Ruysch as a teacher of midwives

Otto P. Bleker, Professor emeritus of Obstetrics and Gynaecology at the University of Amsterdam, The Netherlands

In 1667, Ruysch was invited by the burgomasters of Amsterdam to teach anatomy to the surgeons. He wanted to improve the teaching and examination of midwives as well. Every year, 6000 children were born in Amsterdam. The city held 200 thousand inhabitants. In case of labour, the mother to be called upon one of the circa 140 midwives for professional assistence. Sometimes the help of a surgeon-obstetrician was called for. A surgeon-obstetrician was a surgeon who knew about obstetrics. He was able to deliver a mother of her child, in difficult circumstances. Over 200 surgeons worked in Amsterdam. About 6 or 10 of them also worked as a surgeon-obstetrician. To become a surgeon one had to pass the master’s examination. Surgeons were trained in a master-pupil -system. You had to assist an established surgeon for a couple of years. If you were lucky you would also receive a few lessons. Midwives were also trained in this system but for them, to pass an exam before being entitled to start their own businesses as a midwife, was not yet obligatory.

Exam-requirements for midwives Ruysch thought midwives didn't know enough about anatomy. He asked the city-council to make an exam obligatory for all midwives. And he succeeded. In 1668 a law came into force. Even midwives that already practised their trade, had to pass the exam. A heavy fine had to be paid if you didn't take the exam. This proved successful. In 1668 alone 134 midwives passed the new exam. In 1672 Ruysch was appointed city surgeon-obstetrician. He was to give assistance in the more difficult deliveries of the poor. He also was to educate the pupil-midwives. Amsterdam was far ahead of its time, in that all midwives with less than ten years experience, had to attend the lectures by Ruysch as well. A great and very early example of permanent education.

The surgeon-obstetrician and the secret instrument The midwive had to know what she could do herself and when she had to call for the assistance of a surgeon-obstetrician. It occurred for instance, that the head of the child is almost visible, but did not move any further. Nowadays a vacuum-extraction is performed in this case. A vacuum-cup is placed on the head and using this the child is pulled to be born. In Ruysch time this instrument didn't exist. What did exist was a secret instrument. This so-called ‘Roonhuijsian secret’ had to be purchased for an enormous amount of money. Ruysch possessed one of these instruments. He did also use it, and sometimes successfully. He joined in the secrecy and profited from selling the secret to other surgeons.

Nineteen questions A list of 19 questions has been preserved in the Municipal Archive in Amsterdam. It is the exam for midwives from circa 1700. The problems in deliveries aren't all that different from nowadays. In a normal delivery, the child's head is born first, then his rump and his legs. One of the questions is: How should we act if the legs or the breech is born first? The midwives could solve this problem themselves using some grips, or they could ask the surgeon-obstetrician for help. A delivery is possible because of the contractions of the womb. If they are not strong enough it is called lingering labour or weak labour. Nowadays very effective medicines are used, in Ruysch’s days a clysma (administering a liquid anally) of a very complex composition was applied. The question in the exam: When and how should we stimulate the contractions.

What to do in case of an incomplete placenta? In a normal case, after the child is born, the naval chord is first ligated and then cut, then usually within an hour the afterbirth (placenta) is born. If the placenta has not been born completely, this can result in an important amount of bloodloss and infections. The law therefore dictated, that if according to bystanders (family and neighbours) the placenta is not complete, the midwife is obliged to show the placenta to a doctor, before it can be discarded. Van Deventer, equally famous as Ruysch, supported the immediate removal of the afterbirth after childbirth, but Ruysch defended a waiting policy , for hours or even for days. Nature would take care of it. Ruysch even discovered a special muscle on the inside of the womb, ‘the musculus orbicularis’, the round womb-muscle, that according to him served the purpose of squeezing out the afterbirth. Ruysch's claim was never confirmed by anyone else, before or after his ‘discovery’.

Ruysch raised the professional skill For Ruysch, being a university trained doctor, to educate midwives and examine them, was completely new. As was the post-graduate course for already established midwives. Ruysch protected his students. By law, they were not allowed to deliver babies without supervision. Ruysch gave the public a stronger voice. The publics judgement in case of a possibly incomplete afterbirth was taken into account. He did not lack vanity (his unique muscle) and money was important to him (the sale of his collection and his obstetrical secret).