Thursday 5 September 2013

Part 2: Man-Midwives and the use of forceps during the eighteenth century.

William Gifford’s journal, the subject of my last blog, ends in 1729. The male/female midwife argument continued for the remainder of the century. In 1733, The Lady’s Magazine contained an article declaring that “‘we can never wish that society should be filled with doctors in petticoats to regale us with Latin and Greek.”[1] Man-midwives questioned whether women’s minds were capable of understanding science, or whether their fingers would be able to manipulate obstetrical instruments. This, together with the exclusion of women from universities and concern over what type of work might be appropriate for a woman, meant that the kind of woman who became a midwife were often uneducated and from the lower-classes, which in turn made it less likely that they would be engaged by the middle and upper classes.
The rise of the male-midwife was not exactly smooth and they were not welcomed into the main body of male medics. The Company of Surgeons passed a bye-law in 1745 prohibiting man-midwives from election to its governing body and, although the College of Physicians resolved in 1783 to grant man-midwives a physician’s licence in midwifery, by 1804 it had repealed some of those rights and banned man-midwives from election to its governing body. The College of Physicians further failed to respond to calls for the regulation and training of midwives, so that the unregulated state of midwifery continued until 1902. As a result, by the end of the eighteenth century and, despite any social assumptions about female propriety during childbirth, the man-midwife advanced from attendance at abnormal births to attendance at nearly all births in both fashionable city and rural areas of the country.
Despite the exclusion of obstetrics (midwifery) from the Royal Colleges, an increasing number of men took an interest in ‘instrumental midwifery.’ Peter Chamberlen invented the obstetric forceps in the late 1500s, however, the Chamberlen family kept their invention a secret for 130 years. By that means the family established themselves as the only people able to save the lives of mothers and babies during difficult deliveries. The secret of forceps was leaked in around 1730, from which time onwards their use became widespread. Edmund Chapman published his design in 1733 and William Gifford’s modification (the ‘Extractor’) was published in 1734: a drawing of Gifford’s design appear in the 1734 edition of his journal.[2]
From thereon, it likely that barber-surgeons led the way with forceps in midwifery as women were barred from surgical practices. In 1770 Mrs Stephens, a midwife, advised midwives to send for a man where forceps might be necessary because, if either the mother or child died, people would be more reconciled to the outcome when the procedure was undertaken by a doctor. The attendance of a ‘professional’ man-midwife provided an insurance cover for the ‘untrained’ midwife.

Destructive scissors and crotchets. From William Smellie's A Sett of Anatomical Tables, 1754
William Smellie taught both men and women about the study and mechanics of delivery, including the use of forceps, although men and women were taught separately, suggesting that the roles each played in the birthing process were quite distinct. Some midwives objected to the involvement of man-midwives and the use of forceps and outspoken midwives, such as Elizabeth Nihell, focussed their attack on Smellie, even though he, William Hunter and others advocated against the excessive use of instruments. 

Cases referred to below are taken from William Perfect, (1783) Midwifery Vol., 1, Rochester: T. Fisher. (The Wellcome Library).

Perfect’s journal includes accounts of 68 cases from the 1760’s in which he was called upon to attend women during child-birth. It includes extracts of correspondence between Perfect and Dr Colin Mackenzie concerning the use of forceps. In the introduction, Perfect credits Mackenzie and Smellie with influencing his work:
            I was influenced by Doctor Colin Mackenzie who died in 1775.
Dr Smellie, to whom the world is much obliged for his obstetric improvements, and many useful communications, and to whose mechanical plan, the art of Midwifery will ever stand greatly indebted.
Case VII and VIII: letter to Dr Colin Mackenzie, the case concerns the delivery of twins.25 September 1762: On the delivering the first twin he wrote:When finding the head pretty low down, ... without the least hesitation I had recourse to the forceps. The second child appears to have been delivered naturally.
The reply from Mackenzie concluded with the following postscript:
In using the forceps I have not a doubt of your care; but you will do well to remember the rules of their application, which are laid down by Smellie; and are truly the most valuable parts of his book.
Case XII: letter to Mackenzie
20 January 1763: Being just recovered from the fatigue of one of the most melancholy cases that can happen in Midwifery, I embrace the first opportunity of giving you a circumstantial detail thereof, as follows.
The woman was described as being very small from having had rickets as a child, deformed and aged 17 years old.
About four months since she informed me of her desire that I should attend her labour; which, from the deformity of her shape, debility of her constitution, and depression of spirits, I was induced to prognosticate would not prove the most favourable, and therein I was not deceived.
Perfect goes on to describe how he was first called on 12th January when he did not consider her yet fully in labour and called again on the 19th when he prescribed a draft and was called again the next day. On examination he found the head of the child to be too large, the pelvis very small and the child probably already dead.  He then wrote:
I left as much to nature as was safe; that the life of the mother was now in utmost danger, and that I must proceed in such a manner as to secure her life, if possible, as that of the child was of the least consequence; besides, that I did apprehend the child was already dead… The attendants were satisfied with my determination. [He described how he first tried to remove the baby using forceps, but]  ... as the patient grew weaker and weaker, and the women concluded her at the verge of death, turned all my thoughts to the crotchet.

