Jacksonian Miscellanies, #32

October 7, 1997

Topic: State of the Art Midwifery, 1849

Copyright by the editor, Hal Morris, Secaucus, NJ 1997. Permission is granted to copy, but not for sale, nor in multiple copies, except by permission.

Jacksonian Miscellanies is a weekly* email newsletter presenting short** documents from the United States' Jacksonian Era, which you can receive it for free by sending to hal@panix.com a message with

as either the subject line, or as the *only* line in the message body. If you want to make a comment or query, please send a separate message to hal@panix.com.

Jacksonian Miscellanies can also be read at http://www.panix.com/~hal/jmisc. The WWW version is augmented with much biographical, bibliographical, and other information.

Please direct responses and comments to hal@panix.com,.

Topic: State of the Art Midwifery, 1849


  • Any information about Rankings Abstracts, or their author, W.H. Ranking?
  • Any knowledge of "Mr. Gream"?
  • How were "contagion" and "infection" defined or conceptualized in those days, without reference to microbes? (see the last excerpt on "Puerperal fever").
  • A number of people wrote me on the subject of "interestingness" in the early 19th century U.S., saying that they observed it too, in various contexts. No one was able to shed any great light on it. The Oxford English Dictionary gives as an obsolete meaning of interesting: "that concerns, touches, affects, or is of importance; important", consistent with what we've observed, and another usage, where "in an interesting condition" means pregnant, which brings us to the current topic.

    The following are excerpts from Rankings Abstracts, or The Half-Yearly Abstract of the Medical Sciences ..., edited by W.H. Ranking, M.D., Cantab., late Physician to the Suffolk General Hospital. No.9, January-June 1849, Philadelphia: Lindsay and Blakiston (1849 or 1850).

    It is evidently a Brittish publication, republished in the United States, representing, I suppose, the most up-to-date information available. The first excerpt lets William Channing, the brother, 6 years younger, of William Ellery Channing, make the case for the use of anaesthesia in childbirth. Anaesthesia, using ether, was first applied to surgery and dentistry in the United States in the 1840s, though Sir James Young Simpson, a Scottish obstetrician was among the earliest adopters (using chloroform, however). Simpson was knighted, perhaps in large part for the delivery, under anesthesia, of Queen Victoria's 7th child.

    After reading the 2nd excerpt, "on Vomiting during pregnancy", you would probably want to say, if you lived back then, "Give me the coffee and dry toast treatment."

    pp269-70, Anaesthesia in Midwifery.

    The interest excited by this subject, though somewhat abated, has not subsided entirely, but is still kept publicly alive by the occasional appearance of a pamphlet or book, taking, as the case may be, a favourable or unfavorable view of its applicability. Of this nature, are two productions which we have now to notice; namely, a treatise by Dr. Channing, and a pamphlet by Mr. Gream.

    Dr. Channing, of Boston, an accoucheur in extensive practice, records the results of the inhalation of ether in upwards of 500 cases, these results being altogether favourable. "Anaesthesia has," he observes, "produced no such effects in midwifery as for a moment should suggest that it be laid aside, or which makes its entire safety a question. I have not met with a case, either my personal experience, or on record, in which anything untoward has occurred during etherization in midwifery, which could not be explained without reference to that agent."

    The author's views are succinctly exhibited in the following propositions:-

    1st. I generally take the ether or chloroform with me, and if the pains are severe, I offer inhalation as a sure and safe means of abolishing pain, and this in a perfectly natural labour.

    2nd. In protracted labours, in which dilatation goes on slowly, notwithstanding severe contractions and great suffering, I recommend and employ inhalation.

    3rd. In any labour, if there be imperfect dilatation, or the secretions are deficient, use inhalation.

    4th. In instrumental labour, I use inhalation, always applying the instruments before inhalation is commenced.

    5th. In turning, I employ inhalation.

    The objections to anesthesia., which appear to be much the same in America as in England, are met by Dr. Channing in much the same manner as has been adopted by its advocates here, but, as we have entered fully into these points in former volumes, a repetition would be out of place.

