A Treatise on the Art of Midwifery / Setting Forth Various Abuses Therein, Especially as to the Practice With Instruments: the Whole Serving to Put All Rational Inquirers in a Fair Way of Very Safely Forming Their Own Judgement Upon the Question; Which It Is Best to Employ, in Cases of Pregnancy and Lying-in, a Man-midwife; Or, a Midwife

by Elizabeth Nihell

Introduction.

Notwithstanding the numerous productions of writers on the art of succoring women in labor, all that has hitherto appeared on that subject, still leaves the mind unsatisfied; not that it is so unjust as to expect perfection in any human art, but from its feeling that, in this particular one, too much is given to theory, and too little to the practical part, or manual function.

While the causes of difficult labors are far from solidly or sufficiently explained, and rather obscured by a cloud of scientific jargon, than practically illustrated, they give us no tolerably sure method for preventing or remedying those difficulties. On the contrary, the whole boasted improvement of the art is reduced, to a pernicious recourse to instruments, which cut at once the knot they cannot unty.

It is then no wonder that there should still, in all the books and observations hitherto given on this matter, exist a void lamentably unfilled; and as this void evidently consists less in the theory than the practice, the superior qualifications, and natural endowments of the women for the manual operation, point out the fitness of the greater dependence on them for the filling up what, humanly speaking, can be filled up of that void.

Let the physicians, the surgeons instruct the midwives in so much of anatomy as is necessary to their function; let them afford them, either in writing or verbally, their guidance and direction in the consequences or occasionally in the preliminaries of management of the lying-in; all this is right, salutary, and in due course: but that men should pretend to the manual operation in these cases, it certainly neither is nor can be their business. Nor is this negation of propriety a reproach to them. Will any man think it an indignity to be told, he cannot clear-starch, hem a ruffle, or make a bed as handily as a woman? The exceptions are the shame; and in this department of art it would be truer to say, that there are no exceptions than that there are only a few.

But can we wonder at the insufficiency of the lights thrown into the art of midwifery by that cloud of writers who have treated of it, when so few of them having had any other view than advertising themselves, and being incapable of saying any thing to the purpose, of the art of delivering the women, have filled up their books with insignificant digressions, or things intirely foreign from the point?

In some you see all distempers of women collateral to their pregnancy, which is certainly a very necessary and an infinitely extensive subject, while on the practical article of the deliverance they give you nothing but what is barren, jejune, or even false. Others, by way of filling up, run digressively into a discussion of the methods of treating infants. Others again have written only to recommend some pretended secrets, as powders, preparations, &c. Some have swelled their volumes with the more or less commodious structure of a couch, or the mechanism of a close-stool, or the make of different sorts of syringes for anodine injections. In others you meet with remedies for the deformities of the human body, for the contractions or stiffnesses of the muscles of the shoulders, arms, hands, legs, feet, thighs, haunches, &c. to straiten the crooked, and even, in a treatise on midwifery, to extirpate a polypus from the nose. Others, with all the parade of justly exclaiming against nostrum-mongers, the plausible writing against which serves at once to fill up, and give them an air of superiority to such trumpery, substitute however nothing better of their own than the recommendation of some instrument, which they give you for a master-piece of invention; and to establish which, they cry down every instrument of other practitioners, though not one jot inferior to it in any thing, but the not being the newest. Thus, after having perused such a multiplicity of authors, it is incredible to say how little true, or practically useful knowledge is to be picked out of the whole mass of them. You find almost every thing in them but what you are looking for.

In the mean time, the superficial examiner of things, who sees such a number of volumes, furnished by these pretenders to the art of midwifery, cannot conceive they contain matter so little essential as they do. The scientific air diffused over them, not a little embellished with pretty prints of machines, as of a windowed forceps, a stool, or of a gravid uterus, all these contribute to throw the dust of erudition into the eyes of those, who do not penetrate beyond the surface of things. And thus the aids and appendages of the art, or what is yet worse, even the abuses of it, pass for the art itself, the main of which, as it undoubtedly consists in the expertness or dexterity of the manual practice, can be so little and so imperfectly conveyed by description. I am however far from denying the benefit which may result to midwives, from consulting all that has been written on this subject. I am far from encouraging ignorance in the women of this profession. Their skill in the manual function cannot but be improved by the addition of a sound and competent theory. But it should always be remembered, that the very basis or capital point of the art is the manual dexterity; and in that point, the most learned of the men must yield to the most ignorant of the women. A point which the men surpassing the women in every thing else can never compensate: no not with all those dreadful “artificial hands”, of which they boast so much their invention, in the room of the infinitely preferably natural ones, of which the use, in this office, becomes the men as little, as their hands seem formed for it; and I might add, their heads, if they themselves can possibly think otherwise. In such an opinion the ignorance is theirs.