He then described in detail how two ‘crotchets’ and force were necessary to deliver the dead child.
The reply from Mackenzie supported his judgement in that case and added his own recommendations on the use of crotchets and what was currently in and out of practice. Mackenzie further referred to nine cases reported by Gifford on the use of the crotchet.
26 February 1763:  Perfect reported a previous labour of the woman he was attending, where the delivery with a crotchet was undertaken by a man-midwife.
Perfect appears to have tolerated female midwives for their caring skills and recognised the ‘womanly’ assistance a midwife could provide.
Case III
August 1761: I was sent for at the desire of a midwife, to assist a woman whose efforts of labour had been ineffectually violent for the last ten hours ... The midwife had treated her with much care and tenderness ...
Perfect’s case studies suggest that male practitioners were called upon for their wider medical skills and that instruments were used on few occasions.
Case II
July 1761:  A woman was taken with pains resembling those of labour, upon which a midwife was sent for, who hastily pronounced that she had gone her time, and was in labour; but after waiting many hours, and no signs of delivery appearing, her friends grew uneasy, and solicited my assistance.  Upon examination ... I declared them to be spurious, and that labour was not begun ...  Near a month afterwards I was again called to her; but now her pains were genuine.
Case IV
Beginning of 1762: I was desired to visit a woman who had undergone a lingering labour of five days and nights, and been attended by a midwife.
Case V: on assisting a male-midwife
24 March 1762: My assistance was sought in regard to the placenta of a young woman, who had ... been delivered of a fine male child by a man-midwife, who, upon my coming into the chamber appeared much ruffled and uneasy, averring that his skill had been called in question, and his practice much censured by the attendants, because he had not been able to deliver the placenta; I sympathized with him upon his situation, and begged we might use our joint endeavours to serve the patient.

Case VI: on a breach birth
14 August 1762: She had pains which were taken for those of labour; in consequence whereof I was called ... I left, after exhibiting an oppiate, and assuring her that I would wait on her again as soon as sent for.
The following night he reports having attended her again and having found the baby to be in a breech position he safely manipulated the baby and delivered it.
Case IX: on the problem of identifying twins.
29 December 1762:  I was sent for to a woman ... who had been delivered of one child ... as the placenta of the first child came away without difficulty in the usual time, no remaining child was suspected by the midwife.
Notes to the case:
The continuance of labour pains, after the birth of one child, is generally supposed to indicate a second; but ... that criterion is found to be very uncertain. ... The surest and most infallible determinations in such cases, I should suppose is the application of the hand externally on the abdomen; or a finger and the hand, if necessary, introduced into the uterus.  This rule, however, is not always infallible; for a very judicious practitioner (Mr John Aiken) in the Edinburgh med. comm. vol. ii relates the history of a case, in which he himself mistook a tumour in the abdomen for a second child.
Case XI
1763:  A case concerning a married woman in the fourth month of her pregnancy was found to have a venereal disease causing problems which the midwife could not identify: …the frank confession of her partner, left no room to doubt of the complaint.
Case XXVI On attempted abortions between the fifth to ninth month of pregnancy:
Through the whole of his practice it has been observed, that the skilful man-midwife will seldom meet a trial, which can prove a truer criterion of his skill and dexterity, than that of conducting his patient safely through a case of this kind.    
The eighteenth-century was an age of scientific and technological advancement, which included an extraordinary growth in obstetric knowledge, teaching, and practice, including as William Hunter’s work on anatomy and Thomas Denman and William Smellie’s texts on midwifery. The letters between Perfect and Mackenzie reflected the increased understanding of obstetrics and the application by male practitioners of new surgical techniques. They further illustrate the advantage for literate professionals who shared knowledge over that of the untrained midwife.
The unregulated status of midwifery meant that midwives, as the least educated, would bear the brunt of criticisms about midwifery. The combination of the changing attitude of women to man-midwives, the lack of regulation and licence of ordinary midwives, medical advancements in obstetric procedures and the increasing professionalization of medical practitioners culminated in an irrevocable change in the nature of midwifery practice and the rise of the man-midwife.

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[1] The Lady’s Magazine, IV (1773), p.401
[2] William Gifford, (1734) Cases in Midwifery, London: Edward Hody, The Wellcome Library.

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