Sara Buck
Chicago, IL

The history of obstetrics contains too many notable figures to simply select six key leaders in its development. However, as Laura Kaplan notes in “Changes in Childbirth in the US,” featured in the current issue, modern obstetrics has been greatly influenced by the invention and modernization of the forceps (Chamberlen and Smellie), the introduction of anesthesia (Simpson), and the widespread institution of hygienic practices (Semmelweis). In addition to the physicians who contributed to these advancements, we included in the following gallery both the first Western author of a major gynecology textbook (Soranus) as well as an individual contributed to modernization of the Cesarean section (Sänger). Following the images is a brief description of each physician’s contribution to modern obstetrics.

Soranus of Ephesus

Although Greek physician Soranus of Ephesus (98-138 CE) wrote many medical texts, it is his work Gynacology that has survived in its original form to the present day.¹ Describing antenatal care, labor, infant care, and the first known description of management of malpresentation through internal version and breech extraction, Soranus’ text mirrors the organization of many modern medical textbooks, providing in-depth observation and reasoning for his detailed recommendations.² Forming the basis of the Moschion, a Latin gynecological text from the 7^th century, his insight was so influential that his instructions largely remained unchanged until the invention of the printing press in the 10^th century, with his influence as the foundation of Western gynecological knowledge persisting until the Renaissance.²

The Chamberlen family and William Smellie

The work of the Chamberlen family and William Smellie in England is described both in Kaplan’s article as well as the “Brief History of the Forceps,” also featured in this issue. It should be noted that the image selected for this gallery is that of Peter Chamberlen III, the son of Peter the Younger and the father of Hugh Chamberlen the Elder, the latter of whom unsuccessfully attempted to sell the family secret to his French rival Mauriceau in the mid-1600s.³ Although Peter III is not the inventor of the forceps, it was in his former home that the original Chamberlen forceps was recovered in the early 19th century—two hundred years after its invention.⁴ Peter III was arguably the most famous of the family of accoucheurs, notably attending Queen Henriette Maria in her delivery to the future King Charles II in 1631, preceding his appointment as court physician only a year later.⁴ Reportedly flamboyant in dress and well-versed in multiple European languages, which were reinforced through extensive travel, the physician’s reputation spread as far as Russia, as even the Czar took note of Dr. Chamberlen’s work.⁴

Ignaz Semmelweis

Despite the seemingly miraculous outcomes achievable by the forceps during difficult and obstructed labor, puerperal fever ranked as a major cause of maternal mortality into the early 20^th century.³ Dr. Ignaz Semmelweis (1818-1865) was a Hungarian physician whose first midwifery assistantship placed him at ground zero of a mysterious and large discrepancy in mortality rates between the medical student and midwifery wards at the Viennese School of Medicine’s Laying-in Hospital.⁵ Although both divisions appeared similar on the surface, Semmelweis immediately noticed that mortality from puerperal fever in the medical school was three to five times higher than that in the midwifery school.⁵ In fact, the difference was so notorious that Semmelweis wrote that women, on learning of their admission to the medical school, would “[kneel] down, wringing their hands, to beg for a transfer.”⁵ He also described how:

Women recently confined [to the medical school], with a pulse so frequent that it could not be counted, with abdomens enormously distented, with dry tongues . . . would insist only a few hours before their death that they were perfectly well, the object being to avoid medical treatment, since they knew that medical treatment meant death.⁵

Using statistical analysis and case studies to determine the cause of the disparity, he eventually honed in on the source—medical students, and not midwives, were frequently called from post-mortem autopsy to attend births. Without adequate hygiene protocol, the medical students were introducing cadaveric material to the child and the mother during labor. Insisting thenceforth that all students disinfect with chlorinated lime prior to examination, Semmelweis for the first time observed the mortality rate of the medical student division fall below that of the midwifery division.⁵ Unfortunately, his discovery, while well-received by medical students under his tutelage, was met with staunch opposition from hospital administration, and his discovery would not be widely disseminated until Pasteur vindicated him before the Paris Academy.⁵

