Man-Midwife, Male Feminist: The Life and Times of George Macaulay, M.D., Ph.D. (1716-1766)

Pregnancy and Childbirth: Science and Folklore

In the natural process of giving birth, if all goes well, the necessity of a midwife's assistance may well be minimal. In that qualification "if all goes well," of course, exists a world of room for accident dependent on multiple variables. For women in the eighteenth century, pregnancy and childbirth were rarely easy. Little was known about antiseptics or anesthetics, and Page  98the treatments and pharmaceutical specifics for conditions associated with parturition remained largely those from the practice and pharmacopoeia of ancient and medieval medical lore. For lying-in and post-partem women the remedies most often recorded included bleeding, enemas, laxatives, and sweating mixtures. The renowned surgeon and man-midwife William Smellie's casebook advises that one can administer food and drink in labor, including brandy and water.[1] Smellie goes on to describe a "portable mixture" he carried with him on country calls. This consisted of separate bottles of laudanum (a mixture containing opium), hartshorn, and tincture of castor. Hartshorn was literally taken from the horns of stags, made into shavings, boiled in water, and flavored for drinking. With brandy and water he would give these potions as cordials to alleviate pain during childbirth. If women suffered from excessive vomiting during pregnancy, Smellie advised bleeding and sedation, along with peppermint water and claret.

During the post-partem period, The London Practice of Physic recommended a spare diet and chicken-broth, with warm caudle.[2] If the breasts began to be uneasy from milk stagnating, gentle diaphoretics were prescribed along with applied plasters with camphor. Pain and inflammation of the breasts were treated with a poultice of bread, milk, and oil (153-5). A fever "required the utmost caution in bleeding," rarely necessary; keeping the body open by gentle cooling cathartics, with the use of antiputrescents and large quantities of diluting liquors, and rest. "Let those who value their Lives...be sure to lie in Bed, and not rise and sit up, till the tenth Day at least after Delivery" (84). Clearly, bottom-line oriented, managed-care companies were not consulted about this schedule.

While Macaulay was in Padua at medical school, an anonymous physician in London published "A Practical Discourse on Barrenness in Women, and Impotency, Infertility, and Seminal Weakness in Men," as an addendum to an earlier book devoted to women's health issues.[3] The addendum's preface chides women for their medical ignorance and for their hesitancy in seeking help from a physician: "The slender knowledge the Fair Sex have of their own infirmities and Disorder is the Reason they seldom call for Assistance, Page  99till their Illnesses are arrived at too grat [sic] a Height, for the Management of those they commonly apply to for Help..."(Directory, "Preface" A2).

Of course, most women were accustomed to requesting help from midwives. The physician goes on to lament that:

This book proposed to help women and the midwives gain a better knowledge of women's health issues and to acquaint them with helpful remedies whose sales would line its author's pocket. The unknown doctor says he "has arranged for all recommended medicines to be sold by the Gentlewoman at the Two Blue Posts in Haydon-Yard in the Minories London, at as moderate Prices as any Apothecary would make them" (A2-A3).

A fair assessment of the efficacy of this physician's contribution to the pharmacopoeia of midwifery may be inferred from his detailed instructions for making uterine drops by mixing in a glass vessel iron filings with artichoke hearts and other substances, placing them in a "hot bed of horse Page  100dung" for a month, and using them to cleanse the womb (20). Nevertheless, aside from his financial interest in dispensing his nostrums, this physician also wished, at least, to benefit the women who practiced their craft on other members of their sex. His object was not to control or supplant them.

Another effort with similar motives appeared after Macaulay had begun his London practice. This work, Nicholas Culpeper's A Directory for Midwives: Or, A Guide for WOMEN, In Their Conception, Bearing, and Suckling their Children, promulgated and helped perpetuate a number of superstitions and misapprehensions widely held among his contemporaries.[4]

Culpeper wrote that the clitoris is that which "causeth Lust in Women, and gives delight in Copulation" but went on to repeat the ancient misapprehension that without pleasure one does not conceive, and that "the bigger the clitoris is in Women, the more lustful they are" (17-18).

