University of Virginia Library

INTRODUCTION.

As it was this feature to which my attention was first attracted, I will ask the indulgence of the reader for a few brief introductory remarks, explanatory of the manner in which this entire subject, novel at the time, but now rapidly gaining in interest and popularity, was developed.

IT was my good fortune in 1877 to add a valuable collection of ancient Peruvian pottery to my archeological museum. At the same time, whilst interested in these matters, I was told of an urn or vessel brought from the ancient graves of Peru, which represented a midwife delivering a woman in labor, and was then stowed away in the home of its discoverer, Dr. Coates, of Chester, Penn. My interest was at once aroused and I wrote to the gentleman requesting a photograph or cast of this unique piece of pottery. I received no answer, but constantly bore the subject in mind, until, finally, upon my visit East in 1879, my esteemed friend, Dr. Albert H. Smith, of Philadelphia, enabled me, through the kind offices of Dr. Anna E. Broomall, to examine the specimen, which proved so intensely interesting to me that I determined to satisfy myself as to the correctness and the historic value of this group, and, moreover, to study the subject of posture in labor. This ancient Peruvian funeral urn, well characterized in the heliotype which accompanies this article, is one of the oldest distinct and well authenticated representations of a labor case which is extant. The method of delivery followed by those, at that time, highly civilized people, a thousand or more years ago, seemed to me so peculiar that I was anxious to know whether other people had similar curious customs and whether any traces of these could be found at the present day; moreover, it appeared to me as if a study of obstetric customs among the more primitive people might lead to valuable results which

would serve to guide the practice of the present day. My interest was thoroughly aroused, and by the kind offices of the gentlemen in charge of the Library in the Surgeon-general's office its fund of well-arranged material was kindly placed at my disposal, so that I was enabled at once to enter upon the study of the subject which had so deeply engrossed my attention. I found an extensive literature relating to the subject of posture in labor, but it turns entirely upon the discussion of the relative merits of the dorsal decubitus, as practiced upon the continent of Europe and in America, and the left lateral position, which is favored in England; perhaps, also, the knee-elbow position may come into question, but the discussions are entirely confined to the merits of those positions which are taught by modern obstetric law, and enforced in all civilized communities of the present day where scientific medicine rules. Some had gone beyond this and had attempted to determine the natural position of woman in labor by the study of the position which had been occupied by unfortunate girls, in concealed or secret parturition; thus Schütz,[1] and Dr. Cohen v. Bæren in Posen, who cites one hundred such cases; fifty of which occurred in unusual positions: thirty standing, eighteen crouching or squatting, and two kneeling. Of the fifty cases recorded by Schütz, thirty-two—over half—occupied abnormal positions: fourteen standing, sixteen crouching or squatting, two kneeling. Nægele, on the contrary, sought to discover the natural position in labor by secretly observing the movements of an inexperienced girl who was left alone, while in pains, in a room furnished with a bed, chair, sofa, and an obstetric chair. The girl took all possible positions and was finally delivered tossing about on the bed; she had sought the obstetric chair but gave it up after a moment's trial which appeared so conclusive to her mind that she did not repeat the attempt. Hohl[2] in his clinic made an attempt to see whether women could be confined standing, and, though a great many had been urged to try, only one, induced by a considerable bribe, had been able to complete her labor in this position; hence, he concluded that all accounts of women being thus confined must be false —an erroneous conclusion, as I shall hereafter show. The first who departed from the beaten track and entered upon the proper course to determine the natural position of women in labor, namely, by historical and ethnological researches, was Rigby, in his paper, published in the "Medical Times and Gazette,'' for 1857,[3] "What is the natural Position of Women During Labor?'' He refers to the methods previously followed, then traces those peculiar positions which are still customary in secluded parts of England, Scotland, Wales, and Ireland, and seems to come to the conclusion that accidental circumstances determine in a great measure the position which the unassisted woman assumes when seized with violent pains effecting the expulsion of the child; that she probably walks or tosses about, finally to be delivered in a recumbent position; and rather seems to indorse the views of his West India correspondent, "That there is no natural position, in labor, for the native women, any more than for a man with colic or a West India dry belly.''

The next and most complete work on the subject was by Dr. H. H. Ploss,[4] "Ueber die Lage und Stellung der Frau wæhrend der Geburt bei verschiedenen Völkern.'' He, without entering upon a theoretical discussion of the question, gives us the results of his very thorough study of the positions occupied by women in labor among the ancients and among the uncultured and savage races of the present day. He recognizes the positions assumed as: Firstly, recumbent in a more or less horizontal position. Secondly, sitting: (a.) in bed; (b.) on a stool; (c.) on a chair; (d.) on a cushion; (e.) on the thighs of another individual. Thirdly, standing. Fourthly, kneeling. Fifthly, squatting. Sixthly, swinging. Seventhly, suspended in an erect posture. I shall not infrequently refer to the authorities quoted by Dr.

Ploss, although in some cases the details of reports, which I have obtained, vary decidedly from the often very meagre statements made by him; and in other cases he has based his assertions upon very questionable and indefinite accounts of travelers, which he has evidently made use of in order to make his paper as complete as possible. In the main it is a sound paper showing a great deal of profound research among the best of authorities, ancient and modern. I cannot, however, agree with his conclusion, namely, "that among the majority of people the parturient women assume the recumbent position.'' He seems to think that, though not necessarily in an entirely horizontal position, she is delivered lying upon a bed or a couch of some kind.