As to the treatise herein offered on the art of midwifery, as the object of it is principally to attack particular abuses and dangerous innovations in it, it will not be expected that the same should furnish a compleat general course of practice. But this I dare aver that if I should be induced to attempt such a work, it will not be the worse for my consulting more the experience I have of Nature in her operations in this one of her so capital concerns, than the authorities of men, who seem or pretend to know so little of her, as to think of assisting her with instruments, formed only for her destruction, or at least for doing her more damage by their violence, than any reason to hope good from them can justify.

Here I shall not offer any digressions on physic, anatomy, chemistry, or pharmacy; I shall confine myself entirely to the points of my business of the manual operation. Let the physician prescribe, the surgeon bleed, the chymist contribute medicines, the apothecary make them up; with none of these professions do I presume to interfere. But as to the man-midwife, who not only so often presumes in some measure to represent them all, but to join to them the exercise of an art so unnatural to his sex, I should think myself wanting to my duty in my profession, if I did not point out the mischief I apprehend to result from especially that method of practice, on which he grounds the pretence of necessity for his practising it at all; and this chiefly forms the object of this second part, in supplement to my first.

Of Deliveries.

We understand, by deliveries, in general, the issue of the fœtus out of the mother’s womb.

These are distinguished into two kinds, the one natural, the other preternatural.

The natural one, is that in which the fœtus comes out in the most ordinary way, when it presents the head foremost.

It is deemed preternatural, when the fœtus presents in the passage any other part than the head.

These two kinds are again subdivided into two distinctions of labor, of easy or difficult, because both the natural and preternatural mode of delivery may be easy or difficult.

The delivery is termed easy when the fœtus comes out readily, and without the aid of art.

It is termed difficult, when the labor of it is hard, and the fœtus does not make its way out but with pain, and with the help and assistent industry of the midwife.

In the cases of a natural and easy delivery, there is little or no actual occasion for the presence of the midwife, beyond that of receiving the fœtus, tying the navel-string, giving the child to be kept warm, and then delivering the mother of the after-birth. The spirits of the patient are then to be recomposed, her agitation calmed, a warm and soft linnen cloth applied to the stomach; a warm shift and bed-gown put on her; a linnen cloth to be laid on four-fold over the belly; a double-napkin round her, and she to be placed in a bed well warmed. Such is the summary of the process to be observed in those common cases.

In the deliveries, on a preternatural labor, when they are easy, the same method takes place: there being no difference, but that in one the child will have been received by the head, in the other by the feet.

These kinds of labors are so easy, that there is no need of demonstrating their being to be terminated without the aid of instruments. When the fœtus presents itself promisingly, Nature is best left to her own action, and nothing should be precipitated in the manual function, unless some unexpected accident should intervene, and require interposition, such as a great flooding, or other exigency.

As to the preternatural delivery, the better practice is not to delay the extraction of the fœtus, after the discharge of the waters; nor stay till her strength shall have been exhausted. On the presenting of a fair hold, and a sufficient overture, no difficulty should be made of extracting.

All that is to be observed then, is not to prematurate this extraction: not to proceed, in short, like those unskilful, or inconsiderate practitioners, who are no sooner entered the patient’s room, but they want to have their operation dispatched out of hand. Nothing can be more important to the well-doing of the patient, than for no violence to be used to Nature, who loves to go her own full time, without disturbance or molestation. In this point then great caution and circumspection are requisite.

It should also be observed, that it is wrong for the midwife to leave a woman newly lain-in, however happily delivered. It is necessary to stay by her for some hours afterwards, till she is in such a state of tranquility and ease, as may leave nothing to fear of those after-disasters which too often happen.