Conception, Culpeper explained, occurred when the female egg, referred to as a "seed," united with the male seed. A child's sex, however, was determined by the comparative strength of the father or mother's seed: "If a Man's Seed be strongest, a Male is conceived; if the Woman's, a Female..." Thus, "weakly Men get most Girls, if they get any Children at all" (38).

Children were considered both a blessing and a curse. Besides suggesting remedies for infertility, Culpeper's chapter on what hinders conception, along with remedies, states that all men and women desire children, "partly because they are Blessings of God," or else because they are pretty things to play with. Since lust is probably the cause of begetting more children than the desire for the Blessings of God, the "Pleasure in the Act moves an hundred...It being apparent by the Curse of God upon Eve, I will exceedingly multiply the Conception, that many Children come into the World as a Curse" (53). This same precept—that pleasure, not procreation was the principal motive of sexual intercourse—moved Jonathan Swift's Lilliputians in the first book of Gulliver's Travels to remove children from parental care and turn them over to state nurseries for rearing and education.

Culpeper lists four possible causes of infertility: 1. lack of love between man and wife ("this is the Reason there never comes conception upon Rapes"), 2. similar complexions of man and wife, 3. the letting of blood from a virgin's Page  101arm before menstruation, for "the blood comes not down to the womb as it doth in other Women, but the Womb dries up, and becomes for ever barren;" and 4. too much carnal copulation (54-55).

While today sophisticated medical tests, like amniocentesis and ultrasound, can identify the sex of the baby a woman is carrying, both in Macaulay's era and even now for the majority of pregnant women who do not undergo such procedures, having friends predict the baby's sex is common—particularly since the chances of being right are fifty percent.

Signs presumed to indicate a male in utero included using one's right rather than left hand to steady oneself when rising from a chair, a belly rounder and higher than when carrying a female, feeling the baby's movement on the right side, carrying the baby "not so heavily, but... more nimble in moving," having a right breast that is more plump and harder than the left with the right nipple redder, and finally, a mother's clear—not swarthy—complexion (80-81).

Culpeper blamed having sexual intercourse during menstruation as the greatest cause of birth defects, suggesting that it "was not for nothing God himself forbad a Man not to touch a Woman at such a time" (86).

In an intellectual and clinical climate where ancient and medieval medical knowledge was rapidly being supplemented by the discoveries of empirical science, but where both continued cheek by jowl with popular belief and Biblical fiat, it is little wonder that expectant mothers and women contemplating childbearing sometimes gave themselves over to a kind of fearful and resigned fatalism.

Other than coitus interruptus and nursing one's own baby—practices with limited effectiveness—women could do little to prevent pregnancy. Macaulay's first wife, Leonora, had five babies in six years, and such serial, closely spaced pregnancies were clearly matters of grave concern for many. Lady Stafford in a letter of 1793 was obviously worried after the arrival of her daughter's new baby: "This is the third child in 21 months; that is too much for the strongest constitution."[5] It seems altogether likely that Leonora Macaulay's Page  102numerous pregnancies had undermined her health, for she died seven months after her last infant's birth.

Licensing and Male Pressure

To reduce the risks attendant upon childbearing, the Edinburgh Town Council, as noted earlier, took pains to assure the better qualification of midwives, requiring licensing procedures and hiring a city professor of midwifery, Joseph Gibson (ETCM, 9 Feb 1726). As we also mentioned above, as there is no evidence of Gibson's ever having taught at the university, one can only conclude that he had as his province the training of female midwives. Nevertheless, in Edinburgh, the traditional feminine province of midwifery was in process of subjection to the town council's (and therefore increasingly to male) licensure.

