& recognized five positions assumed by the fetus, but admittedIy declared his ignorance as to which was normaI. He was indeed a conservative and an adept at podaIic obstetrician, version. To this period beIongs the discovery of our modern obstetric forceps by Peter ChamberIen who practiced in London, under Iicense of the Barber Surgeons Company, 1598 to 1630. He was accoucheur to the Queens of James I and Charles I. The three generations which foIIowed him, kept the family secret which was finaIIy sold to Roonhysen of Amsterdam in the latter part of the seventeenth century. SIXTH

PERIOD

In the seventeenth century man-midwives, as obstetricians were caIIed, had

become fashionabIe in France and among those Maurceau was preeminent. He corrected the idea prevaIent that amniotic fluid consisted of materna1 bIood and miIk; he described the phenomenon of norma Iabor, caIIed attention to pIacenta previa, described the necessary steps in the performance of version, denied that the peIvic bones separated in Iabor, discussed diffrcuIties proceeding from the umbiIica1 cord, epidemic puerpera1 fever, and gravity as a factor in vertex presentation, declaring that feta1 movements were not, whiIe muscIes were responsibIe for birth, and was the first to caI1 attention to tuba1 pregnancy. In EngIand, WiIIis defined puerpera1 fever and Needham wrote on feta1 nourishment by way of the pIacenta. Van Deventer, of HoIIand, deaIt chiefly with deformities of the pelvis and spine and their effects on Iabor. PaIfyn presented a paraIIe1, bi-bIade forceps to the Academy of Science in Paris (1717) and was criticized severeIy by De Ia Motte, who wrote ruIes for version. In 1747 SmeIIie or Levret added the peIvic curve to ChamberIen’s invention. Puzos, a French enthusiast, advocated externa1 abdomina1 pressure to contro1 post-partum hemorrhage, the earIy rupture of membranes in pIacenta previa, the protection of the perineum during deIivery and friction of the OS uteri to induce Iabor pains. B au d eIocque contributed treatises on peIvic measurements, symphysiotomy and the induction of Iabor. Germany’s inff uence is comparativeIy ni1 unti1 the next century, though SiebaId performed a symphysiotomy in 1778. Among others whose names have come down to us as significantIy important in their time may be mentioned StahI, Roederer, Stark, Stein, ZeIIer and Heiser of HeImstadt. Heiser was the first to deIiver Iectures on obstetric science. Great Britain offers many names in connection with obstetrics of the eighteenth century. Manningham, Iike his contemporaries SmeIIie and Hunter, empIoyed manikins to demonstrate procedures of examination and deIivery. He vehementIy

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protested against cesarean section, scoring it as a hopeIess risk. With Van Deventer he advocated the depression or fracture of the coccyx as an aid in diffIcuIt Iabor. FieIding OuId, a DubIin physician of 1742, was the first to describe the mechanism of Iabor further eIaborated upon by SmeIIie and Iater revised with an endowment of perfection by NaegeIe. At this time version was the recognized practice of seIection, whiIe deIivery by forceps was rather negIected. However, SmeIIie devised the precursor to Iow forceps, an instrument of appIication in our own day. WiIIiam Hunter, his pupil, and for many years a distinguished practitioner in London, buiIt an anatomica theater in which he demonstrated obstetrics through the use of manikins, and coIIected a series of unexceIIed pIates made during thirty years’ dissection upon pregnant uteri. He discovered the decidua reflexa and, unIike SmeIIie, refused to use forceps of whatever design, and proudIy exhibited his own impIement rusty from disuse. CharIes White was at this period a proIific writer who received the distinction of being the pioneer in antiseptic midwifery; yet a century passed, with its to11 of Iives Iost to puerpera1 fever, before the suggestions of White bore fruit. Thomas Denman’s articIe on the transmission of infections by doctors and midwives was compIeteIy ignored. John Aiken, the advocate of an exsection of part of the bony peIvis in preference to cesarean section, and R. W. Johnson, who devised a forceps with peIvic and perinea1 curves, honored the end of this period in EngIand. In the United States, it is interesting to note that the closing years of the eighteenth century, which witnessed our entrance into the famiIy of nations, aIso marked the beginning of obstetric teaching by the younger Shippen in PhiIadeIphia (17%).

The nineteenth century found obstetrics we11 estabIished in a11 parts of the civiIized worId and its principIes we11 understood and comprehensiveIy set forth in textbooks