Some celebrated practitioners and authors upon midwifery have been surprized to see women, after their going their time without mis-adventure, and after having been readily and happily brought to bed die suddenly. There are too many of both the female and the men-midwives who have no notion of this misfortune till it is too late to prevent it. The cause of this melancholic accident is unknown to many practitioners of the art. Some have confessed their ignorance of it: others have erroneously, others deficiently accounted for it. But all are surprized when the patient is the victim of it: especially as it follows, in some cases that afford the best grounded hopes.

Messieurs Mauriceau and De la Motte give us examples of these unexpected deaths. The first, in his 230th observation, says,

“I delivered a woman of a very corpulent habit, aged about thirty-five years, of her first child, which was a lusty girl, alive, and that came naturally. This woman had been near two days in labor, with small slow pains or throws, after which the waters having burst forth with a strong throw, she had subsequently favorable ones, which made her bring forth as happily as one could wish. I immediately delivered her: but to my great surprize, scarce had she been a quarter of an hour after delivery, that she of a sudden fell into violent faintings, with an oppression at the breast, and a great agitation of the whole body, which was instantly followed by a convulsion, caused by a loss of blood, of which she died a quarter of an hour afterwards.

“This (adds Mr. Mauriceau) was one of those kind of fatalities which no human prudence can elude or parry.”

La Motte had the same case happened under his hands, which I need not repeat here, being inserted in the first part of this work, where, p. 131, I ventured to promise an essay of mine, to give a less unsatisfactory reason of such deaths, than what is to be found even in those two celebrated authors whom our cotemporaries consider as their masters in the art of midwifery. These impute those unforeseen deaths to occult and inevitable causes. I own, I do not intirely think them either occult or inevitable. I doubtless may be mistaken, but of this I am sure, I shall advance nothing but what is authenticated to me by my own observation and experience.

An over-repletion of blood, and a defect in the contraction of the uterus, of which all the vessel being open are too slow in recovering their occlusion, are generally speaking, the causes of these diseases. I could support this opinion by some chirurgical axioms, but I presume it will be thought more satisfactorily proved by the success of the method of practice, which I would recommend to prevent or cure those dangerous or rather fatal causes.

As to know that a woman may thus perish unexpectedly a quarter of an hour after delivery, is enough to require the being on one’s guard for using a salutary prevention; I would advise attention, especially to her constitution.

Whenever therefore a pregnant woman is observed to be remarkably corpulent, and full of blood, with a good constitution, she should be advised to lose some blood, once or twice during her pregnancy, by way of precaution. This is of great service to rarefy the blood, and obviate those excessive hemorrhages, which are to be dreaded on their lying-in. Then nothing is to be precipitated during their labors, that Nature may have full time to predispose the uterus to enter into contraction by due degrees, that is to say, neither too quick, not too slow. But if, notwithstanding these precautions, there should, after delivery, supervene any considerable loss of blood, followed with faintings or oppressions, the patient must be stirred, excited to cough and sneeze contributively to the evacuation of the blood, which otherwise is apt to clot in the uterus, and would suffocate her if not expelled.

If by this mean the evacuation does not naturally take place, which may be perceived by the faintings of the patient, the midwife must, without losing time, put her hand into the bowel, and extract all the clots of blood she will not fail of finding there, and of which the presence, as being extraneous matter, necessarily oppose the contraction of this organ, and quickly suffocates the woman, if she is not timely relieved.

These hemorrhages are but too frequent, especially with those women who neglect the precautionary bleeding; and such sudden death too commonly the consequence of neglecting, or of not knowing that the most salutary practice, in these cases, is to well evacuate the uterus by the operation of the hand, where Nature appears in the least tardy or deficient.

The long experience I have of this manual help, which has never failed of success with me, warrants my averring, that there is little or no danger, in these cases, to women, provided the midwife employs herself dextrously to clear them while time serves. Their relief is instantaneous. They come to themselves presently: they are restored to a freedom of respiration: nor will they have so much as been sensible of this operation of the hand, which will nevertheless have saved their lives.

