CHILDBIRTH IN HISTORY - continued

In the sixteenth century more attention was beginning to be given to the plight of women in labour and especially the care of the unborn child. One of the pioneers in this area of study was Ambroise Paré of France, who went to Paris in 1529, aged 19, having been a barber's apprentice. He received his early surgical training as a dresser at the Hotel Dieu. This institution was typical of the existing hospitals at that time, It was said to have been founded between 641 and 649, by Saint Landry, Bishop of Paris; the first mention of it in records being in 829, and was described by Tenon in his memoirs of the hospitals of Paris. In the Hotel Dieu there were 1,200 beds, of which 486 were for single patients; from three to six patients occupied each of the remaining beds, which were five feet wide. The large halls, unlighted and unventilated, held 800 or more patients crowded together and often lying about on heaps of straw which were in a vile condition.

Max Nordau said of the hospital: "In one bed of moderate width lay four, five, or six persons beside each other, the feet of one to the head of another; children beside grey-haired old men; indeed, incredible but true, men and women intermingled together. In the same bed lay individuals affected with infectious diseases beside others only slightly unwell; on the same couch, body against body, a woman groaned in the pangs of labour, a nursing infant writhed in convulsions, a typhus patient burned in the delirium of fever, a consumptive coughed his hollow cough, and a victim of some disease of the skin tore with furious nails his infernally itching integument........The patients often lacked the greatest necessities. The most miserable food was doled out to them in insufficient quantities and at irregular intervals. The nuns were in the habit of feeding with confectionary those patients who seemed to them pious enough, or at least those who reeled off their rosaries with sufficient zeal, but the body exhausted by disease required not sweets, but cried for meat and wine. Such food, however, the sick never received in profusion, save when it was brought to them by the wealthy citizens from the city. For this purpose the doors of the hospital stood open day and night. Anyone could enter; anyone bring whatever he wished; and while the sick on one day might be starved, on another day they might very likely get immoderately drunk and kill themselves by overloading their stomachs. The whole building fairly swarmed with the most horrible vermin, and the air of a morning was so vile in the sick wards that the attendants did not venture to enter them without a sponge saturated with vinegar held before their faces. The bodies of the dead ordinarily lay twenty-four hours, and often longer, upon the deathbed before they were removed, and the sick during this time were compelled to share the bed with the rigid corpse, which in this infernal atmosphere soon began to stink, and over which the green carrion- flies swarmed....."