    In a subsequent part of his essay, the author gives the results of anaesthetic midwifery in America, as derived from personal experience, and from the experience of numerous physicians, who replied to a circular letter making inquiries on the subject These results are of sufficient import to warrant their detail.

    In 516 cases of cephalic presentations in which anesthesia was induced, mother did well in all.

    In 51 cases of instrumental, preternatural and complex labours the deaths were four-a mortality as Dr. Channing remarks, so small as was never before presented. These cases included forceps and craniotomy cases, arm and breech presentations, cases of unavoidable hemorrhage, and of convultions among which were the four fatal cases.

    Mr. Gream, the author of the pamphlet entitled "The Misapplication of Anaesthesia in Childbirth" is known, doubtless, to most of our readers as one of the earliest and most uncompromising of the opponents to anesthesia in obstetrical practice. His opposition is, however, we must observe, of that violent character which deducts largely from the credence which we might otherwise attach to his writings. There is, in fact, so great an air of partisanship of an almost morbid hostility to Dr. Simpson, and the other advocates the other side of the question, that the mind instinctively prepares itself to receive his remarks cum grano salis.

    The author starts by assuming that the requiem of anesthesia in midwifery is already sung, as far as the public is concerned - a fact, by the by, the existence of which we beg leave to doubt; and he then proceeds to inform us that he has collected information by means of a circular letter, the answers to which are such that, not only have all his former assertions been substantiated, his prognostications of injury to a frightful extant exceeded. With this introduction, he commences his opposition by the enunciation of certain allegations --to wit, that anesthesia from ether and chloroform is no more or less than drunkenness, that it gives rise to indecent dreams, expressions, and actions that it induces convulsions: and, lastly, that it may cause death. Each of these he endeavours to substantiate by facts, most of which are derived from the sources above mentioned.

    Want of space prevents our following the author through the details thus accumulated; but we cannot avoid the remark, that some of the facts by which he supports the second proposition are such as we are surprised to meet with in a pamphlet, which whatever may be the author's intentions, will doubtless find its way into some of the "drawing­rooms" whither he accuses Dr. Simpson's writings to have preceded him. If such be the case, we submit that pages 33, 34 contain notices scarcely suitable for the perusal of modest maidens and matrons.

    That, with this possible contingency, such indecent details should have been printed, is the more to be wondered at, that Mr. Gream prides himself not a little on his delicacy, refusing on that score even to avail himself of the use of the speculum. We would not be understood to find fault with Mr. Gream for his opposition to chloroform in midwifery ; although entertaining a favourable opinion respecting it ourselves, we willingly acknowledge the paramount importance of caution in its employment and would deprecate the resorting to it in cases not absolutely requiring it. With these views, we think some good may arise out of Mr. Gream's pamphlet, by its keeping within due bounds those whose opinions might, without reading, both sides of the question, be a little too enthusiastic in the favour of obstetric anaesthesia.

    --In the volume above referred to, Dr. Meigs also records his objections to anesthesia in midwifery, which are in the main the same as are generally urged, viz., that a certain amount of pain is necessary and beneficial, and that etherization is only another term for intoxication. For the refutation of these observations, the reader is referred to our former volumes.

    Pregnancy ­­ Labour The Puerperal State.

    Pp278 - 279, on Vomiting during pregnancy.

    ­­ Dr . Stoltz, of Strasburg, lays down the following rules for the treatment of this distressing affection.-