There have been men-midwives, that pass even for learned, but who from their ignorance of this so simple and easy method of relief, have been in the disagreeable circumstance of seeing many women perish under their hands, though they had to all appearance been very happily delivered.

With respect to pregnant women, there is again another point of great consequence to ascertain. Great care must be taken not to mistake the signs of delivery. This is a very essential matter. Nothing scarce can be more dangerous, than to excite a woman to the last labor-pains, which will not fail of exhausting that strength of her’s, in vain, which had so much better be reserved for the support of her in the time she will really need it. So that a midwife ought to make it her business clearly to distinguish the spurious pains from the true ones. Where a woman near her time feels pains in the belly, the loins, or even the sexual parts; they are not always to be taken for the true labor-pains. In this point, the touching will be a great guidance.

If the fœtus is still high in the uterus, and the situation of it does not indicate a readiness for extrusion; if the waters are not sufficiently prepared, or their pressure down not in due forwardness, the pains must be assuaged by some calming anodine remedies: the patient must be left to her rest, till things declare themselves more openly; and then, as she will not have been fruitlessly fatigued and tormented, the labor may proceed happily.

There have been men-practitioners so very unskilful, or at a loss for delivering women by the operation of their hands, that they tortured their heads to discover medicines to save themselves the tediousness of Nature’s taking her own time, as if she was to do her work the better for their hurrying her. Towards the atchievement of this end, they brought into play certain drugs, to which they gave the appellation of hysteric, and placed or pretended to place great confidence in them.

Even some of our modern practitioners prove, at least, by their practice, that they have faith in the virtue of such drugs, since they continue to use them. They are still suffered to make a figure in many of the Pharmacopœas, though no sure experience hitherto has verified their efficacy. On the contrary, a thousand and a thousand examples might be quoted in demonstration of their insufficiency and danger. I shall content myself with producing here the testimony of Mr. De la Motte, in the second book of his observations, and he is not the only man-midwife that does such medicines the justice of disapproving them.

Observation 174.

“A celebrated man-midwife of this town (says Mr. de la Motte) pretended to have a marvellous powder to provoke labor-pains, and accelerate parturition. This powder was composed of galbanum, myrrh, savin, rue, and other drugs, of which he made the patient take a dose, to hasten a delivery, when the labor was lingering, from half a drachm to a drachm, and after the effect of this medicine, which ended commonly in leaving the patient in a worse condition than before the taking it, he substituted the use of the crotchet, which was indeed an infallible method of putting a speedy end to the labor; and of which he as well as his fellow-practitioners made such a murderous use, the aid of the hand well conducted being unknown to them.

“The same operator (says Mr. de la Motte) was sent for to assist a lady who had continued in labour for three days, to whom he proposed a dose of his powders, to which she readily consented in the hopes of a speedy delivery. Unluckily, not most certainly for the lady, but for the honor of the powders, the operator, not having had the providence of having them about him, was forced to go home for them. The lady, in the mean while, was brought very happily to bed, just as he was re-entering the room with his dose for her. What a pity this was! What would not have been the boast of the virtue of those pretious powders, if the delivery had waited for them but half a quarter of an hour, though they would not have had the least share in it, since it would have been purely the work of Nature and Time.

“This celebrated man-midwife was called to two other women of my acquaintance, of whom the labor somewhat resembled that of this lady, but of which the consequences were very different: he had made them take his powders to no manner of purpose, when seeing that a day had passed without their producing the expected effect, he had recourse to his crotchet, with which he quickly dispatched both the deliveries.”

Observation 174, of the same Mr. De la Motte.

“A gentleman who lived upon his fortune, without professing surgery, though he had served his time to it, and had even formerly exercised it, not only in France, but in Italy, and in other foreign countries, told me, in conversation, that he had an infallible remedy to make a woman bring forth instantaneously, however lingering and difficult her labor might naturally be. Of this, he said, he had made undoubted experiments, and that he had obtained this secret from an Italian, under oath of not disclosing it to any one. He was more than a little surprized at finding me without curiosity to learn from him this pretended secret, which he imagined must concern me so much, as one who made open prefession of the obstetrical art; and still greater was his surprize at seeing me change the subject, without any sign of attention to what he had been saying on this head.”

