Speaking of pregnancy competing truthclaims

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There have been several historical studies of the emergence of the man-midwife, or accoucheur, in the eighteenth century and of the gradual supplanting of the female midwife, first in upper-class and then in middle-class households.1 However, the main focus of such accounts has been the struggle over the management of childbirth and the use - and alleged abuse - of obstetric instruments. The debate between midwives and accoucheurs over the management of pregnancy has received less attention. This debate involved not only practice, but also hermeneutics: indeed, the key issues were epistemo-logical. How could pregnancy be known, and who had the authority to speak of it? One of the fiercest exchanges in this respect was between William Smellie and Elizabeth Nihell. The picture is interestingly complicated here in that the quarrel took place, at least in part, by proxy. Elizabeth Nihell's Treatise on the Art of Midwifery was thought by many to have been written by her husband, while Smellie was defended against Nihell's attacks by his friend Tobias Smollett. Smellie published the first two volumes of his Treatise on the Theory and Practice of Midwifery in 1752 and 1754: these, like his Anatomical Tables (1754), concentrated on an 'accurate' description of 'the situation of the parts concerned in parturition' and also gave practical advice on 'touching' to diagnose pregnancy.

Nihell's response was vehement: her 1760 Treatise characterises the activities of all man-midwives as gross and indelicate. In a swipe at Smellie's anatomical background, she argued that many men-midwives turned to midwifery because they were failed physicians, and she considered with horror the prospect of a man-midwife's touching a woman:

Will the husband be present? What must be the wife's confusion during so nauseous and so gross a scene? Will he modestly withdraw while his wife is so served? What must be his wife's danger from one of those rummagers, if she should be handsome enough to deserve his attention, or a compliment from him on such a visitation of her secret charms?2

Nihell deploys the coarse language of seduction ('served', 'rummagers') to depict an inappropriate invasion of female space. A contemporary engraving, 'The Man-midwife, or Female Delicacy after Marriage', is even more emphatic about the dangers of such encounters: the man-midwife examines a pregnant woman who lies in a seductive pose with one arm draped around him, as her husband is led out through a door surmounted by a picture of an ass (signifying cuckoldry). The pregnant woman is presented here as sexually attractive and active, in marked contrast with nineteenth-century representations of her as a quasi-virginal figure, removed from the sphere of sexual activity.3 This understanding of the pregnant woman as an object of lustful desire is repeated in literary texts such as Charlotte Smith's Montalbert, although no indication is given there that the woman reciprocates such feelings.

Moving on from questions of modesty, and drawing on contemporary notions of 'consent' between parts of the body, Nihell argues that women practitioners have, by definition, a more finely tuned understanding of pregnancy. She writes that 'midwives, besides their personal experience, being sometimes themselves the mothers of children, have a kind of intuitive guide within themselves, the original organ of conception, itself pregnant, in more cases than that, with a strong instinctive influence on the mind and actions of the sex' (pp. 98-9). Despite her use of the term, Nihell's text is not simply invoking what we would now derogatively call 'female intuition'. The doctrine of consent proposed that organs or parts of the body were, under certain circumstances, in sympathy with each other. Pregnancy was a prime example, when it was thought that the excitation of the uterus after conception stimulated and disturbed the stomach and breasts. Alexander Hamilton, Professor of Midwifery at Edinburgh University, went so far as to argue in his 1781 Treatise of Midwifery that 'every part of the female frame sympathises with the womb'.4 Moreover, the

Man Midwife 1773

Tit M, I ,V -MID WIFE, r'f F KM A1, K I> EL TT A /" I' ,0r, if A HR TAGE

Adilwfciit lu (Is.

Figure 1 A male-midwife suggestively examines an attractive pregnant woman. Line engraving, 1773. Wellcome Library, London.

Tit M, I ,V -MID WIFE, r'f F KM A1, K I> EL TT A /" I' ,0r, if A HR TAGE

Adilwfciit lu (Is.

Figure 1 A male-midwife suggestively examines an attractive pregnant woman. Line engraving, 1773. Wellcome Library, London.

notion of consent assumed, on occasion, a reciprocal influence between mind and body. Nihell thus draws on an established school of medical thought to ground her claim that female embodiment brought sex-specific sensations and perceptions.

