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523
MILESTONES IN MIDWIFERY*By JOHN H. PEEL, M.A., F.R.C.S., F.R.C.O.G.
Obstetrician and Gynaecological Surgeon, King's College Hospital and Princess Beatrice Hospital.
In these days the practice of obstetrics hasreached a level that seems almost inconceivablewhen one goes back but a few hundred years toconsider the art as it was practised then.Nowadays if we have a case of contractedpelvis we can do a Caesarean section. If thereis delay in labour, due to a bad position of thebaby or to inadequacy of uterine action, we candeliver the patient with forceps. If we have acase of ante-partum haemorrhage, or toxaemia,we can induce labour. If, as a result of any ofour interference, sepsis arises, we can ad-minister blood transfusions, penicillin andsulphonamides. If we go back to the yearI500, not one of these procedures was knownor practised.
I choose the year I500 because it was in thatyear that we read of the first recorded case ofCaesarean section on a living patient withsurvival of the mother, and a few years laterthat great French surgeon, Ambrose Pare, wasborn.There would be enough material to cover a
lecture on primitive methods in obstetricpractice before that date. In the vast majorityof cases, of course, a normal pregnancy is pre-ceded by a normal labour and puerperium,without the necessity for any kind or sort ofinterference. Because of that fact, the humanrace survived. But imagine, if you can, acondition of affairs in which there was noantenatal care; the patient presented herself toa midwife whose knowledge of midwifery wasbased entirely on experience without instruc-tion when her labour started. If everythingwas normal, well and good, but if any abnor-mality arose, then almost invariably the baby,and more often than not, the mother died.Nothing was known of the prevention andtreatment of toxaemia, and the whole range ofconditions which go under the name ofdystocia or difficult labour had to be met and
dealt with if, and when, they arose. Themethods at the disposal of the midwife werecrude to a degree. More often than notnothing active was done at all, but in thosesuperficially devout ages invocations to theDeity and solemn incantations did considerablyless hhrm than such active steps as might betaken. Assistance in labour took the form ofsuch qrudities as annointing the abdomen andvulva with -various medicaments, exposure tovarious forms of vapour baths and fumigationand, sometimes, more direct violence, such askneading the abdomen, violent fundal pressureand the like.
In many cases, after the midwife had failedthe physician was sent for, but it was manyyears before the physician became popular inthe lying-in room. -This was not entirely dueto prejudice against him. It was due, in part,to the fact that obstetrics was considered be-neath the dignity of the physician, and partlyto the fact that when he was summoned thepatient was nearly always in extremis and all hecould do was some form of mutilating opera-tion which usually led to the death of themother as well. The instruments at his dis-posal was a simple knife, the hook or crochet,and various types of fillet. To the physician ofthose days,. the main problem was whetherembryotomy should be performed only on thedead child or whether it was jutifiable, in thehope of saving the life of the mother, to do anembryotomy on a living'child. In the majorityof cases, this must have been rather anacademic argument because they had fewcertain methods of determining whether thechild was, or was not, alive. In practice, itmeant waiting nearly always until the labourhad dragged on for days, and the mother wasutterly exhausted and the child dead. Suchembryotomies must have been gruesome and
* Presidential address delivered to the ListerianSociety of King's College Hospital, 947.
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524 POST GRADUATE MEDICAL JOURNAL November 1947
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A Caesarean operation in the Seventeenth Century
barbaric procedures, and the following descrip-tion is worth reading in detail :-
'When the child cannot be brought forth,the physician may employ the knife in such away that he by no possibility cuts a living childwith it, for if the child is injured the physicianmay destroy both mother and child together.Having cheered up the woman, he then graspsin his hand the sickle-shape knife, cuts inpieces the head of the (dead) child, drags downthe cranial bones, seizes with a hook the breastor shoulder of the child, and draws it out bythe cut head, the eyes or the chin. If theshoulder is near, he cuts off the arm close up,makes an incision into the abdomen, distendedlike a bellows, or filled with air, extracts theintestines, and draws it out by the cut head,the eyes or the chin. Whatever limb, however,the physician seizes must be cut off and drawnout, and he must preserve the woman carefullyfrom injury.'The dawn of the I6th century is the first big
milestone in the evolution of obstetric practice.The ancient Jews, Egyptians, Greeks andRomans achieved a certain degree of knowledgeabout obstetrics which is, at times, quite re-markable, but most of what they thought andpractised seems to have been lost in theMiddle Ages in Europe. Certainly this istrue of obstetrics.