In Scotland and elsewhere the exclusively male medical profession also asserted pressure to bring obstetrical practice under its control—an effort that has been closely studied by Jean Donnison in her admirable Midwives and Medical Men: A History of Inter Professional Rivalries and Women's Rights.[6] In 1688, Donnison reports, a midwife, Elizabeth Cellier, petitioned James II for the re-establishment in London of institutional lying-in for "destitute parturient women" (31). Cellier was convinced that the episcopal licensing of midwives was "no more a guarantee of skill than it had ever been."[7] She proposed incorporating all the skilful midwives of London into a Midwives' College, which would provide for the instruction and supervision of members and furnish a forum for the discussion of professional matters. Besides this, she wanted the Midwives' College to finance a Royal Foundling Hospital and twelve associated lying-in houses for female paupers to be cared for by women sent by the Overseers of the Poor.[8] Predictably, the scheme foundered, as did other proposals for incorporating female midwives into a professional, quasi-autonomous body, on the objections of physicians and on the novel idea that the women might be capable of governing themselves. Donnison Page  103recounts that in 1736 John Douglas, a well-known London surgeon, and brother to James Douglas, an eminent man-midwife, "demanded the establishment of lying-in hospitals in all the principal cities of England" (24).

Beyond the attempts by female midwives to organize themselves into a professional body, there were also efforts by male surgeons and accouchers to organize the women under their administration and tutelage. Some of these attempts, like that of Dr. Hugh Chamberlen (d. 1720), whose family controlled the secret of the obstetrical forceps and who attempted to gain control of all London midwives, were patently self-serving schemes whose principal advantage would have been the production of income for their proposers; they were never seriously entertained—at least, not for long. Others, with a view to improving skills, proved useful. In 1739, for instance, a prominent London man-midwife, Sir Richard Manningham, instituted a "Charitable Infirmary for the relief of poor married women in two wards of St. James' Infirmary, Westminster," where both men and women would be trained as midwives (25).

One of the most successful, though at the same time controversial, of the methods employed by men to establish control over the profession, however, was precisely the training of "men-midwives," a phrase first used in the mid-seventeenth century. The oxymoronic nature of the phrase gave rise to a good deal of satirical screed and several graphic images. The most renowned example, perhaps, of the latter is Isaac Cruikshank's etching, "A Man Midwife," that portrays a bifurcated male-female figure surrounded by the nefarious instruments of the trade: forceps, crotchets, scalpels and saws. [See Plate 10: Isaac Cruikshank's etching "A Man-Midwife."][9]

Just as there were two classes of female practitioners, two sorts of men-midwives engaged in obstetrical practice. The first included men who, like Macaulay and his friend the famous and controversial Dr. William Smellie, Drs. John and William Hunter, Richard Manningham, Thomas Denman, and Christopher Kelly, had been trained in medicine, anatomy, surgery, and midwifery in the principal universities of Europe. These men, whose surgical qualifications in fact did equip them with specialized skills—including the use of instruments like the forceps, hook, and crotchet—could in cases of Page  104difficult birth sometimes make the difference between a mother's or a child's life or death. A second order of man-midwife, however, was comprised by men with no medical training except a crash course in midwifery. Instead of specializing at universities, this class of practitioner attended lectures and demonstrations afforded them by doctors like Smellie, who had actually invented a contrivance—a kind of artificial mother—by means of which to demonstrate for the edification of such pupils the birth process.

Man-midwives of this second sort all too often gained practical experience by casually accompanying their mentors to births where, having first observed, they next assisted, and then, armed with a certificate, struck out on their own. Like their female counterparts, some of these practitioners were doubtless well trained and competent. Many, however, acquired their experience at the expense of the lives and health of mothers and infants. Most disturbingly they also sometimes undertook to instruct others in their scant knowledge.

