Table of Contents The Left Atrium History’s labour travelled 60 miles on horseback bearing her ovarian cyst from her log farm- Reading birth and death: a history of obstetric thinking house to McDowell’s knife and, per- Jo Murphy-Lawless haps unsurprisingly, lived to age 78. Indiana University Press, Bloomington and Indianapolis; 1999 James Marion Sims (1813–1883) in- 352 pp. US$39.95 (cloth) ISBN 0-253-33475-6 vented the position by which he is re- US$19.95 (paper) ISBN 0-253-21258-8 membered after examining a woman who had been thrown from a horse. He n Reading Birth and Death Jo Mur- power, influence and opinions of their developed his speculum from a bent I phy-Lawless places much of the bur- selected clientele. spoon and popularized his operation for den of obstetric misadventure on the Among the man-midwives was that vesicovaginal fistula in Europe while “man-midwife,” a creation of 17th- and “great horse godmother of a he-mid- draft-dodging the American Civil War. 18th-century Europe hated equally by wife” William Smellie (1697–1763) of Murphy-Lawless’ book has the po- proud barber-surgeons and jealous, Pall Mall, exponent of the obstetrical tential to help those involved with sometimes gin-besotted, but “grave and forceps. This device had been invented childbirth to understand the roots of modest … Midwives.”1 The latter were to pull out the fetal head, and ideally certain obstetric practices, ideologies informed with rather startling inertia by the rest along with it, probably by Peter and paralytic paradigms, in part by re- Thomas Raynalde’s The Byrth of Man- “The Elder” Chamberlen (1560–1631), vealing their flaws. For those who enjoy kynde (c. 1540), translated from Eu- a Parisian Huguenot refugee.2 Cham- the death rattle of sacred cows, there charius Röslin’s Rosengarten (c. 1513). berlen’s family concealed their secret may be particular pleasure in the au- That body of knowledge was the only for 125 years for reasons that were thor’s interpretations. She does a par- update after 14 centuries of a Roman clearly financial. They were prominent ticularly creditable job of uncovering obstetrical compendium by the memo- enough to be called to deliver Queen major cracks in the foundation of “high rably named Soranus of Ephesus (AD Anne in 1692. A bereft descendant sold risk” thinking, that metastatic mythol- 78–117). That first English obstetric the idea in 1693 — or rather half of it, ogy that entraps and corrupts contem- resource lasted until the 13th edition by revealing only one of the two blades porary obstetric thought.3 As well, was published in 1654, illustrating that — to the son of Hendrik van Roon- linked effectively to false ideologies of obstetric knowledge was at best static. huyze, the master of cesarean section. prediction and its implied power, she “Obstetric thinking” began in a pe- Smellie purloined the mounts a worthy attack on riod of human existence when every concept, adding finesse by the Dublin-espoused ap- woman able to conceive was likely to do clothing his blades in proach of “active manage- so at least once in her lifetime unless leather to avoid terroriz- ment of labour,” which will she remained celibate. When such ing his patients with the be enjoyed by everyone ex- events happened only once, it was often noise of interlocking steel. cept Kieran O’Driscoll and because death had occurred during or He taught students to use his acolytes. soon after the first pregnancy. In this them at three guineas per Historical analysis can “cycle of perpetual parturition ... doc- lesson, using a leather “in- liberate us from the error tors were rarely in attendance at births, fant” jammed into the Fred Sebastian of outworn creeds. Care- and when they were, concentrated on pelvis of a female skeleton. fully wrought, it can teach the rich, for obvious reasons.”2 The Gynecology was largely an Ameri- that humans raise structures that confine man-midwife served only a tiny minor- can construct, created in part to correct and define their own actions, and then ity, based for the most part on who the ravages of obstetric — and mid- build systems of thinking and language could afford their services. By the end wifery — practices. Where there were to deny those structures. But a central of the 17th century it was customary to developments unrelated to pregnancy, weakness of this otherwise useful effort call in a man-midwife for the most dif- the circumstances typically were re- is its presumptions. Historical systems ficult cases, many of which were in ex- markable, but only as seen from our are unpredictable and complex. Long tremis or irretrievable from the River era. The first oophorectomy was car- chains of causation