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OBSTETRICS
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OBSTETRICS , the See also:science and See also:art of midwifery (See also:Lat. obstetrix, a See also:midwife, from obstare, to stand before). Along with See also:Medicine and See also:Surgery, Obstetrics goes to See also:form what has been called the Tripos of the medical profession, because every See also:person desiring to be registered under the Medical Acts must pass a qualifying examination alike in medicine, surgery and midwifery. The See also:term See also:Gynaecology (q.v.), which has come to be applied to the study of the diseases of the See also:female generative See also:system, in its See also:primary sense includes all that pertains to See also:women both in See also:health and disease. Obstetrics, or midwifery, is more specially that See also:part of the science of gynaecology which deals with the care of a pregnant woman and the ushering of her See also:child into the See also:world. Tokology—the See also:doctrine of parturition—is the most distinctive See also:sphere of See also:interest for obstetricians, and here their activities bring them into a closer approximation to the See also:work of surgeons. As a science it demands a study of the phenomena of labour, which in their ordered See also:succession are seen to See also:present three distinct stages: one of preparation, during which the uterus dilates sufficiently to allow of the See also:escape of the See also:infant; a second, of progress, during which the infant is expelled; and a third, of the extrusion of the after-See also:birth or See also:placenta. In each of the stages See also:analysis of the phenomena reveals the presence of three elements which are known as the factors of labour, viz. the See also:powers or forces which are engaged in the emptying of the uterus; the passages or canals through which the ovum is driven; andthe passenger or See also:body that is being extruded. The mechanism of labour depends on the See also:balance of these factors as they become adjusted to each other in the varying phenomena of the several stages. The diversities that are met with in different labours even of the same woman have led to their being classified into different See also:groups. A natural labour is commonly defined as one where the child presents by the See also:head and the labour is terminated within twenty-four See also:hours. From this it is obvious that no See also:case of labour can be defined at its onset. The relation of the factors may See also:warrant a favourable expectation; but until the labour is completed, and completed within a reasonably safe See also:period, it cannot be classed as natural. The See also:element of See also:time has this importance, that it is found that, apart from all accidents and interferences, the mortality both to See also:mother and child becomes greater the longer the duration of the labour. Hence lingering or tedious labours, in which the child still presents with the head, but is not expelled within twenty-four hours after the onset of labour-pains, are properly grouped in a See also:separate class, although they are terminated without operative interference. In the class of preternatural labours, where the head comes last instead of first, there are two subdivisions, according as the child presents by the See also:breech and feet, or lies transversely as a See also:cross-birth, and has usually to be delivered artificially. Operative or instrumental labours vary according as the procedures adopted are safe in principle to mother and child, such as turning and the application of the midwifery forceps; or as they involve damage to the infant in the various forms of embryotomy; or are more dangerous to the mother, as in the Caesarean See also:section and symphysiotomy. A final class of labours includes the cases where some complication or See also:anomaly arises and becomes a source of danger, independently of disturbances of the mechanism or of any operative interference. These complex labours are due to complications that may be maternal, such as See also:haemorrhage and See also:convulsions; or foetal, such as twins or prolapse of the umbilical See also:cord. To See also:cope with these anomalies an obstetrician requires all the resource of a physician and all the dexterity of a surgeon. The interest of obstetricians in their patients does not end with the birth of the See also:children, even after natural labours. The puerpera is still a subject of care. The uterus, that during its nine months' See also:evolution had been increasing enormously in all its elements, has in six See also:weeks to undergo an involution that will restore it to its pregravid See also:condition. The allied See also:organs See also:share in their measure in the See also:change, all the systems of the body feel the See also:influence, and especially the mammary glands take on their See also:function of providing See also:milk for the nutriment of the new-See also:born