How Midwives and Childbirth Helped Bring on the Age of Modern Surgery

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Midwives —people trained specifically to assist women in childbirth— date so far backward in history that they have played central roles in some of our oldest pieces of literature. Having witnessed the birth of her twin brother Apollo cause great pain to her mother Leto, Artemis was considered a goddess of childbirth and the first midwife in ancient Greece, while the Biblical narrative features the infant Moses spared of death, thanks to a scheme carried out by his midwife mother and sister.  Later, in Elizabethan times, Shakespeare wrote various midwife characters into his plays. From early modern times to the 19th century, obstetrics gradually emerged as a specialty within medicine and surgery and began taking on much of the childbirth by the time that the 20th century began. But the transition period from the middle to the late 19th century also relates to major developments outside of childbirth, within medicine and especially surgery, particularly when it comes to infection control. The advent of blood transfusion and of anesthesia (the deliberate elimination of pain) also come into play.

Looking back through the history of healthcare, you will notice that surgery was an entirely different endeavor by the early 20th century compared to what it had been had been less than a century earlier. In the 1830s, surgeons had a very bad reputation, even among physicians, because surgery was brutal. Surgical patients often died of infection and most of the operations that are considered routine today were not possible, because of major blood loss and pain. In the Western World, certain anti-pain agents, such as opium, were available, plus there were stories of surgeons from other regions of the world having knowledge for utilizing such agents to enable painless surgery, but they were stories and nothing else. Consequently, operations performed mostly were procedures that were needed to prevent certain death if they were not performed, such as amputation of a wounded limb that would become gangrene if left alone, or removal of a tumor that was clearly pushing on something in a way that would be fatal soon, or in a way that caused terrible pain. The goal of such operations was to perform them extremely fast, minimizing the time of pain and without the patient bleeding to death. This didn’t leave room for any other goals. Also, in the era, doctors knew nothing about infection, the basis of most of the disease that they saw every day and that caused most of the deaths.

Childbirth was a realm in which infection came into play frequently, as maternal mortality (death of the mother) was very common. Known as childbirth fever in Europe, such deadly infections struck both women tended by midwives and those tended medical doctors who were pioneering what would become the field of obstetrics. This all came to a head in Vienna of the 1840s, where the Hungarian physician, Ignaz Philipp Semmelweis, worked and taught in an environment in which childbirth fever struck and killed astonishingly high numbers of women, following childbirth or spontaneous abortion (miscarriage). The situation involved both a medical school with a teaching hospital as well as a school for midwifery students and childbirth fever struck five times as frequently in women tended by obstetricians and medical students than in women tended by midwives, or by midwifery students. In fact, since the childbirth clinics were operated by midwives some days of the week and by physicians the other days, pregnant women actually were at greater risk showing up to give birth on the physician days than on the other days.

Alarmed about this difference, Semmelweis looked for differences between the birthing methods. It turned out that the women who died under physician care were being studied with autopsy in which a pathologist examined the deceased body, assisted by medical students, who subsequently made contact with other patients and doctors in the clinic. In contrast to medical students, midwifery students did not participate in, nor even observe, autopsies. From this, Semmelweis deduced that the disease was caused by something that transferred between people and their hands. He proposed that doctors might solve the problem by washing their hands in between treating different patients, and when he put this into practice in his own clinic, the percentage of women dying of childbirth fever dropped dramatically to below 1 percent. Given his success, Semmelweiss proposed that all doctors, and midwives, should wash hands, and for this the medical community decided that he was a madman, and committed him to an asylum where he was beaten by guards and died of complications at age 47.

As the years went on, the French scientist Louis Pasteur provided experimental evidence supporting the germ theory of disease —the idea that microorganisms cause infections that harm the body. Embracing the germ theory across the Channel in England, the surgeon Joseph Lister recognized that Semmelweiss had been correct about the hand washing, but realized that microorganisms were the disease-causing agent. Rather than simply handwashing, Lister began applying antiseptic chemicals (chemicals that kill bacteria) to surgical instruments and to his hands and the hands of those who assisted him in surgery. This raised the survival rate from surgery dramatically and made possible various operations that had not been possible before and it happened at a time when surgeons had finally learned to use chemical compounds that prevented pain while putting patients into a deep sleep-like state. Emerging by the late 1840s, these chemical compounds included three anesthetics, one being a gas called nitrous oxide (“laughing gas”), which was the safest of the three, but also the weakest, so it could not be used for all operations. The other two were liquids that released fumes that had to be inhaled. One of these was diethyl ether (known commonly as ether) and the other was chloroform, an agent that really brought anesthesia to prominence, when Queen Victoria decided to have it administered to her to enable the painless childbirth that had eluded the mother of Artemis.

Although anesthesia was introduced in the 1840s and was adopted fairly quickly, with Queen Victoria’s experience helping to popularize it, Joseph Lister’s promotion of his anti-septic practice happened in the latter half of the 1860s and it took a generation before all surgeons were convinced that it was a good idea. Lister’s following was initially in Great Britain and other parts of Europe, but the older generation of American surgeons —the ones who were training the newer surgeons— generally didn’t want to bother, even with hand-washing, let alone treating their hands and instruments with antiseptic chemicals. Thus, when US President James Garfield was shot in 1881, more than a decade into the Listerian era, Garfield eventually died, not of his wound —the bullet turned out to be encased in a cyst in a spot where it would not have killed him— but from infection resulting from the surgeons probing and extending the entry wound with their dirty fingers and instruments.

But the practice in that era for budding, young, American doctors who could afford it, was to travel to Europe to observe European practitioners of their field of interest. One such young doctor was a rising star in surgery, William Steward Halsted, who left New York for Europe in the late 1870s, then returned in 1880, fully committed to the Listerian anti-septic approach, and also ready to take full advantage of the fact that when patients are anesthetized, there is no need to rush through surgery, trying to complete the operation in a couple of minutes. Instead, Halsted introduced the practice of operating slowly and carefully, clamping or ligating (tying) blood vessel after blood vessel to stop and prevent bleeding in the surgical site and treating body tissues very carefully. Effectively, this launched the age of modern surgery and thus, Halsted, at least in the United States, is remembered as the father of surgery.

Now, earlier we mentioned blood transfusions connected with pregnancy as well. The ability to transfuse patients with donated blood was absolutely vital in launching the age of modern surgery and Halsted played a little role in this too. One day in 1881, after giving birth,  Halsted’s sister, Minnie was bleeding dangerously and, desperate to save her life, Halsted drew some of his own blood from a vein through a needle and transfused it into Minnie. This was almost two decades prior to the discovery, by Karl Landsteiner, of what we now call the  the ABO blood groups, and many previous attempts at transfusion between people had been fatal. Fortunately for Minnie, she and her brother just happened to be matched appropriately for him to donate to her.

There is little question that all of these developments needed for the emergence of modern surgery would have happened one way or the other, but it just happens that in our timeline childbirth was an important factor.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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