History's labour; Reading birth and death: a history of obstetric thinking; Jo Murphy-Lawless; Indiana University Press, Bloomington and Indianapolis; 1999; 352 pp. US$ 39.95 (cloth) ISBN 0-253-33475-6; US$ 19.95 (paper) ISBN 0-253-21258-8 FIGURE 1
In Reading Birth and Death Jo Murphy-Lawless places much of the burden of obstetric misadventure on the "man-midwife," a creation of 17th- and 18th-century Europe hated equally by proud barber-surgeons and jealous, sometimes gin-besotted, but "grave and modest ... Midwives."1 The latter were informed with rather startling inertia by Thomas Raynalde's The Byrth of Mankynde (c. 1540), translated from Eucharius Röslin's Rosengarten (c. 1513). That body of knowledge was the only update after 14 centuries of a Roman obstetrical compendium by the memorably named Soranus of Ephesus (AD 78-117). That first English obstetric resource lasted until the 13th edition was published in 1654, illustrating that obstetric knowledge was at best static.
"Obstetric thinking" began in a period of human existence when every woman able to conceive was likely to do so at least once in her lifetime unless she remained celibate. When such events happened only once, it was often because death had occurred during or soon after the first pregnancy. In this "cycle of perpetual parturition ... doctors were rarely in attendance at births, and when they were, concentrated on the rich, for obvious reasons."2 The man-midwife served only a tiny minority, based for the most part on who could afford their services. By the end of the 17th century it was customary to call in a man-midwife for the most difficult cases, many of which were in extremis or irretrievable from the River Styx. To the extent that men-midwives influenced obstetric thinking, it was not so much due to their success with large numbers of births as to the wealth, power, influence and opinions of their selected clientele.
Among the man-midwives was that "great horse godmother of a he-mid-wife" William Smellie (1697-1763) of Pall Mall, exponent of the obstetrical forceps. This device had been invented to pull out the fetal head, and ideally the rest along with it, probably by Peter "The Elder" Chamberlen (1560-1631), a Parisian Huguenot refugee.2 Chamberlen's family concealed their secret for 125 years for reasons that were clearly financial. They were prominent enough to be called to deliver Queen Anne in 1692. A bereft descendant sold the idea in 1693 - or rather half of it, by revealing only one of the two blades - to the son of Hendrik van Roonhuyze, the master of cesarean section. Smellie purloined the concept, adding finesse by clothing his blades in leather to avoid terrorizing his patients with the noise of interlocking steel. He taught students to use them at three guineas per lesson, using a leather "infant" jammed into the pelvis of a female skeleton. FIGURE 2
Gynecology was largely an American construct, created in part to correct the ravages of obstetric - and mid-wifery - practices. Where there were developments unrelated to pregnancy, the circumstances typically were remarkable, but only as seen from our era. The first oophorectomy was carried out in 1809 in Kentucky by Edinburgh-trained Ephraim McDowell (1771-1830). His unanesthetized patient was Jane Todd Crawford, 47, who travelled 60 miles on horseback bearing her ovarian cyst from her log farm-house to McDowell's knife and, perhaps unsurprisingly, lived to age 78. James Marion Sims (1813-1883) invented the position by which he is remembered after examining a woman who had been thrown from a horse. He developed his speculum from a bent spoon and popularized his operation for vesicovaginal fistula in Europe while draft-dodging the American Civil War.
Murphy-Lawless' book has the potential to help those involved with childbirth to understand the roots of certain obstetric practices, ideologies and paralytic paradigms, in part by revealing their flaws. For those who enjoy the death rattle of sacred cows, there may be particular pleasure in the author's interpretations. She does a particularly creditable job of uncovering major cracks in the foundation of "high risk" thinking, that metastatic mythology that entraps and corrupts contemporary obstetric thought.3 As well, linked effectively to false ideologies of prediction and its implied power, she mounts a worthy attack on the Dublin-espoused approach of "active management of labour," which will be enjoyed by everyone except Kieran O'Driscoll and his acolytes.
Historical analysis can liberate us from the error of outworn creeds. Carefully wrought, it can teach that humans raise structures that confine and define their own actions, and then build systems of thinking and language to deny those structures. But a central weakness of this otherwise useful effort is its presumptions. Historical systems are unpredictable and complex. Long chains of causation may separate final effects from their causes.4 Those who would understand must strive for understanding more than judgement. Did history follow its course because of others' actions, or because of the environments that led to those actions? Were the actions of the past wrong because we are right or, more simply, are they incongruous with present values and beliefs?
If this work were fully balanced to include midwifery as a component of the origins of "obstetric thinking," it might be obliged to report that 17th-century midwives conducted brutal searches for evidence of adultery, to discover the "devil's marks" on women accused of witchcraft and sorcery, and to determine the veracity of those who sought to escape punishment on the grounds that they were pregnant.
It would also reveal that, as was first pointed out in 1671, men enjoyed a superior education to women and, unlike the latter, could gain knowledge of medicine and anatomy as well as of Latin at a university.5 Man-midwives had the advantage of knowledge, not to be confused with understanding and wisdom. One of the primary perinatal killers was "childbed fever." Although doctors and midwives had an equal share of ignorance as to its cause, death from puerperal fever far more commonly followed examination by midwives than by manmidwives, simply because the former had a much larger clientele. Dr. William Harvey called for cleanliness to prevent fever, and midwife Jane Sharp for a herbal cleaning bath at the onset of labour, but it took painfully plodding recognition that Holmes (1843), and Semmelweis (1847) had been correct to arrest the death of countless parturients from puerperal sepsis.
This work is worth the attention of anyone involved with childbirth. If you are one of those, you might do well to write two things on your bookmark. One is a reminder that the conclusions of any investigator are shaded by his or her own culture and values. The other was captured by Marcus Aurelius, who suggested that the opinion of future generations will be worth no more than that of our own. To heir is human.