James Young Simpson

The Scottish physician James Young Simpson (1811-1870) claims an important, but controversial, role in the history of obstetrics. In 1847 Simpson was the first obstetrician to use ether analgesia during labor—against the opinion of many religious and scientific leaders who questioned the practice on medical, moral, and religious grounds.⁶ On realizing that ether was inflammable and slow-acting, making it inappropriate for his purposes, he immediately sought alternatives.⁷ On the advice of a chemist colleague, that same year Simpson employed chloroform to deliver a child, later christened Anaesthesia.^7,8 Pointing to a statistical analysis of chloroform use with limb amputation, he convinced surgeons of its safety, and its ease of use quickly made the anesthesia the most popular in the UK.⁷ While reports of death related to choloform’s use quickly emerged, Simpson staunchly argued that the deaths resulted from improper administration, rather than a fundamental issue with the drug itself.⁷ Chloroform eventually fell out of use due to safety concerns, but despite chloroform’s failure as an anasthetic, Simpson’s legacy is most certainly the popularization of anesthesia use in childbirth.⁶

Max Sänger

Determining an appropriate individual to represent the evolution of the Cesarean section proved most challenging. Although the procedure was by no means new, many 19^th– and 20th-century innovations resulted in its rise to become the most commonly performed surgery in hospitals today.⁹ In the 20^th century, popularization of the extraperitoneal lower-segment incision, the discovery of penicillin, and the availability of blood transfusion all contributed to the general safety of the procedure.^3,9 However, it was Max Sänger, one of the most renowned German gynecologists of 19^th century, who helped revolutionize the Cesarean section by recommending the closure of the uterine wound with silver sutures.¹⁰ Hemorrhage was a major cause of death following the Cesarean section, which, prior to late 19^th century innovations, had a nearly 100% fatality rate for mother and child.¹¹ Eduardo Porro’s (1842-1902) introduction of the oophorohysterectomy following the surgery—just six years before Sänger’s discovery—greatly improved outcomes, with only 58% maternal mortality and an infant survival of 86%—but left survivors at risk for infection and unable to bear future children.^10,11 As Porro’s procedure gained popularity for its ability to reduce hemorrhage and mortality, Sänger argued that procedures meant to replace more destructive methods for fetus removal (see “A Brief History of the Forceps”) would require not only the preservation of the mother and the child, but also the mother’s reproductive organs.¹⁰ The use of metal sutures was quickly adopted by his colleagues, and by the end of the 19^th century maternal mortality from the procedure had dropped to 10%.¹⁰

References

1. Anonymous. (1957). Soranus’s Gynecology. Proceedings of the Royal Society of Medicine, 50: 56. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888953/
2. Raju, T.K. (1980). Soranus of Ephesus: Who was he and what did he do?. In G. F. Smith & D. Vidyasagar (Eds.), Historical review and recent advances in neonatal and perinatal medicine. Retrieved from the Neonatology on the Web website: http://www.neonatology.org/classics/mj1980/ch27.html
3. Drife, J. (2002). A brief history of obstetrics. Postgraduate Medical Journal, 78: 311-315.
4. Dunn, P. M. (1999). The Chamberlen family (1560-1728) and obstetric forceps. Archives of Disease in Childhood: Fetal and Neonatal Edition, 81: F232-F235.
5. Elek, S.D. (1966, April). Semmelweis and the Oath of Hippocrates. In W. S. Copeman (President), Section of the History of Medicine. Symposium conducted at the meeting of the Royal Society of Medicine, London.
6. McKenzie, A. G. (2011). The bicentenary of James Young Simpson (1811-1870). Anaesthesia, 66: 438-440. Retrieved from http://www.ncbi.nlm.nih.go
7. Rae, S.M. & Wildsmith, J. A. (1997). So just who was James “Young” Simpson?. British Journal of Anesthesia, 79(3): 271-273. Retrieved from http://www.ncbi.nlm.nih.gov
8. Dunn, P.M. (2002). Sir James Young Simpson (1811-1870) and obstetric anaesthesia. Archives of Disease in Childhood: Fetal and Neonatal Edition, 86(3): F207–F209. doi:10.1136/fn.86.3.F207
9. Todman, D. (2007). A history of caesarean section: From ancient world to the modern era. Australian and New Zealand Journal of Obstetrics and Gynaecology, 47: 357-361. doi: 10.1111/j.1479-828X.2007.00757.x
10. Hem, E. & Børdhal, P. E. (2003). Max Sänger — father of the modern Caesarean section. Gynecologic and Obstetric Investigation, 55: 127-129. doi: 10.1159/000071524
11. Todman, D.H. (2007). Eduardo Porro (1842-1902) and the development of caesarean section: A reappraisal. The Internet Journal of Gynacology and Obstetrics, 7. doi: 10.5580/222a