In her Complete Practice of Midwifery (1737) Sarah Stone writes: "More mothers and children had died at the hands of raw recruits just out of their apprenticeship to the barber surgeon than through the worst ignorance and stupidity of [female] midwives." Yet by adopting a 'finished assurance,' and claiming that their knowledge exceeded any woman's, these young 'Gentlemen-Professors' so secured their position that "if Mother, or Child, or both, die, as it often happens then they die Secundum Artem [in keeping with the best medical practice]; for a Man was there, and the Woman-Midwife bears all the blame" (Cited in Donnison 26).

Objections to male midwifery; Philip Thicknesse's Polemic Satire

Not surprisingly, other objections to man-midwifery arose in multiple quarters on several grounds. Some objected on the grounds of female modesty. These ranged from a settled preference on the part of some women for female attendance in intimate circumstances to heartfelt objections on religious and moral grounds to male intrusion into the most private of female domains. Other objections particularly arose from women's well-founded fear of the instruments the men used in delivery. Some who objected fanatically accused men-midwives of wholesale seduction of their patients and of salacious liberties with women's breasts and genitalia.

The most fanatic of the last sort was typified by P. Thicknesse's pamphlet, Man-Midwifery Analysed: and the Tendency of the Practice Detected and Exposed.[10] This pamphlet responded satirically to William Smellie's great 3-volume work on the practice of midwifery that first appeared in 1752. Thicknesse was principally incensed about a male practitioner's handling the female generative and excretory organs on the grounds that doing so cuckolded husbands and debauched wives. But he also blamed men-midwives for their use of surgical instruments: levers, boring scissors, hooks, forceps with the attendant sacrifice of the lives of children and women.

Thicknesse considered the man-midwife an unnatural monster, and he listed 1745 as the year of the monster's birth. This date corresponds to the founding of Westminster Hospital, but also to the year in which the female midwives of London again applied for and failed to obtain an organizational patent that would have institutionalized their profession on the same footing with barbers, surgeons, and other historic guilds—a failure that can principally be attributed to the Royal College of Physicians' self-interested and patriarchal mode of thinking.

In his zeal to condemn man-midwives, Thicknesse told the following probably apocryphal story as true:

La Motte and Mauriceau wrote notable treatises on midwifery. Smellie modeled his reference on that of La Motte, and Mauriceau wrote of the diseases of women.[11] The male writers of the anti-man-midwife party blame the French for founding of the movement. This view, as we shall see below, was also shared by female practitioners of the art.

Both Thicknesse's satirical tone and his (probably fictive) illustration found reasonable grounds in the practices and attitudes of the worst of the male midwives. Thicknesse's reading of Smellie's text, which had had the benefit of Tobias Smollett's editing, suggests, however, a high degree of prurient projection into a physician's manual examination of a woman to determine pregnancy and the degree of its advancement. Based on Smellie's instructions for conducting such an examination, Thicknesse imagined as habitual a seduction in which he takes on a first person, physician-roué's persona. "The touch" to which he alludes involves palpation of the rectum and genitals. His man-midwife imagines a home call and examination:

Elizabeth Nihell's Treatise

If Thicknesse's critique tells us more about his fantasy life than about sensible objections to man-midwifery, a more reasonable though overlapping case on firmer and, one might say, on better medical and feminist grounds, was made by Elizabeth Nihell in A Treatise on the Art of Midwifery. setting forth Various Abuses therein, especially as to the Practice with Instruments: The Whole serving to put all Rational Inquirers in a fair Way of very safely forming their own Judgment upon the Question; Which is it best to employ, In cases of Pregnancy and Lying In, A Man-Midwife; or, a Midwife.[12]