I might add that in 1870, a paper appeared in Breslau, by H. v. Ludwig,[5] in which the author, upon theoretical grounds, advocates the kneeling or squatting positions to be assumed during the expulsion of the child, and insists that the women of savage races, of people who still exist under the most natural conditions, instinctively assume these positions. As soon as my attention had been once directed to this subject by that remarkable funeral urn, representing the custom of the ancient Peruvians, and I had entered upon the study of the posture occupied during labor by the women of other people, I found a great variety in their customs; but it soon became evident, and impressed itself forcibly upon my mind, that the recumbent position in labor is rarely assumed among those people who live naturally and are, as yet, governed by their instincts and have escaped the influence of civilization and of modern obstetrics. It certainly appeared as if the ordinary obstetric position of to-day must be an unnatural one, and in order to study the question as to what is the natural position of women in labor, the proper and only course to be followed seemed to me to investigate:—

1. The position occupied by women in labor among the

nations of the past; especially among those who boasted of higher civilization.

2. To observe the position assumed by women in labor among savage races of the present day whose movements are still governed by instinct.

I deem it a great mistake that we in this age of culture, should follow custom or fashion so completely, to the exclusion of reason and instinct, in a mechanical act which so nearly concerns our animal nature as the delivery of the pregnant female. If we wish to obtain an idea of the natural position we must look to the woman who is governed by instinct, not by prudery; and it is only among the savage races that we shall find her at the present day. In this purely animal function instinct will guide the woman more correctly than the varying customs of the times.

3. In our obstetric practice of to-day to observe the movements of women and the positions which they involuntarily assume in the agony of the expulsive pains when instinct comes forward, to the exclusion of every other feeling. I have accordingly—

1. Sought such information as history could give me— as could be afforded by our larger libraries, especially that of the Surgeon-general's office in Washington; and I have made free use of the references given by Ploss in his work already referred to, and by Goodell,[6] in his instructive paper on "Some Ancient Methods of Delivery.''

2. In order to obtain information as to the positions assumed by those people among whom no modern obstetric law or custom as yet prevails—among the savages of the present day—I have corresponded with leading obstetricians in foreign countries, as well as travelers who were likely to assist me in this inquiry. I have sought information from physicians in various portions of our own country, partly by correspondence, partly by questions kindly put to their readers, by a number of our medical journals. The most valuable information, however, I have obtained through circulars sent to the medical officers of the army and the

physicians to the Indian Agencies, through the Bureau of Ethnology of the Smithsonian Institution in Washington.

3. I have made it my duty to observe the positions assumed by women at the very moment of the expulsion, during the agony of the last pains.

The subject will be divided as follows:—

THE INTRODUCTION.

PART I., treating of the position of women among people whose labor is governed by instinct and not by prudery or the laws of obstetrics.

PART II. The position of women among civilized races of the present day, in the agony of the expulsive pains.

CONCLUSIONS; and these, I will briefly state, are: that the semi-recumbent and inclined positions are the correct ones for the parturient woman,—anatomically, theoretically, and practically,—and that we have unquestionable ethnological proof of this assertion. We must resume the semi-recumbent position, and it becomes a question whether we should return to the obstetric chair or not.

I have classified the positions, according to the inclination of the axis of the body, into: The perpendicular or upright, the inclined, and the horizontal or recumbent.

A. Perpendicular:—

1. Standing.

2. Partially suspended.

3. Suspended.

B. Inclined:—

1. Sitting erect on stool, cushion, or stone.

2. Squatting, as in defecation.

3. Kneeling.

(a.) With the body inclined forward, and resting on a chair or staff.

(b.) Knee-elbow position, knee-breast, or knees and hands.

(c.) With the body erect or inclined backwards.

(d.) Not definitely described.

4. Semi-recumbent.

(a.) Sitting semi-recumbent on the ground, a stone, or stool.

(b.) On the lap or between the thighs of an assistant who is seated on a chair or on the floor.

(c.) The obstetric chair.

(d.) Semi-recumbent positions, strictly speaking.

C. Horizontal or recumbent.

(a.) On the back.

(b.) On the side.

(c.) On the chest and stomach.

I have been aided in this work by so many kind friends and fellow practitioners that I feel it my duty to express my thanks to, at least, some of them, for the valuable assistance rendered. Dr. Isaac Coates, formerly of Chester, Penn., gave the impulse to this undertaking by kindly permitting me to photograph the historic urn which he unearthed from its resting place, that it might reveal to us the life of a people long since passed away; and it is owing to the efforts of Dr. Anna E. Broomall that I was actually enabled to do this. The kindness of Drs. Billings and Fletcher readily enabled me to obtain much important information from the vast and well catalogued materials of the Surgeon-general's library. To Dr. H. C. Yarrow my especial thanks are due for his unceasing efforts in the interest of this undertaking; his position and his researches in the library of the Surgeon-general's office enabled him to extend to me many favors; with the consent and at the direction of Major J. W. Powell, in charge of the Bureau of Ethnology of the Smithsonian Institution, aided by other friends, he has sent out a series of circulars to the surgeons of the army and Indian Agencies requesting information as to the obstetric practices among our North American Indians; I also gratefully acknowledge my indebtedness to the medical officers of the United States army, and the physicians to the Indian Agencies, for the valuable information given, and their cheerful and generous response to the circular sent. Dr. Raoul Fauquez, of Paris, had the kindness to offer information upon the subject in the various departments of France. Several of our medical journals placed before their readers

my questions as to the obstetric practices in remote regions of this country, and numerous professional friends throughout the entire land have given me valuable information as to the country practice in earlier days. Mr. Ad. Bandelier, that ardent archeologist from our neighbor State, gave me an insight into the customs of the natives at the time of the conquest by reference to his valuable library of ancient Spanish authorities. To my friend Dr. C. W. Cooper I owe thanks for valuable assistance rendered throughout the entire work.

Quite a number of the instructive illustrations I owe to the genius of St. Louis' talented artist, Mr. Carl Gutherz whilst Dr. H. H. Ploss, of Leipzig, has permitted the use of several of the cuts from his own work.