infant. A patient with some latent flaw in her constitution may pass the test of pregnancy and labour with success, only to succumb during the puerperium. Of patients who become insane in connexion with child-bearing, a See also:half See also:manifest their See also:mental disorder first during the days or weeks immediately succeeding their confinement, and See also:numbers more whilst they are suckling their infants. A woman may have had an easy labour, and may have been thankful at the time for help from a See also:hand that she did not know to be unclean; three days later germs See also:left by that hand may have so multiplied within her that she is in mortal danger from septicaemia. The management of the puerperal patient requires not only the warding off of deleterious influences, but the watching of the normal processes, because slight deviations in these, undetected and uncorrected now, may become later a source of lifelong invalidism. It remains further to be noted that to obstetricians belong the earliest stages of pediatrics in their care of the new-born child. In some old See also:works practitioners of this See also:branch of the profession are described as 6 u/ aAor6yoe, because their first business was to cut the umbilical cord. The causes of the high See also:death-See also:rate among infants, whether due to ante-See also:natal, See also:intra-natal or neo-natal conditions, come under their observation. They have See also:charge of the whole wide See also: ' MgO. K2O. Na2O. See also:H2O. I. Yellowstone See also:Park 74.70 13.72 0.62 I•0I 0.78 0.14 4'02 3'90 0.62 II. See also:Iceland . 75.28 10.22 . . 4.24 I.81 0.25 2'44 5'53 0'23 Ig See also:Historical See also:Sketch.—The origin of midwifery is lost in the mists of the See also:Renaissance, and was used as the basis of the first obstetric of human origins. The learned See also:Jean See also:Astruc, who gave a See also:lead to higher critics in their analysis of the See also:Pentateuch by pointing out the presence of Elohistic and Jehovistic elements, exercised his See also:imagination in fancying how the earliest pair comported them-selves at the birth of their first child, and especially how the See also:husband would have to learn what to do with the placenta and umbilical cord. His speculations are not in the least illuminative. The See also:Mosaic writings let us see women of some experience and authority by the See also:side of a See also:Rachel dying in labour, or a Tamar giving birth to twins, and superintending the easy labours of See also:Hebrew slaves in See also:Egypt. The See also:Ebers See also:Papyrus (1550 B.C.), which See also:Moses may have studied when he See also:grew learned in all the See also:wisdom of the Egyptians, is the See also:oldest known medical See also:production. It contains prescriptions for causing See also:abortion, for promoting labour, for curing displacements of the uterus, &c. But there is no indication as to how labours are to be managed, and with regard to the child there are only auguries given as to whether it will live or See also:die, according, e.g. as its first cry after it is born sounds like ni or bd. The See also:story of the rise and progress of midwifery is intimately See also:bound up with the See also:history of medicine in See also:general. The obstetrician, looking for the See also:dawn of his science, turns like his See also:fellow-workers in other medical disciplines to the Hippocratic writings (4o0 B.C.). Now the See also:father of medicine was not an obstetrician. As with Egyptians and See also:Hebrews, the skilled attendants on women in labour among the Greeks were also women. But since nothing that concerned the ailments of humanity was See also:foreign to See also:Hippocrates, there are indications in the writings that are accounted genuine of his interest in the disorders of See also:females—in their menstrual troubles, in their sterility, in their gestation symptoms, and in their puerperal diseases; his See also:oath forswears the use of abortifacients, and he recommends the use of sternutatories to hasten the See also:expulsion of the after-birth. In the Hippocratic writings that are supposed to be products of his followers, some of these subjects are more fully dealt with; but whilst the physician is sometimes called in to give See also:advice in difficult labours, so that he can describe different kinds of presentation and can speak of the possibility of changing an unfavourable into a favourable See also:lie of the infant, it is usually only with cases where the child is already dead that he has to See also:deal, and then he tells how he has to mutilate and See also:extract it. So these writings furnish us with the earliest See also:account of the accoucheur's armarnentarium, and let us see him possessed of a µaxaiptov—a See also:knife or perforator for opening the head; a irtevrpov—a comminutor for breaking up the bones; and a iXi vorilp—an extractor for hooking out the infant. The classical writers of See also:Greece give the same