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of the different Ianguages. Henceforth, there remained, with the exception of anesthesia and the deveIopment of the antiseptic theory, onIy the improvement or eIaboration of ideas IaboriousIy wrought down through the ages. It was a century preeminentIy devoted to teaching as shown by the foIIowing 0utIine: In Iearning Germany ranked first with her eIegantIy reguIated universities, guided by geniuses of ski11 and erudition. Vienna, where instruction is truIy German, remains, with her AIIegemeines Krankenhaus, an attractive center for students from a11 parts of the worId. It was there that SemmeIweiss preached the “Doctrine of CIeanIiness to deaf ears,” and Iost his mind in disappointment and chagrin when his efforts faiIed. The foIIowing generation reaIizing that his hands, dipped in chIoride of Iime, were by far cIeaner than the hands of those who scoffed at his theory, erected a monument to his memory. Germany at this time aIso had pride in such men as Bozr, Schmitt, Gustav, Car1 Braun and Spaeth. Prague University had KIein, WBchter, and Jungmann; Munich, Hecker and WinkeI; BresIau had Spiegelberg; Wtirtsburg had Doutrepont, Kiwisch, and Scanzoni; BerIin, Von SeebaId, Busch, Edauard Martin, Schraeder and Gusserow; Leipzig, Sanger, who perfected cesarean section. OriginaI works of the period were indeed not wanting. Deformities of the peIvis were carefuIIy studied and pIaced in the Iiterature by NaegIe, Rokitansky, Leitzman, Stein, MicheaIs and KIein. Other German scientists, assured pIaces in posterity through their contributions, were WaIdemeyer, WaIcher, Cred&, WenzeI, Stark, HohI, Carus, Wigang, Ritgen, KiIian, FehIing, ZweifeI, AhIfeId and LeopoId. In France, Paris was the center of Iearning. At the University were Velpeau, Baudelocque and StoItz, the Iast-named being the first to associate his name with the study of premature Iabor. Two books, the seeds from which texts subsequentIy sprang, compiIations from

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the study of 40,000 cases, were written by Mesdames La ChappeIIe and Boivin, French midwives of commanding inteIIect. To the Iatter is attributed the first description of hydatidiform moIe. With the appearance of Lord Lister’s antiseptic theory, Tarnier cIosed French obstetrica history for the period with his contribution of the axis-traction forceps. In the nineteenth century Great Britain gave birth to many obstetricians and by the Iuster of her schooIs at DubIin, Edinburgh and London, acquired others. EngIish texts bear the names of ChurchiII, Barnes, Leishman, PIayfair, MiIne, GaIabin, Duncan and Ramsbotham. Barnes contributed the diIating bag, and Braxton Hicks the combined interna and externa1 version. In EngIand it was the period of physioIogicaI acknowIedgment, where nature was granted her portion in contradistinction to the previous form of “meddIesome midwifery.” SEVENTH

PERIOD

The most briIIiant and usefu1 obstetric discovery of this century was that of chIoroform anesthesia for Iabor by James Simpson of Edinburgh. AIthough the anesthetic powers of suIphuric ether had aIieady been announced by the Americans, Morton, Jackson, WeIIs and Riggs, Simpson was a pioneer in eIiminating painfu1 Iabor. But even more important than the discovery of a means to eIiminate or at Ieast mitigate pain, was Lord Lister’s theory of antisepsis, in which the bud nurtured by White and SemmeIweiss burst into bIoom. SurgicaI obstetrics took a firm footing ItaIy where during this century in GaIbiati, and GigIi revived Morisani, symphysiotomy and Bossi introduced the mechanica diIator. American obstetrics, aIthough a new eIement among scientific forces, was abIe to exert great influence through the teachings of Dewees, Hodge, Meigs, Goode11 and Parvin in PhiIadeIphia. Their text-

books, with that of Lusk, have influenced American obstetric practice even to this day. In New York, Boston, BaItimore and Chicago schooIs have gained prominence through their exceIIent work. EarIy in the century, 1808, John Stearns of New York introduced ergot to the profession. In 1843Dr. OIiver WendeII HoImes wrote a noteworthy essay on “The Contagiousness of PuerperaI Fever,” and thus we are Ied to the threshoId of the present, to our contemporaries, who are putting forth their best efforts to soIve remaining probIems. The work of contemporaneous American obstetricians is not yet a matter of history; but in teaching, in the deveIopment of textbooks and treatises, and in the practica1 appIication of the science and art of obstetrica practice, the American obstetricians of today are in the forefront and doing work as good as is done anywhere in the worId. This paper couId have no greater purpose than to commend to teachers and students the remaining probIems of obstetrics, with specia1 emphasis on practica1 instruction in the Iying-in chamber, on perfection in the management of norma Iabor, and on genera1 obstetrica research and the introduction of the antiseptic methods of the hospita1 into private practice. REFERENCES

COURIER, A. F. History of Obstetrics. In: Handbook of the Medical Sciences. Ed. 3, N. Y., Wood, 1916. DERRAH, B. V. History of obstetrics, Je$ersonian, 8: I, 19x6. ENGLEMANN, G. J. History of Obstetrics. In: Am. System of Obstetrics, by B. C. Hirst. PhiIa., Lea, I: 17, 1888. ENGLEMANN, G. J. Labor (Ethnological). St. Louis, Chambers, 1883. FAIR, H. D. An epitomy of the history of obstetrics. Am. J. Obst. &Gynec., IO: 7451755;874-884, 1925. GETCHELL, S. H. The Renaissance of Obstetrics. Introductory Iecture to a course in 1872. Ms. Phila.. 1872. GODFREY, G. C. M. Indian women in Iabor. Med. Rec., 46: 690,

1894.

KING, J. C. Obstetrics among aborigenes. Codex Med., 3: 128, 1897. TREON, F. Obstetrics among Sioux women. Cincin. Lancet ti Clinic, 24: 12-14, r8go.