In I5IO Ambrose Pare was born. Now thisfamous French surgeon is perhaps betterknown for his contributions to surgery. 'Heworked in the Hotel Dieu in Paris, but inthose days, as in these, the civilian surgeon andaccoucheur was frequently called to the field ofbattle. Consequently we find Ambrose Parecareering all over Europe and being present atseiges of innumerable cities and towns. It was
in these fields of battle that Pare showed him-self the true experimenter and pioneer in newmethods. It was the custom in those days totreat the horrible lacerated wounds of thesoldier by cauterizing the surface. Themethods of cautery employed were either ared hot iron, or boiling oil. The primarymotive in such applications was to stophaemorrhage, but the disastrous effects are notdifficult to conceive. One day Pare ran out ofhis supply of boiling oil, and consequentlysome of his patients had their wounds dressedwith balm and, to his surprise, next day hefound such cases were in far better shape thanthose who had had the recognized treatment.From that day, he abandoned all forms ofcauterization of wounds and, later, was thefirst to introduce the practice of ligaturingsevered blood vessels. Subsequently he paidthe greatest attention to details in doingdressings. Pare disclosed his true greatnessand modesty in that famous saying of his:
'I dressed their wounds, God healedthem.'
Pare's contributions to obstetric art wereequally important. He advocated the sutureof lacerations, quite a new departure at thattime, but his most important contribution wasthat of podalic version. The practice of, turn-ing the baby in utero had been mentioned byone author before him, and that was Soranusof Ephesus, who practised medicine in Romein the time of Trajan and Hadrian. Exactlywhat method he advocated is not clear, nor isit clear if he advocated that it should be done.It would appear, however, that he referredchiefly to turning the baby from transverseposition into a sephalic position during theearly stage of labour, but version seems to havebeen lost' for nearly I,500 years until Pare re-introduced it. He advocated podalic versionin cases of transverse lie where the child wasstill alive, but he went further than that; headvocated it as a method of treating ante-partum haemorrhage, so that it would appearthat he was really the first to rupture themembranes and bring down the leg in cases ofplacenta praevia. His methods were alsoapplicable to cases of head presentation wherethe pelvis was contracted.The story of the birth of a son to one
Marguerite de Puis in the year 1548 is well
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November 1947 PEEL . Milestones in Midwiferyworth the telling, assisted as it was in the endby the great Pare. This young bride of imonths was expecting her first child-allpreparations had been made and the famousmidwife, Louise Grisson, had been chosen forher great knowledge of the midwives' art. PoorMarguerite laboured through several days andnights, attended by Madame Grisson, herAunt Therese, and two cousins, Anne andRenee, but there was still no sign of the birthof the child. Francois, the anxious husband,became restive. The famous Barber Surgeonmust be summoned. Madame Grisson andAunt Therese were aghast at the idea of a manin the sacred lying-in chamber, but the youngercousins were on the side of Francois. Rumourhad it that the great man had some newmethod of delivering women. And so thecouncils of the younger generation prevailedand Pare was sent for. The great man sooncame and offered up a sacred prayer before heentered through the door of the sick room.
'In the lying-in chamber he at oncebecame master of the situation, assuringMarguerite that her pain would soon be over.He placed her athwart the bed, raising herbuttocks on a hard stuffed pillow, and proppedher back with a bolster, so that she was halfsitting, half lying. He instructed her to bendher knees and to draw her heels close to herbody. She was bound in this position with abroad linen bandage, the bandage was hungabout her neck and crossed over her'chest, andmade to encompass her feet, legs and thighs.Maitre Pare applied it so tightly that she wasunable to move. To reinforce this vice inwhich she was held, the bystanders firmlygrasped her legs and shoulders. Her privyparts and thighs were covered with a warmdouble cloth, that neither air nor wind mightenter into the womb, and the operation mightbe done with more decency. Pare noted themask of terror which disfigured Marguerite'sface, and once more assured her that all wouldbe well. They then laid her head upon abolster and put a cloth over her eyes.'He took off his two finger rings, the one the
famous 3o-ecu diamond given him byMonsieur d'Estampes, and the other the sealof Monsieur de Rohan, under whose bannerhe had campaigned in lower Brittany. Hecrossed himself and without further pre-
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A room in the Hotel Dieu
liminary rolled up the sleeves of his doubletand annointed well his bare arms and handswith oil. Further, he lifted the modesty clothand poured much oil into the birth passage tomake it slippery. He inserted his hand todetermine the form and situation of the child.Immediately he encountered the intact bag ofwaters which he broke between two fingernails, kept especially long and sharpened forthis purpose. A dark turbid fluid gushedforth, and all who watched knew by that signthat the babe would be lost unless deliverycould be speedily effected.'He pushed up the head which presented,