impression as to the See also:primitive See also:stage of obstetrics. Women, like the mother of See also:Socrates, have the charge of parturient women. Where divine aid is sought, goddesses are invoked to facilitate the labour. Gods or men are only called in where graver interference is required, as when See also:Apollo rescued the infant See also:Aesculapius by a Caesarean section performed on the dying See also:Semele. Some midwives are known to history, and extracts from the writings of one See also:Aspasia are embedded in the works of later authors. In the See also:great medical school of See also:Alexandria, when the science of human See also:anatomy began to take shape, Herophilus rendered a service to obstetrics in giving a truer See also:idea of the anatomy of the female than had previously prevailed; other physicians give See also:evidence of their interest in midwifery and the diseases of women, and some experience was gradually being acquired and transmitted through the profession until we find from See also:Celsus (in the reign of See also:Augustus) that when surgeons were called in to help the attendant woman they could sometimes bring about the delivery, without destroying the infant, by the operation of turning. In the 2nd See also:century See also:Soranus wrote a work on midwifery for the guidance of midwives, in which for the first time the uterus is differentiated from the vagina and instruction is given for the use of a See also:speculum. A contemporary, Moschion, wrote a See also:guide for midwives which, with that of Soranus, may be said to See also:touch the high-See also:water See also:mark of archaic midwifery. It is written in the form of question and See also:answer, was much prized at the time See also:xtx. 31*work that issued from a See also:printing-See also:press. Philumenos wrote a See also:treatise of some value at the same See also:epoch, but it is only known from the See also:free use made of it by subsequent writers, such as See also:Aetius in the beginning of the 6th century. Like Oribasius, who preserved in his compilation the work of Soranus, Aetius draws largely on preceding writers. His See also:treatises on female diseases constitute an advance on previous knowledge, but there is no progress in midwifery, though he still makes mention of turning. This operation has disappeared from the pages of See also:Paulus See also:Aegineta, an 8th-century author, the last to treat at length of obstetrics and gynaecology ere the See also:night of the dark ages settled down on the See also:Roman world, and it is not heard of again' till a See also:millennium had passed. During the centuries when the progress of medicine was dependent on the work of the Arabian physicians, the science of obstetrics stood still. We are curious to know what Rhazes and See also:Avicenna in the 9th and loth centuries have to say on this subject. But they know little but what they ' have learned from the See also:Greek writers, and they show a great tendency to relapse to the rudest procedures and to have recourse to operative interferences destructive to the child. Interest attaches to the work of Albucasis in the 12th century, in that he is the first to illustrate his pages with figures of the knives, crushers and extractors that were employed in their gruesome practices, and that he gives the first history of a case of extra-uterine pregnancy.
We come down to the 16th century before we begin to see any indication of the development of obstetrics towards a See also:place among the sciences. Medicine and surgery profited earlier by the intellectual awakenings of the Renaissance and the Re-formation. In anatomical theatres and See also:hospital wards associated with See also:universities great anatomists and clinicians began to discard the dogmas of See also:Galen, and to See also:teach their pupils to study the body and its diseases with unprejudiced minds. But the practice of midwifery was still among all See also:people in the hands of women, and when in 1513 Eucharius Roesslin of See also:Frankfort published a work on midwifery, it See also:bore the See also:title Der schwangeren Frawen and hebammen Rosengarten. Translated into See also:English by See also: The See also:close of the 16th century is rendered further memorable in the See also:annals of midwifery by the publication of a See also:series of works specially devoted to it. Three sets of compilations, containing extracts from the various writers on obstetrics and gynaecology from the time of Hippocrates onwards, were published under the designation of Gynaecia or Gynaeciorum—the first edited by Caspar See also:Wolff of Zurich in 1566, the second by Caspar See also:Bauhin of See also:Basel in 1586, and the third by See also:Israel Spach of Strassburg in 1597. Spach includes in his collection not only Pare's obstetrical chapters, but the Latin translation of the important Traitte nouveaux de l'hysterotomotokie, published by the French surgeon See also:Francis Rousset in 1581, which is the first distinct treatise on an obstetric operation, and See also:advocates the performance of Caesarean section on living women with difficult labours. From this time onwards evidence accumulates of the growing interest