Smollett naturally took an entirely different line. Arguing in defence of Smellie in The Critical Review, he commented caustically that:

the difference ... between the male-practitioner who has attended lectures, and the female who has not, is this; the first understands the animal oeconomy, the structure of the human body, the cure of distempers, the art of surgery, together with the theory and practice of midwifery, learned from the observations of an experienced artist, and the advantage of repeated delivery: the last is totally ignorant of everything but what she may have heard from an ignorant nurse or midwife, or seen at the few labours she has attended.5

The disagreement turned on the relative value of knowledge gained through sympathy versus observation. Nihell was arguing not only for the medical attendant's need to know the individual constitution of the patient, but also for a kind of sympathetic identification with their experience. Smollett, who had trained in medicine at Edinburgh, and who had assisted in the production of Smellie's Treatise on the Theory and Practice of Midwifery, was arguing for the superior diagnostic power of knowledge grounded in experimental physiology and in anatomy. Such knowledge was, of course, more readily available to male practitioners, but it was not unavailable to women: Smellie's classes, for example, were open to midwives. Nihell's appeal to the value of sympathetic experience only available to women was thus above all strategic, a political move in the struggle for control over obstetrics.

The struggle was intense because the stakes were relatively high. Attendance on a wealthy woman could be extremely lucrative for a qualified physician, who could charge far more than a midwife.6 Yet it would be inaccurate to see the rise of obstetrics simply in terms of a movement driven by ambitious men who were able to exploit vulnerable female patients. The role of accoucheur certainly did offer a measure of upward social mobility. Thomas Denman, for example, was born in quite humble circumstances, as was William Hunter: both gradually built up extensive private practices among the aristocracy, and Hunter eventually became Physician-Extraordinary to Queen Charlotte.7 Yet all the evidence would suggest that the rise of the accoucheur was achieved not through exploitation of women but in collaboration with them. The man-midwife could offer women a certain degree of protection by virtue of his professional status and women were not slow to perceive the advantages of this. For example, the authority of the accoucheur could be invoked in support of travel to (or indeed from) a husband or mother during pregnancy and confinement. The attendance of the accoucheur also added to the status of the pregnant woman: it added value to what might be called the profession of pregnancy among well-off women. The specialism of obstetrics thus emerged through a process of negotiation in which women were active participants, not passive dupes. Adrian Wilson makes a similar point in his study of man-midwives, but while he emphasises the role of the accoucheur as fashion statement (the employment of the man-midwife as 'conspicuous consumption', in his phrase), I would stress the role of the accoucheur as social protector. In this respect, it is significant that William Hunter staked out his claim to primacy in obstetrics on the basis of his understanding of women rather than on his (unparalleled) anatomical knowledge. In a paper on infanticide read to the Medical Society after his death in 1783, he wrote:

The world will give me credit, surely, for having had sufficient opportunities of knowing a good deal of female characters. I have seen the private as well as the public virtues, the private as well as the more public frailties of women in all ranks of life. I have been in their secrets, their counsellor and adviser in the moments of their greatest distress in body and mind. I have been a witness to their private conduct, when they were preparing themselves to meet danger, and have heard their last and most serious reflections, when they were certain they had but few hours to live.8

Hunter's testimony, which also became his last testament, confirms the social, even psychological, role of the accoucheur. For although anatomical knowledge had increased rapidly over the previous twenty-five years, and Smellie, in particular, had shed new light on the processes of labour, many of the mechanisms of pregnancy and childbirth were still little understood. Most crucially, there was no means of monitoring foetal growth and development during pregnancy. It was not until 1822 that the foetal heartbeat was detected, opening up the possibility of auscultation to establish whether or not a foetus was alive.9 While mechanical intervention in childbirth could save lives, for example through the use of forceps, in relation to pregnancy the function of the medical adviser remained overwhelmingly that of providing reassurance - antenatal care as placebo, so to speak. This is clear from a study of the advice books written by doctors in this period and aimed at female patients as adjuncts to or substitutes for personal consultation. Alexander Hamilton, for example, in his Treatise on Midwifery (written, according to him, in 'the most plain and familiar manner'), assures his readers 'that the pregnant state, however inconvenient, is generally free from other disorders; and that labour, though painful, is almost always natural, and the event happy' (p. xxiv). Repeatedly, women are urged to trust themselves to nature: so Denman confirms that 'in every thing which relates to the act of parturition Nature, not disturbed by disease, and unmolested by interruption, is fully competent to accomplish her own purpose'.10 However, as has been noted in the Introduction, 'nature' is a slippery ideological construction. Here, in a paradox which continued to structure antenatal care, the authoritative professionals can do little more than suggest faith in nature, that is, non-intervention, as a medical strategy. Other than this, the advice in these texts consisted of bland injunctions to eat a balanced diet and exercise moderately. Venesection (blood-letting) was still sometimes recommended, and much attention was paid to constipation.11 This latter was considered a serious matter, as it might lead women to use strong purgatives, which could in turn induce a miscarriage.