and dexterously turned the child in the wombso that it came feet foremost. Despite theimprisoning bandages Marguerite struggledand writhed in agony. She was bathed in acold sweat. He brought forth one foot and alittle above the heel tied a silk band in-differently tight. He then returned this footinto the womb, leaving the loose end of theband protruding, and manoeuvred to bringdown the second foot. When he had accom-plished this, he pulled on the band attachedto the first foot and it too came forth. Hegrasped both feet close together and pulling onthem, delivered the buttocks and genitals of amale child. A m'urmur of excitement ranthrough the room, and Renee went out to tellthe men that for some woman as yet uncon-ceived a lover was being born. By this timeall the women kin had crowded into the smallroom to be present at this miraculous and newoperation, for just within the month Par6 hadpublished his book, which contained a chapteron the method of extracting an infant from thebelly of the mother when Nature was not able
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The squattinig position, the parturient supported by thefaithful friend. The accoucheur blows.warm vapourson the patient's vulva, thus softening the parts and
overcoming any rigidity of the maternal soft parts
to bring it forth. The midwives were amazed,the relatives astonished-all seemed to enjoythe spectacle, though poor Marguerite still-screamed. Pare made further traction on thefeet, and soon the belly and then the chestappeared. He then slipped a hand into thewomb past the baby, and placed one of itsarms above its head and the other alongside itsbody, because only when the arms were socould the 'child pass out of the womb. Hedirected the midwives to help by pressing thepatient's belly downward with their hands, andat this juncture exhorted Marguerite to closeher mouth and nose, and to drive'her breathdownward with great violence, but she wastoo exhausted ,to be of much assistance. Bythe combination of pulling and pushing theboy was born.
' His part completed, Pare withdrew to thehall, where the women crowded about himwith congratulations. He was further com-plimented by Francois and the other men.With becoming humility he said that praise andthanks were due to God alone, for if He hadnot inclined His ear unto his petition, deliverycould never have been effected. Francoisopened his purse and counted out ten silverecus. Affected by the uncorimon generosity ofhis host, the master Barber Surgeon deter-mined to remain in the house in case he couldbe of further assistance.'And so poor Marguerite's son was delivered
alive, where otherwise he would have perishedand probably Marguerite as well.Although to Pare must go the credit for this
tremendously important innovation, he did notsucceed--to use a modern colloquialism-in
'putting it across.' It was left to Guille-meau, and the more famous Mauriceau, in thesucceeding generations to popularize themethods which Ambrose Pare preached.Here at last was the practical method of ex-
tracting a child with reasonable rapidity, andthereby saving the life of the child quite fre-quently and, still more frequently, the life ofthe mother. It is said that Ambrose Pare wasthe only Protestant to escape the famousMassacre of St. Bartholomew in I57I, due tothe. special intervention of Catherine deMedici, whom he had served. But two yearsbefore that famous night, another Hugenotescaped from Paris and landed in Southamp-ton. That was William Chamberlen, thefounder of the famous Chamberlen family.That family played a vital part in the practiceof obstetrics during the next I50 years, andtheir fascinating story is unique in medicalhistory.
William Chamberlen's chief claim to fame isthat he was the father of five children, of whomthe eldest and youngest were both called Peterand both were surgeons. Peter the elder wasborn in I560 and came with his father toEngland in 1569, and he later became amember of the Barber Surgeons Company inLondon. It was he who was in all probabilitythe inventor of the famous iron tongs, but weknow less of his activity with these instrumentsthan of his constant controversies with hiscolleagues, the Barber Surgeons, and with theCollege of Physicians. He was constantly inbad odour with the former for failing to live upto his professional and social obligations. The
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Accouchment to music, the jazz band artists, prototypesof which may be heard in most modern flats in the form
of gramophones or wireless.
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November 1947 PEEL : Milestones in Midwifery 527
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Partially suspended attitude for difficult labour. Thepatient kneels and during a pain is hauled up by twolusty women while the third exerts fundal pressure.The manoeuvre is said to be always followed sooner orlater by the birth of the child. The results to the
mother are not always happy.