A midwife herself and married to an apothecary, Nihell of course had a vested interest in trying to stem the rising tide of man-midwifery. Not only were men thronging into the profession, women seemingly cooperated in their incursion into a traditionally female realm by finding it fashionable to entrust themselves to the ministrations of the male practitioners. That her objections to what she perceived as a danger to lying-in women, however, were heartfelt and did not arise merely from pecuniary interest appears everywhere in her closely argued text. Nihell, having defended herself against the expected accusations of those who would reproach her for self interest, in part by reporting that she had delivered no fewer than nine-hundred women gratis, goes on to assert (probably fairly) that men-midwives are too rash in the application of their instruments (50). They often caused more problems than they solved, and they lacked the natural tenderness that one woman has for another. She admitted the justice of some of the accusations of ignorance often lodged against female midwives: "I own Page  109however there are but too few midwives who are sufficiently mistresses in their profession. In this they are some of them but too near upon a level with the men-midwives..."(viii). But, given equal ignorance in the practice of the men and the women, she draws a further distinction between them, one favoring the female practitioners:

Nihell continues by defending the historical preference evinced both by the general public and the medical profession for female midwives and by concurring with other critics in attributing the fashion for male practitioners to the French and their "eternal fondness...for novelties."

With trenchant irony, she doubts whether William Smellie, who had accused her and her husband of self-interest, had ever delivered a woman gratuitously unless he counted the pseudo-deliveries performed on the simulacrum he used to instruct his students in midwifery. "This," Nihell reports, "was a wooden statue, representing a woman with child, whose belly was of leather, in which a bladder full, perhaps, of small beer, represented the uterus. (Male midwives often administered beer as an anesthetic to women in labor.) "This bladder," she goes on to say, "was stopped with a cork, to which was fastened a string of packthread to tap it, occasionally, and demonstrate in a palpable manner the flowing of the red-colored waters. In short, in the middle of bladder was a wax-doll, to which were given various positions" (50). Nihell credits this "admirably ingenious piece of machinery" for the production of the "innumerable and formidable swarm of men-midwives, spread over the town and country. By [Smellie's] own confession, he has made in less than ten years nine hundred pupils, without Page  110taking into the account the number of midwives whom he has trained up, and formed in so miraculous a manner" (51).

Like Thicknesse, Nihell was a proponent of the ministrations of Mother Nature: "Lying-in women," she said, "principally require an early assistance. For unless they are pregnant of a monster with two heads...there need never be an occasion of recourse to a surgeon: or in this case, of a monster, it must be the affair of a most profoundly skilled operator, and not of merely a common man-midwife" (56-57).

Like Thicknesse as well, Nihell has her doubts about the objectivity of men—particularly young men—when they employ "the touch" as part of their diagnostic procedures. "In pure justice to all parties," she observed:

Although with respect to the motives of men in this particular she presents a much more balanced view than does Thicknesse, at root, the concerns of the two critics of male midwifery are essentially identical. Man-midwives were too often ignorant, rough, impatient, too stiff in the hands and fingers, and over-ready to use the injury-inflicting instruments of their trade, insensitive to the fears and concerns of their patients, and suspect in their objectivity toward their privileged access to the privy members of their female patients. Female midwives, by contrast,

Like Thicknesse, Elizabeth Nihell too has her horror stories to recount. Hers, however, savor more of fact than fancy. "Here," she tells us, "in the history of one single woman, I give the history probably of thousands."

She reports that a healthy woman who had experienced an easy delivery with her first child had trouble with her second. Over her objections, the male midwife, whom she had selected because he avoided the use of instruments, used them and accidently killed her baby (92-94). Nihell's description of the incident is detailed and graphic.

Nihell's objections to men-midwives, however, did not extend to female midwives' proper recourse to university-trained physicians and surgeons when circumstances called for them. She herself called on the men for assistance, as we learn from the case book that the then late George Macaulay's colleague at the Lying-in Hospital, Dr. Christopher Kelly, kept in 1771-72 concerning patients suffering from puerperal fever: "Mrs. Thane Aged abt 30 was taken labor with her first Child, Tuesday Morning Oct. 20, 1772 about 7 o'clock and continued lingering pain and with little rest till Thursday morning two o'clock when she was deliverd of a dead Child by Mrs. Nihile her Midwife."[13]