The medical profession found their lack of firm knowledge about pregnancy both frustrating and embarrassing, however. A telling case in this respect is that of Joanna Southcott, a self-educated prophet and visionary who achieved a cult following after she joined the Wesleyans in 1791. A year later she issued a series of 'sealed' prophesies and, in 1801, published a collection of writings, The Strange Effects of Faith. She eventually gained about 140,000 followers who formed an influential millenarian movement. In 1802 she predicted she would give birth to Shiloh, the second Christ, and in 1814, when she was 64, a 'miraculous' pregnancy was announced. In August of that year several doctors were called in to examine her, with conflicting results. Dr Richard Reece, author of the popular Domestic Medical Guide (1805), found her breasts enlarged and her abdomen distended. His account continues:

These facts not being sufficient evidence of the pregnancy, I expressed a wish to be permitted to keep my right hand over the womb, for the purpose of discovering the motion of the foetus, on which she observed that it generally moved when she took nourishment; a piece of ripe fruit was then handed to her by her female attendant, on masticating which the motion of the foetus was very evident.

Reece was satisfied that she was pregnant.12

Dr John Sims, visiting on the same day, disagreed, finding her breasts plump only with 'the corpulence of an old woman' and detecting no foetal movement. He wished it to be put on record, however, that he

Figure 2 Joanna Southcott the prophetess exposing herself to three physicians in order to validate her pregnancy. Coloured etching by T. Rowlandson, 1814. Wellcome Library, London.

was convinced that 'this poor woman is no imposter, but that she labours under a strong mental delusion' (p. 27). Southcott continued to affirm her pregnancy, but acknowledged that 'should it prove not to be a child in the end, it must bring me to the grave'. She died on 27 December 1814 and, according to the Dictionary of National Biography, the autopsy revealed no pregnancy and no functional disorder or organic disease. However, in his 1837 Exposition of the Signs and Symptoms of Pregnancy, W.F. Montgomery claims that at the autopsy putrid matter was discovered, which did suggest disease. It is impossible to determine whether Southcott was in fact suffering from organic disease (for example, a tumour or fibroid growth) or whether hers was a case of what we would now call hysterical pregnancy.

The case became notorious and inspired much satirical comment, not only at the expense of Southcott but also at that of the clergymen and doctors who had supported her case. Thomas Rowlandson's cartoon 'A Medical Inspection: or Miracles Will Never Cease' is particularly instructive. It shows a monstrously corpulent Southcott, from the rear, lifting her skirts to display her belly and towering over a clergyman on her left and three doctors on her right. The clergyman is William Tozer, one of her staunchest followers: he crouches in her shadow drinking caudle (a spiced drink often administered to women to induce labour). The credulous doctors crouch on their knees next to a box labelled 'prophesies': the sketch suggests that their professional opinions are likely to be as fantastic and as little founded in fact as Southcott's prophesies. The case certainly fuelled public scepticism about the diagnostic powers of male practitioners, and Montgomery was still fuming about it twenty years later. In his monograph on the signs of pregnancy he refers repeatedly to Southcott the 'mock prophetess', accusing her of deliberate imposture and of manipulating her abdominal muscles in order to imitate foetal movements.13

Between 1750 and 1820, textbooks by accoucheurs increased rapidly in number, as the discourse of obstetric medicine became established. The sections which follow trace the dominant themes which are threaded through obstetric textbooks, advice books, medico-social and literary texts of the period, constructing a particular, if sometimes contradictory, cultural understanding of pregnancy.

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Pregnancy And Childbirth

Pregnancy And Childbirth

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