    The first thing to be done when we have to treat a pregnant woman affected with obstinate vomiting, is to examine carefully whether the affection be the result of simple pregnancy or whether there be any complication. In the latter case, the first indication is to treat the complications. Thus if there be signs of plethora, venesection must be practiced, without any anxiety as to the term to which pregnancy has advanced. We may also have recourse to the application of leeches to the hypogastrium, to the upper part of the thighs, or to the perineum, in cases of uterine congestion or inflammation, indicated by a feeling of weight in the pelvis, and gains in the hypogastric region. If there be a feeling of uneasiness in the gastric region, we adopt a mild antiphlogistic treatment, apply some leeches to the epigastrium, give cooling drinks, and administer laxative enemata; a remedy which is by far preferable to evacuant medicines. After having thus simplified the problem by removing its complex elements, if the vomiting continue, the cause must be sought for in certain general or particular conditions which are entirely peculiar to pregnancy; such as the general excitability of the nervous system, which is reduced by antispasmodics, or the morbid excitability of the stomach, the remedies for which are cold or iced drinks in small quantities, the application of an opiate plaster over the stomach, and the internal administration of oxide of zinc and trisnitrate of bismuth. In some women, instead of a morbid sensibility of the stomach, the mucous membrane appears to be deficient in tone. It is then that the greatest benefit is obtained from the use of mild stomachics; such as aromatic infusions, distilled waters, infusion of calumba, alcoholic liquors, excitant and antispasmodic draughts; and if this nervous excitability be complicated with a more or less apparent state of chlorosis, tonics and preparations of iron are administered, and recourse may be had to the application of belladonna to the hypogastric region, or a continuance in the horizontal position. There are still, though fortunately rare, some cases of vomiting which the best-directed efforts fail in curing. In such cases, if the woman is reduced to a state of extreme emaciation, if hectic fever has manifested itself, if every kind of food is rejected, if marasmus makes continual progress, if the patient is threatened with death from inanition, at an earlier or later period, is it not evident that abortion ought to be provoked? Since it has been observed that these symptoms have then disappeared, where the vomiting was purely sympathetic with pregnancy, or with a morbid state which it induced or maintained.

    With the object of giving clearness to the part of the treatment of vomiting during pregnancy, the author has collected a great number of facts, already reported, or which have been communicated to him. He has arranged them under three categories: The first includes eleven cases of vomiting terminating fatally; in six, abortion had not been proposed; in three others, abortion had been proposed, but not practiced, in consequence of a difference of opinion; finally, in two others abortion, had been unsuccessfully tried; but in one case, the operation failed in consequence of an obstacle.

    The second category comprehends cases of severe vomiting, cured by spontaneous abortion or premature labour. Cases of this kind are very numerous. Finally, the third category includes the cases of severe vomiting cured by artificial abortion. In this category, are reckoned three well-observed cases of premature labour, and many others simply mentioned. Finally, a case of abortion - properly so called - and others, which are mentioned very briefly by authors. One case alone (and that of doubtful authority) is known in which severe vomitings have permitted pregnancy to arrive at its full term.

    -- Dr. Meigs states that in a great number of the cases of obstinate vomiting in pregnancy, the symptom may be suspended by causing the patient to take a cup of hot coffee and dry toast very early in the morning, after which, she is to be quiet till her usual time of rising.

    Pp 284-6 The Puerperal State - Puerperal fever

    - Professor Martin, of Jena, concludes an able memoir on this subject with the following summary:--

    1st. The term puerperal fever is one which deserves to be retained in our medical nomenclature, since all the febrile diseases incidental to childbet originate in one common cause.

    2d. This common cause may be traced to the peculiar character of the blood of women in childbed.

    3d. Besides this general cause, which is necessarily incidental to the puerperal condition, there is another special incidental cause, not of invariable, although of very frequent occurrence, which is connected with the simultaneous deviations in the character of the blood that are observed in many cases, and which appear to influence the nature of the febrile condition, and in part, likewise, the mode and locality of the deposition.

    4th. These incidental deviations in the character of the blood are the causes of the epidemic occurrence and difference of the puerperal fever; but they may also be induced in some women by individual circumstances, in which case, they affect the symptoms, course, and termination of the disease in the greater number of those affected at the same period, although there may not actually be any epidemic at the time.

    5th. Such sporadic cases of puerperal fever do not, however, necessarily presuppose a special disposition, since any morbid exciting cause may induce puerperal fever where there is no other predisposing cause than that incidental to childbirth generally.

    6th. A distinction between the differences in the character of the fever is fully as important for the prognosis and therapeutics of the disease, as for the separation of the individual local affections, which, in their turn, influence the different forms of puerperal fever.

    7th. These local affections consist in the derangement of certain constituents of the blood, or in the transformation of the blood itself, and vary considerably, according to the epidemic or sporadic character of the blood on the occurrence of the disease, whence plastic depositions and softening of the tissues (in consequence of infiltration with serum) may equally occur.