of members of the medical profession, and more especially of in See also:London, but by a See also:man not of English birth. The Huguenot, surgeons, in the practice of midwifery, and after the middle of
the 17th century they began to publish the records of their experiences in See also:special treatises. The most important of these writers were French—as Mauriceau, Viardel, See also:Paul Portal, Peu and Dionis. The work of Mauriceau, which first appeared in 1668, is specially interesting from its having been translated into English in 1672 by See also:Hugh Chamberlen, who in his See also:preface made the then incredible statement that his father, his See also:brothers, and himself had See also:long attained to and practised a way to deliver women in difficult labours without hooks, where other artists used them, and without See also:prejudice to mother or child. Many years had still to elapse before the See also:secret of the Chamberlens leaked out. In the course of this century some women who had large experience in midwifery appeared as authors. Thus in See also:England Jane See also:Sharp in 1671 wrote The Midwives' See also:Book, or the whole art of Midwifery discovered; in See also:Germany, Justine Siegemund, in 169o, Die Chur-Brandenburgische Hoff-Wehemutter; and earlier and better than either, in See also:France, See also:Louise See also:Bourgeois in 1626 published Observations sur la sterilite et maladies See also:des femmes. Perhaps they were beginning to feel that there was some need to assert their See also:power, for it was during this century that parturient ladies began to See also:call in men to attend them in natural labours. According to Astruc, Madame de la Valliere wished her confinement to be kept secret, and See also: This was accomplished successfully. The See also: See also:Southampton his wife, his two sons, and a daughter. William Chamberlen seems to have been a surgeon, and his descendants through four generations had large and lucrative practices in London. The eldest son See also:Peter, who was old enough when he came to England to be able to attest the birth and See also:baptism of a younger See also:brother, is, on See also:good grounds, credited with being the inventor of the forceps, which for a century was kept a secret among brothers, sons and grandsons. Hugh, indeed, a great-See also:grandson of William, and the translator of Mauriceau, had offered to sell the See also:family secret for ro,000 crowns; but his failure to effect delivery in a test case that Mauriceau put to him led the profession to believe that he was a boastful See also:quack. Palfyn of See also:Ghent, when in Paris in 1723, putting a work on anatomy through the press, laid before the See also:Academy of Science a pair of forceps, which was figured in Heister's surgery in 1724. He has thus the See also:honour of first laying before the profession a midwifery forceps. But his See also:implement was See also:ill-constructed, and never came into general use. Meanwhile the knowledge that the Chamberlens were really possessed of a serviceable instrument must have stimulated other practitioners. Perhaps a colleague with a keen See also:eye may have got sight of it on some occasion, or an intelligent midwife had been able to describe the " See also:tongs " which she had seen one of the family apply. In 1734 Dr See also:Edward See also:Hody published a See also:record of Cases in Midwifery that had been written by Mr William See also:Giffard, " surgeon and man-midwife." The See also:dates range from See also:January 1724 to 1731. Amongst the cases are several where he effected the delivery by means of the forceps—" extractor," he calls it—of which a figure is given; and when See also:Edmund See also:Chapman, who practised first at See also:Halstead and afterwards in London, published his Treatise on the Improvement of Midwifery in 1733, he speaks of the use of the forceps as " now well known to all the See also:principal men of the profession both in See also:town and See also:country." In the course of the 18th century the development of midwifery in the hands of medical men made greater strides than in all the preceding ages. The progress was accelerated by the See also:establishment of chairs of midwifery in the universities of various countries, See also:Edinburgh taking the lead in the See also:appointment of a See also:professor in 1726, and Strassburg coming closely after in 1728. In Strassburg the See also:chair had the See also:advantage of being at once associated with a clinical service. Lecturing was carried out, moreover, by men who were devoting themselves as specialists in midwifery and the diseases of women and infants, and were succeeding in developing lying-in institutions for the benefit of poor women in labour that became See also:schools of instruction both for