may separate final ef- Styx. To the extent that men-midwives ried out in 1809 in Kentucky by Edin- fects from their causes.4 Those who influenced obstetric thinking, it was not burgh-trained Ephraim McDowell would understand must strive for under- so much due to their success with large (1771–1830). His unanesthetized pa- standing more than judgement. Did his- A. M. Todkill numbers of births as to the wealth, tient was Jane Todd Crawford, 47, who tory follow its course because of others’ CMAJ • DEC. 14, 1999; 161 (12) 1563 © 1999 Canadian Medical Association or its licensors De l’oreille gauche actions, or because of the environments fused with understanding and wisdom. her own culture and values. The other that led to those actions? Were the ac- One of the primary perinatal killers was was captured by Marcus Aurelius, who tions of the past wrong because we are “childbed fever.” Although doctors and suggested that the opinion of future right or, more simply, are they incon- midwives had an equal share of igno- generations will be worth no more than gruous with present values and beliefs? rance as to its cause, death from puer- that of our own. To heir is human. If this work were fully balanced to peral fever far more commonly followed include midwifery as a component of examination by midwives than by man- References the origins of “obstetric thinking,” it midwives, simply because the former might be obliged to report that 17th- had a much larger clientele. Dr. William 1. Rueff J. The expert midwife, or an excellent and most necessary treatise of the generation and birth of century midwives conducted brutal Harvey called for cleanliness to prevent man. London: 1637. Translated from De conceptu searches for evidence of adultery, to fever, and midwife Jane Sharp for a et generatione hominis of 1554. Rueff was a sur- geon who argued that midwifery was the “pecu- discover the “devil’s marks” on women herbal cleaning bath at the onset of liar business of women ... only sacrificed to men accused of witchcraft and sorcery, and labour, but it took painfully plodding by default of learning.” 2. Fraser A. The weaker vessel: woman’s lot in seven- to determine the veracity of those who recognition that Holmes (1843), and teenth century England. London: Methuen; 1985. sought to escape punishment on the Semmelweis (1847) had been correct to 3. Hall PF. Rethinking risk. Can Fam Physician 1994;40:1239-44. grounds that they were pregnant. arrest the death of countless parturients 4. Diamond J. Guns, germs and steel: the fates of hu- It would also reveal that, as was first from puerperal sepsis. man societies. New York: W.W. Norton; 1999. 5. Sharp J. The midwives book, or the whole art of pointed out in 1671, men enjoyed a su- This work is worth the attention of midwifery discovered. London: 1671. perior education to women and, unlike anyone involved with childbirth. If you the latter, could gain knowledge of med- are one of those, you might do well to Philip F. Hall, MD, BScMed icine and anatomy as well as of Latin at a write two things on your bookmark. Department of Obstetrics and university.5 Man-midwives had the ad- One is a reminder that the conclusions Gynaecology vantage of knowledge, not to be con- of any investigator are shaded by his or University of Manitoba, Winnipeg Expiation and celebration never met. The others have the kind of profile that tells me we could talk. Each Patients and doctors: one has an interesting story to tell. life-changing stories from primary care Each one has sought sense in an appar- Edited by Jeffrey Borkan, Shmuel Reis, Jack H. Medalie ently senseless world, and I commend and Dov Steinmetz them for their highly readable, personal University of Wisconsin Press, Madison, WI; 1999 testimonies. 228 pp. US$24.95 (cloth) ISBN 0-299-16340-7 I believe that doctors write for two reasons, expiation or celebration. Expia- ’ve been interested in the value of baffled boatloads of professors. “I don’t tion: seeking to exorcise a personal de- I anecdotal evidence for a long time. It know how you do it,” one bewildered mon, searching for forgiveness of a pro- all began years ago when my wife and I colleague had said after another (ac- fessional error whether real or perceived. went out to dinner to celebrate a wed- cording to the raconteur), “but you’re Celebration: recording with admiration ding anniversary. We chose our favour- absolutely right every time.” From my the many facets of the human spirit it is ite restaurant on the northwest out- point of view, the interesting thing was our privilege to observe and the remark- skirts of Glasgow. The weather was that he didn’t know how he did it ei- able heights to which it soars.