College of Physicians arraigned him for pre-scribing drugs and not confining himself tothe practice of surgery, and he was actuallyimprisoned in Newgate for this offence. Hewas released by the intercession of 'QueenAnine, because he had established himself as anaccoucheur of considerable renown and hadattended the Queen in her confinements. Hesubsequently attended Henrietta Maria, wifeof Charles I. Peter the elder seems to have hadgreat popularity in Court circles, arid it maywell be that a good deal of professional jealousywas at the bottom of the quarrels with theBarber Surgeons and the Fellows of theCollege of Physicians. Peter the younger wasadmitted to the Company of Barber Surgeonsin 1596, and it is interesting to read that ini6oo he was licenced by the Bishop of Londonto lecture on surgery. Such was the positionof midwifery in the year I6oo that anecclesiastic had the final say in who should beallowed to practise the art. Peter the youngershared with his elder brother the disapprovalof his colleagues and a great deal of popularitywith his patients and with one section at leastof the midwives of the day. These latter madea petition to the Privy Council and AttorneyGeneral that the midwives should be in-corporated and made 'a 'Society. TheChamberlen brothers sponsored this petition,but it was rejected by the influence of theCollege of Physicians who held in very poor
esteem the women who practised this art andstill more the physicians and surgeons whoassisted them in their difficulties. Peter theyounger died before his elder brother, but heleft behind him the best known, and in manyways the most arresting, member of the family,Dr. Peter Chamberlen. This boy had beengiven every opportunity of study by his fatherand he had been to I1eidleburg and Padua tostudy and take his degree of Doctor ofMedicine. He then studied at both Oxfordand Cambridge, and was eventually admittedFellow of the C6llege of Physicians in i626,but not without a rather offensive admonitionfrom the learned authorities 'that he changehis mode of dress and no longer follow thefrivolous passion of the youth at Court andthat he be not admitted until he conforms tothe customs of the College and adopts thedecent and sober dress' of its members.' Dr.Peter Chamberlen very soon established agreat reputation abroad and became achampion of the midwives. He endeavouredto do what his father had failed to do and wasagain opposed by the all-powerful College ofPhysicians, who opposed his endeavours tomonopolize the licencing of midwives 'basedon the presumption that he hath more exactskill than all the grave and learned physiciansin the kingdom on those cases, for hethreateneth that he shall not repair unto suchwomen as are distressed whose midwives haverefused to conform themselves to him.' ButDr. Peter himself continued to thrive, and inI647 was appointed to attend the ladies atCourt ' that with greater secrecy and ease theirladyships may be helped with their mosttroublesome and pressing affairs.' In I66o hewas appointed Physician in Ordinary to
THE CHAMBERLENS
The Chamberlen Family (Aveling)William Chamberlen
Peter the Elder Peter the Younger
Dr. Peter Chamberlen
Hugh Chamberlen Sr. Paul John
IssueHugh Chamberlen Jr. one son no issue
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POST GRADUATE MEDICAL JOURNAL November I947
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Peter Chamberlen (I560-I63I)Inventor of the obstetrical forceps
Charles II. Besides his medical activities, Dr.*Peter had a very active part in religious andpolitical intrigues prior to the restoration of theKing. It is interesting to note that theseappointments followed his dismissal from theCollege of Physicians after a series of bitterquarrels and controversies, in which he wasaccused of unprofessional conduct in manyways. He published a lengthy defence of him-self under the title of 'A Voice in Rhama orthe Cry of Women and Children as Echoedforth in the Compassion of Peter Chamberlen.'.In this document he refers on more than oneoccasion to the family secret.
Eventually Chamberlen was, like his fatherahd uncle, dismissed from the College ofPhysicians for insubordination, and eventuallydied in i683 at the age of 82 years-regardedby many as a madman.