    8th. Local affections are most frequently met with in the interior portion of the sexual organs, especially in the uterus; but they likewise often occur in remote parts of the body, without there being any evidence of a previous uterine derangement. These affections are not, therefore, of special importance with reference to puerperal fever.

    As the principal objects for future inquiry into the nature of puerperal fever, the author mentions the following:--

    First. Chemico-microscopical examination of the blood, urine, sweat, &c., of women in childbed, pursued simultaneously in the case of many, and renewed at different times, with a comparison of the results of investigations carried on simultaneously with reference to the blood of healthy women not pregnant, and not immediately after childbirth.

    Second. Chemico-microscopical investigations of the blood, the secretions and excretions of women suffering under puerperal fever, carried on simultaneously in the case of many, or at different periods and at different epochs of the disease, having constant and special reference to the symptoms, mode of treatment, and the termination of the disease.

    Third. A careful investigation of analogous dyscrasic processes of exudation, as, for instance, of rapidly fatal termination of peritonitis exsudativa in scrofulous and gouty persons.

    Fourth. A more careful distinction between the different febrile characters, that is to say, between the peculiar varieties in the symptoms and exudations observed in the case of one and the same local affection, and a comparison of these with the individual character of the blood. And finally,

    Fifth. A distinction between individual local affections and between the different forms of puerperal fever.

    Causes of Endemic Puerperal Fever. - The prominent causes of puerperal fever, as it occurred in the midwifery hospitals of Vienna, have been noticed, in a communication to the Medico-Chirurgical Society, by Dr. Routh. The remarks, however, apply only to one hospital, in which the deliveries average from 250 to 300 a month. These labours are conducted in two departments, one devoted to the instruction of medical men and midwives, the other to midwives only.

    The mortality in the division for midwives and medical men has generally been thirty per month, and has occasionally been seventy. In the division for midwives only, the number of deaths has generally been from seven to nine per month. The clinical instruction is conducted on precisely the same general plan in the two departments; but the medical men receive also practical instruction in a private course, in which the operations are performed on the dead body of some female, while the midwives receive this instruction by means of a leather figure. The frightful mortality in the division to which medical men are admitted became the subject of a governmental inquiry, and the number of students in attendance was reduced from forty to about thirty. The mortality, however, remained the same as before. On inquiry, it was found that, in other countries, where there were two divisions in the lying-in hospitals, one for midwives and another for medical men, the mortality was far greater in the latter. The author shows that this difference could not depend on the manipulations of male attendants being more rough than those of midwives, nor to the influence of contagion or infection. He adopts the explanation proposed by Dr. Semelweiss, the assistant physician of that division of the Vienna Lying-in Hospital in which the great mortality has occurred - namely, that the real cause of the mortality from puerperal fever there, was the "uncleanliness of medical men and students in attendence;" their hands being impregnated with cadaveric matter through dissecting, making autopsies, and performing obstetric operations on dead bodies. Dr. Semelweiss recommended all students attending his division of the lying-in hospital not to handle the dead matter, or if they did so, forbade them making any examination of the patients til the following day. And he directed every student to wash his hands in a solution of chlorine prior to and after every examination made on the living subject. The result was that the number of deaths was reduced from thirty per month to seven per month, the usual average mortality of the division for midwives only. The author makes some remarks on the modes in which the cadaveric matter may be introduced from the hand of the medical attendant into the system of the woman. He then describes the characters of the puerperal disease so fatal in the Vienna Hospital, with the view of demonstrating its resemblance to the effects of a poisoned dissection wound; and he concludes by recapitulating the inferences which he believes to be justified by the facts stated in his paper.

    [In the above accusation, that medical men and students passed from the post-mortem table to the lying-in ward without washing their hands, it must be remembered that Dr. Routh is speaking of a continental hospital. That such uncleanliness was not unfrequent, we can perfectly believe, for our own reminiscences of medical students in foreign hospitals is that they may be included among, personally, the very filthiest of civilized humanity.]

    You can support this site at no cost if you make an Amazon purchase using this link to get to Amazon: Thanks