Not only did Nihell call on Kelly, she also called in Dr. William Hunter, and the two of them consulted with Dr. Garthshorn as well. Nihell probably chose to call these men because she knew them to be extremely conservative in their employment of instruments. William Hunter, though perfectly Page  112willing to employ instruments to save a mother's life, observed that his forceps had rusted from disuse in normal deliveries.[14]

Late Term Abortion: Cranial Reduction: The Petition of Unborn Babes

The late twentieth-century debate concerning late term abortions was anticipated in the mid-eighteenth century in the discussion of an operation, alluded to above, euphemistically termed "reduction of the cranium." Responsible physicians had recourse to this desperate measure only in cases where the mother's pelvic structures were too narrow or too deformed to permit a normal delivery with a resultant threat not only to the infant's life, but also to the mother's. Contemplation of the deliberate termination of the life of a healthy child who had been brought to term occasioned precisely the same sort of public horror that it does now.

The critics of man-midwifery seized on that horror to try to incense the public against its practitioners. In doing so, at least one of them singled out as principal objects for his vituperative scorn the British Lying-in Hospital for Married Women in Brownlow Street and its staff. This tract, The Petition of the Unborn Babes to the Censors of the Royal College of Physicians of London, appeared shortly before George Macaulay joined the hospital's staff.[15] [See Plate 11: The Petition of Unborn Babes.] It begins by asserting the right of the unborn to the protection of the law. We quote from it at length because it frames the debate and because it directs its attack specifically against the hospital and staff where George Macaulay was to serve:

The pamphlet continues in a broadly satirical, indeed Swiftian vein, excoriating men-midwives and anticipating many of the arguments of the Page  11321st century's right-to-life movement. Dr. Pocus seems to have lampooned Dr. Daniel Peter Layard; Maulus, Dr. William Hunter; and Barebone, Dr. William Smellie.

After charging the doctors with malpractice and lying, and after making other unfounded charges, including the usual ones about sexual misconduct and about the complicity of the nurses in the physicians' malfeasance,in an extended footnote to pages 4 and 5 of the petition, its author alleges that the Censors of the Royal College of Medicine had recently been required to sit as a court of inquest into the deaths of six children who had died in deliveries attended by a man-midwife. It may very well be the case that this inquiry, if it indeed took place—we can find no record of it—together with the Petition and the publicity surrounding both played some part in the resignation of Macaulay's predecessor, Dr. Daniel Peter Layard. The author of the anonymous Petition, very likely a physician, was certainly displeased with the outcome of the inquiry, whose putative proceedings he scornfully recounts:

In response to this clearly fictive, logic-chopping rationalization, the pamphlet's author invokes the spirit of the renowned discoverer of the circulation of blood, Gabriel Harvey, whose bust had overlooked the Royal Society's proceedings. With the ire of a patriarchal prophet, Harvey's offended ghost admonishes the assembly:

Facts against Polemics: The Hospital's Response

To this scathing condemnation of the charity's practice (not to mention the xenophobic assault on Scotch physicians) the board of Governors of the British Lying-in Hospital felt itself obliged to respond. At its weekly meeting of 23 January 1752, the board authorized publication of a simple recital of the facts that the Petition had distorted so polemically.

The board reported that 545 women had delivered 550 babies between November 1749 and January 1752. Of these babies, 29 had been stillborn. Page  118On the 20th of January, the previous year, the board continues, four women (not six), included in the above numbers did have stillborn children. Three of those four were assisted in easy deliveries, not by men-midwives, but by one of the two resident female midwives. The fourth mother had indeed been delivered by one of the men, and she had borne twins, one of whom was born alive. The other had evidently been killed when the woman fell three weeks before coming to the hospital.