However, the family tradition went on withHugh Chamberlen his son, born in London inx630. Hugh seems to have inherited most ofthe characteristics of his' father and grand-father, and to have spent his life in bitter con-troversy with his contemporary physicians,though he never became enrolled on the list ofFellows of the College of Physicians so that hedid not share the distinction of his father andgrandfather in being dismissed. He practisedmidwifery widely and became a great successin Court circles. He was appointed Physicianin Ordinary to Charles II in i673, and was
admitted Fellow of the Royal Society in i68i.He was called for the birth of James the OldPretender, but apparently James was a B.B.A.He subsequently had the honour to lay thePrincess, Anne of Denmark, subsequentlyQueen Anne, of a son who immediately died.He had Ioo guineas for his pains. He spentten years of his life in a wild scheme for ahand bank-a proposal to make Englandrich and happy. The whole scheme was acolossal failure, and Hugh absconded toHolland with all the funds of the bank andnever came back. He apparently did notleave the business with 'clean hands nor thecountry with honour:-'To give you his character truly completeHe's doctor, projector, man-midwife and
cheate.'However, before this catastrophic end Hugh
had done midwifery a tremendous service.He had in I670 visited Paris and met the greatFrench physician, Mauriceau. At that timehe tried to sell the secret of the forceps for0o,ooo livres. He would probably have founda market, but for Mauriceau, who advisedagainst acceptance. He had boasted of hisprogress with the secret and so Mauriceauproduced a patient with severe rachitic pelvisand Hugh, after labouring for several hours todeliver the baby with the aid of his instrument,failed and both mother and baby perished.However, Hugh Chamberlen and Mauriceauwere not estranged by this unfortunate in-cident. Hugh left the seed of an idea inMauriceau's mind, who says:'The extraordinary difficulty which this
case presented led me to invent an instrument,to which I have given the name of "Tire-Tete," because -of its usage, which accom-plishes its purpose incomparably easier andmore surely than the hooks. If I had thenhad such an instrument, I am certain that withits help I could have saved the life of thiswoman. I have included a picture of it in mybook, in which I have also described veryaccurately its method of use.'Hugh returned to England and translated
Mauriceau's book on obstetrics into English ini672. This brought Hugh himself a con-siderable fortune, but undoubtedly presentedEnglish physicians with a book that set thestandard of midwifery for many years to come.
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November 1947 PEEL: Milestones in Midwifery 529
In his preface to this translation we read theonly direct reference to the forceps.
This translation was undoubtedly Hugh'sgreatest claim to distinction, and there is nodoubt his effort was of inestimable value toBritish midwifery, because Mauriceau was un-doubtedly the first obstetrician of his day.Many years later when Hugh had to leaveEngland, he did eventually sell the secret of theforceps to Roger van Roonhuyze in the earlyyears of the I8th century. It is said that evenhere Hugh Chamberlen cheated and sold onlyhalf the instrument, the vectis or lever, butthis is not really an established fact, and thereis little doubt that in the early 1700's theforceps came into fairly general use, both inEngland and on the Continent.The last of the Chamberlens was Hugh
junior, who seems to have departed fromfamily tradition-born in i664, he took hisCambridge M.D. and, subsequently, theequivalent of the modern M.R.C.P. of theCollege of Physicians, later to be elected aFellow. He even appears to have turned thefamily table and preferred charges of mal-practice against one Gort, a surgeon, forprescribing internal medicines to one of hispatients, in the very best and orthodox practiceof the day. He was subsequently made Censorof the College, and ended a wholly respectable,but thoroughly dull, life in 1728, and even hada bronze tablet erected after his death inWestminster Abbey. Such is the estimate offame by contemporaries.The last chapter of interest in the life of this
remarkable family was the final discovery ofthe actual instruments used by the firstChamberlens. The forceps were discovered byaccident in the family residence of WoodhamMortimer Hall in Essex. The house had beensold in 17I5 by one of the less known membersof the Chamberlen family to William Alex-ander, a wine merchant, and he in turn left thehouse to the Wine ' Coopers ' Company. The
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discovery of the forceps came nearly Ioo yearslater and were secured by a local doctor, oneDr. Carwardine, and were presented by him tothe Royal Medical and Chirurgical Society ofLondon in I8I8. In his address he states :-'The principal entrance to the mansion is
through a porch, the masonry of which beingcarried up with the building, serves as closetsto its respective stories. Two or three years.ago, a lady with whom I am intimatelyacquainted (and from whom I had the par-ticulars), discovered in the floor of the uppercloset a hinge, and tracing the line she sawanother, which led to the obvious conclusionof a door, this door she soon found means toopen. There was considerable space betweenthe floor and the ceiling below, and thisvacancy contained divers empty boxes, etc.Among these was a curious chest or cabinet, inwhich was deposited a collection of old coins,trinkets, gloves, fans, spectacles, etc., withmany letters from Dr. Chamberlen to differentmembers of his family, and also the obstetricinstruments. Being on terms of intimacy withthe family resident at Woodham MortimerHall, these instruments have been presented tome, and I have now the gratification of de-positing them with your Society for thegratification of public curiosity, and to secureto Chamberlen the meed of posthumous famedue to him for his most useful discovery.'
(To be concluded)
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