“In process of time, he married, and his wife being pregnant was got into the time of her labor-pains towards delivery. It became now expedient for him to declare this famous secret to me, which was no other than half a drachm of borax in a glass of any innocent liquid agreeable to the palate of the patient. But as this dose happened to be administered by one who had no sort of faith in it, it had no effect: his wife lay four days and four nights in labor; the child died the moment after it was born, and the mother narrowly escaped following it.”

Observation 176, (of M. De la Motte)

“As I was at Caën, a town of Normandy, attending the lying-in of a lady there, an old stander of a practitioner of that place, and a man of good abilities, told me, that he had been lately sent for to a woman who had continued several days in labor, with slow and moderate pains. As he found the fœtus well situated, he made the patient take an infusion of three drachms of sena in the juice of a Seville orange, in order to quicken the throws and advance the delivery, which indeed came on ten or twelve hours afterwards, but the woman died, one may say, immediately after it.

“To this account (continues M. De la Motte) I opposed, for answer, that being at Bayeux, on the like occasion, an old practitioner in surgery of that place, in conjunction with whom I had been called to visit a patient, told me, in conversation, that he understood midwifery very well, that he had even, not long before terminated a delivery given over by another surgeon; that the child, one arm of which hung out, was dead, before he put his hand to it, and that the mother, though well delivered, died soon after.”

These examples may suffice to prove, that the notion of giving histeric medicines, for which the inventors did not forget to make themselves be well paid, existed in M. De la Motte’s time, who is not but a modern author: nor are they even to this hour absolutely exploded, tho’ some of the men-midwives themselves have joined Mr. de la Motte’s cry against them. It gives however those men-practitioners, who exclaim against a quackery in others, by which themselves get nothing, a good sort of an air: it serves even to render that more pernicious quackery of their instruments the less obnoxious to suspicion. Nothing is easier to give up than that by which nothing is got. If the instruments were not a plea for the very essence of such a thing as a man-midwife, they too would be given up. However, it will hardly be denied, that those same pompous histeric medicines were the invention of learned men-practitioners, and not of those poor ignorant midwives, who, with respect to women in labor, are of opinion, that there can nothing be more effectual for their well-doing, than in the first place giving Nature fair-play, and, when requisite, to assist her with the management of natural hands skilfully conducted: always observing neither to lapse nor precipitate the critical time of such assistence. In the mean time, let a humane reader but reflect how many mothers and children must have been, and perhaps still continue to be the victims of a reliance in such medicines, and he will allow, that such errors of practice, tho’ not capital in the intention, are too often deplorably so in the effect. Is it not true to say, considering the havock of the human species, so presumably made by quackery and empiricism in general, that the lives of the subject are less sacred than their property? Surely they are less guarded, either by the laws, or by common sense.

As to a fœtus that presents an arm, or any other part than the head or feet, there is rarely any thing to do but to slide the hand all along that arm, or other part it may present, to find out the feet, and terminate the delivery; without its being necessary to attempt the reduction of any part or member.

Most of the writers on midwifery often start difficulties where there are really none. They often give us emphatical accounts of a head too large, and a passage too narrow, in which they state them as difficulties that are invincible, when the case is far from being so. When the fœtus presents fair, and is in a good posture, our method of practice is, to advise the patient to remain as quiet a-bed as possible, avoiding every thing that may tend to fatigue her body, or hurry her spirits, to reserve in short her strength as much as possible. With time and patience the head of the fœtus scarcely ever fails of moulding itself to the passage, through a particular providence of Nature, which has so ordered it, that the parietal bones of the head of the fœtus, so flexile as to ride over one another, form a kind of oval figure, which facilitates the issue, and dispose it for making way for itself, through the extrusive pressure of the labor-throws. Mean while nothing should be done to irritate the pains; the membranes should not be unnecessarily or untimely burst, which loses the benefit of the waters. You can hardly, in this case, rely too much on the benevolent efforts of Nature: she is constantly at work for the patient’s delivery. Interruptions sometimes only serve to mar or retard a favorable crisis: but all abrupt force or violence is carefully to be avoided. As to bad postures of children, I shall treat of them in the sequel, and of the means to remedy them.