midwifery nurses and for medical students. Two new operations came during this epoch to enhance the powers of the obstetrician, viz. symphysiotomy, first introduced by Sigault in Paris; and the See also:induction of premature labour, first carried out by Macauley in London in circumstances described by See also:Denman in the preface to his Midwifery. William See also:Hunter in London, See also:Sir See also:Fielding Ould in See also:Dublin, Roderer in See also:Gottingen, See also:Camper in See also:Amsterdam, Baudelocque in Paris, Saxtorph in See also:Copenhagen, and many other authors contributed to progress by their atlases and their books. But there are three whose names stand out pre-eminently because of the influence they exerted on the whole obstetric world—Levret, Smellie and Bo ;r. See also:Kilian, in his vidimus of the history of midwifery, calls Levret " one of the greatest masters in the See also:department that ever lived." Of Smellie he says: " Inferior to Levret in nothing, he excels him in much." See also:Boer he characterizes as " the most meritorious and important of See also:German obstetricians." Levret improved the construction of the forceps, and widened the sphere of their applicability; Smellie worked in the same direction, and furnished, moreover, descriptions and illustrations of natural and morbid labours that are of classical value; and Boer first clearly placed pregnancy (which Mauriceau, e.g. had spoken of as "a nine months' disease ") and parturition in the See also:category of physiological processes that might be hindered rather than helped by the pragmatical interferences of meddlesome See also:mid-wives. Throughout the 19th century midwifery continued to advance, gynaecology grew into a special department with an extensive literature, the mechanism of labour See also:developed under the clinical observations of men like Nagele and the study of such frozen sections of cadavera as were made by Braune, the indications for interference became more clear and the methods of interference more See also:simple and safe, and a whole See also:realm of antenatal pathology and teratology was added to the domain of science, while practitioners learned the art of saving premature and delicate infants by the use of the incubator and proper alimentation. Every advance in all the cognate sciences was appreciated and applied for the See also:advancement of obstetrics. But there are two achievements which will make the 19th century for ever memorable in the annals of midwifery—the abolition of the pains of labour and the See also:arrest laid on mortality from the so-called puerperal See also:fever. In See also:February 1847 Sir J. Y. See also:Simpson, choosing a case where he had to deliver by turning, put the patient asleep with See also:ether. Seeing that the uterine contractions continued, though the attendant See also:pain was abolished, he proceeded to administer ether in cases of natural labour, and in See also:November of the same See also:year demonstrated the virtues of See also:chloroform, and so furnished the most serviceable anaesthetic, not only to the obstetrician in the lying-in room, but to the surgeon on the battlefield, and to the general practitioner in his everyday work. Ignaz Philipp See also:Semmelweiss, assistant in the maternity hospital of See also:Vienna, was struck and saddened with the appalling mortality that attended the delivery of the women under his care, as many as one (in some months three) out of every ten of the puerperae being carried out dead. He observed that the mortality was much higher in the wards allotted to the tuition of students than in those set apart for the training of nurses. In the See also:spring of 1847 he saw at the See also:post-mortem examination of a See also:young colleague who had died of a poisoned See also:wound, that the appearances were the same as he had too often had occasion to see at the post-mortem See also:examinations of his puerperae. He ordered that every student who assisted a woman in her labour must first See also:wash his hands in a disinfectant See also:solution of chloride of See also:lime, and in 1848 already the mortality was less in the students' than it was in the nurses' wards. Thus the first See also:light was See also:shed on the nature of the See also:mischief of which multitudes of puerperal patients perished, and the first intelligent step was taken to lessen the mortality. When, some twenty years later, See also:Lister had applied the bacteriological principles of See also:Pasteur with beneficent results to surgery, obstetricians gladly followed his lead, and the 19th century beheld added to the comfort of anaesthetic midwifery the confidence of midwifery antiseptic and even aseptic. The most exhaustive treatise on the earlier history of midwifery is von See also:Siebold, Versuch einer Geschichte der Geburishiilfe (See also:Berlin, 1839). (A. R. Additional information and CommentsThere are no comments yet for this article.
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