In this hospital there were beds for children; in fact, eight such beds which accommodated a total of 200 infants and young children. About one-fifth of the patients in the hospital died and recovery from surgical operations was rare.                                                                                                A ROOM IN THE HOTEL DIEU From a woodcut of the sixteenth century. The beds shown were intended for two patients, but frequently five or six, regardless of sex or disease, were crowded into each one. Less fortunate patients found refuge on heaps of straw in the dark hall-ways. This hospital was indescribably filthy, as were all others at this period.                  HOSPITAL PATIENT IN BED WITH A CORPSE                                                              AN ETCHING BY DAUMIER The following description of a hospital accommodating 549 patients in Lyons in 1619,  outlines the attention given to surgery: "There was only one medical man whose duty it was to look after the surgical cases; he resided outside of the building. When this surgeon required assistance in the dressing of wounds or in performing surgical operations, he was authorised to make use of the 'apothecary boy'. The stock of surgical instruments possessed by the hospital consisted of just five, which included a trephine for opening the skull and a mouth plug for keeping the jaws separated."  After three years of training in the Hotel Dieu, Paré became an army surgeon and after pioneering development of procedures, particular to the wounds of soldiers, he went on to concentrate on the care of the unborn child. Podalic version, as described by Paré, was to be used in those cases where the child was not in the normal position to be born. It required inserting the hand into the uterus, grasping one or both feet (hence podalic - pod - foot ) of the unborn child, and turning it (i.e. version - the manual turning of a foetus in the womb to make delivery easier) into such a position that it could be born. The child was usually pulled out at the same time. Prior to the development of this procedure, cases of the child being in the wrong position to be born were usually fatal for both mother and child. The only reason for calling in the physician or barber was to, possibly, save the mother's life at the sacrifice of that of the child, by killing the child and removing it with instruments that the pagan priests and later the physicians devised for this purpose. There was one alternative procedure to podalic version which saved the life of the child at the expense of the mother - a procedure advocated by the Roman Church - Caesarean section. This operation consisted in removing the child through a cut made in front of the abdomen. The name Caesarean attached to it has tended to suggest that Julius Caesar was born by this means, but there is no evidence that at the time of his birth this operation was performed on a living woman, but only after death as a religious measure; his mother, Julia lived many years after his birth as is proved by his letters to her. The operation probably obtained its name from the fact that the Roman law required this procedure in case of the mother's death. In 715 BC the king, Numa Pompilius, codified the Roman law, and in the lex regia as it was called, it was ordered that the child should be removed from every woman who died when far advanced in pregnancy, even in cases where there was no chance of survival for the child, so that the mother and child might be buried separately. The lex regia became lex Cesare under the rule of the emperors, and the operation became known as the Caesarean operation, or section. A CAESAREAN OPERATION IN THE SEVENTEENTH CENTURY Very few such operations were performed at that time, for there was no anesthesia, asepsis, or adequate means of controlling haemorrhage. The woodcut shown here appeared in the works of Johann Schultes, a surgeon of the seventeenth century. Ambroise Paré opposed Caesarean section, indeed, few such operations had been performed on living women at that time, and Paré's opinion influenced the advancement of the procedure for more than a century. Even a few centuries later it remained an operation of last resort because of the suffering and high mortality involved. Paré's alternative - podalic version, however, was not applicable to women with abnormally small pelvises, but Paré believed ( as had the Greeks ) that the pelvis separated in the middle and opened out during the birth of the child and this was the cause of the pains of childbirth. Even so podalic version was at the time a considerable advance in the saving of the lives of infants and the suffering of women; it laid the foundation for the medical discipline - obstetrics. In Paré's time a school for midwives was opened at the Hotel Dieu in Paris. The women who graduated from the school of midwifery were rather superior to the uneducated females who had formerly provided 'assistance' to women in labour. Louise Bourgeois, 'sworn midwife' of the city of Paris, was among the first of the graduates; in 1601 she officiated at the birth of Dauphin (later Louis X111), and afterward at the birth of the other children of Marie de' Medici. The next step was the participation of the physician himself in midwifery. Boucher was called in to attend La Vallière, mistress of Louis X1V, and the king is said to have confirmed his interest in this reinstatement of male midwifery by watching the procedure whilst hiding behind some curtains. In 1670 Julian Clement attended Madame de Montespan at the birth of the Duc de Main, and in 1682 he delivered the Dauphin. Clement received the title of accoucheur, to replace the derisory name of man midwife, or midman. Soon male midwifery became the fashion among the ladies of the court. Even though Paré had furthered the development of obstetrics and Clement earned a dignified name - accoucheur - for the profession, the attempts of the physicians to practice obstetrics were met with extreme prudery, except in the case of attending royalty. Sometimes he was forced to tie one end of a sheet to his neck, and the other end to his patient's neck. Both could see above the cover, but the physician could not see beneath it and made his manipulations blindly. Insulting names were often used to undermine physicians who practiced obstetrics. When Dr. William Smellie, in the eighteenth century, established a school in London for teaching midwifery, he was christened by his competitor, Mrs. Nihell, the Hay Market midwife, " a great-horse-godmother of a he -midwife." Smellie is remembered in medical history because he made and published the first exact measurements of the pelvis. As late as the eighteen-forties John Stevens, of London, denounced and exposed in his pamphlets ' the dangers and immorality ' of employing ' men in midwifery '. he dedicated his efforts to the Society for the Suppression of Vice.   The extent of  prudery - a physician operating under the sheets For thirteen centuries the physicians of Europe were not allowed to attend normal cases of delivery, but in the seventeenth century they began to participate to some extent, but they were met with extreme prudery and were often forced to carry out their manipulations blindly. A woodcut from the works of a Dutch physician, Samuel Janson, 1681 Three Kids Gripped By Evil By Polly Mullaney      Amazon Kindle, Amazon paperback http://www.amazon.co.uk/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=Three%20kids%20gripped%20by%20evil