The men-midwives assisted in delivery, the board carefully explained, "only in any appearance of Danger, about once in 30 or 40 cases" (MB, 23 January 1752). Finally, the board's report makes clear that of the 545 deliveries, only two required the use of instruments capable of hurting—both times on children already dead and then only after both men-midwives agreed the procedures were necessary to save the lives of the mothers. In both cases, the mothers were in fact saved.

Beyond that, Thomas Yewd, the charity's secretary, caused the following retort to be printed in The General Advertiser, for Saturday, 18 January 1752 (NUMB. 5382):

Nonetheless, a procedure that involved opening a baby's head, even to save a mother's life, horrified and repulsed the public. We must understand that Caesarian section in cases where the pelvic structures were either too narrow or too deformed to admit an infant's passage was not an eighteenth-century option—at least not if the mother's life were to be preserved. Though the child might live, Caesarian section almost invariably proved fatal to the mother. It was only ordinarily attempted in an effort to save a child whose mother had already expired or was irretrievably moribund. William Smellie in his career attempted the operation three times after the death of a mother, but in each case the child, too, had already died. Smellie reports and Spenser following him confirms only one case in the British Isles where both mother and child survived, and that seems to have been a case of pure luck. The operation was performed by Mary Donally, an illiterate but widely respected Irish midwife, in January 1738/39. This was the first successful Caesarean section in the British Isles with both mother and child surviving.[16]

The second part of Nihell's treatise devotes itself to an examination of the difficulties that various male authorities report concerning cranial reduction, preternatural and difficult births, and their unhappy results. She also discusses what she, in her experience as a carefully trained and much practiced midwife, would do either as a precaution against just such difficulties, or as a palliative when they occur. Her attempt—variously successful—is to undermine the authority of the authorities. Advising the use of bare hands in circumstances where surgeons generally employed instruments, she catalogues in horrifying detail the various methods the men had proposed for bringing away the head when it is too narrow to pass naturally and those for extracting the head of the Fetus, severed from the Body, and remaining in the uterus and offers advice.

Macaulay and "The English Operation"

There is little wonder that the doctors of London thought it a good idea to devise a way for obviating the necessity of cranial reduction and inducing labor before a child was too fully developed for an easy delivery through narrow or deformed pelvises. Partly as a response to the public outcry against this particular procedure, and partly, surely, from purely humanitarian motives, George Macaulay was among those instrumental in convening a conference of eminent London surgeons and physicians to consider alternatives.

They met in 1756 to discuss the implications, moral and medical, of inducing early labor. If a child were born before its head grew too large for narrow or slightly deformed pelvises, the necessity for cranial reduction would be obviated. The members of the committee discussed the issue of whether or not intervening in the natural process was ethical. Concluding that, in view of the enormous benefit such a procedure would produce, it was indeed ethical, they appointed Macaulay himself to perform the first such operation when it became necessary, and this he did in 1756, successfully delivering the wife of a London linen draper in the Strand.[17]

Macaulay's procedure itself involved carefully puncturing the amniotic sac with a silver wire and drawing off approximately a spoonful of amniotic fluid. This operation had the same effect as the water breaking in triggering the mechanisms that induce labor—usually within forty-eight hours. Macaulay's method for encouraging early labor became known as "the English operation," and over the next century and a half was responsible for saving the lives of many women and children who otherwise would have been lost either to Caesarian section or to cranial reduction. Macaulay's "English operation" passed next to Christopher Kelly and from him to Thomas Denman. As more doctors learned to perform it, the procedure became dissociated from Macaulay's name. Surely, it was his greatest contribution to obstetrical practice.

The Science of Anatomy

In the ongoing debate between the midwives and the physicians, the latter frequently alleged their superior knowledge of anatomy as grounds for preferring their services. As commentators like Jean Donnison remind us, except Page  121in Italy, women had no access to the universities and the dissecting theaters of places like Padua and Edinburgh or to the medical degrees they offered.

Nihell, however, remained unconvinced by these arguments from a superior knowledge of anatomy: "It may be true," she said,

Vis-a-vis anatomy, her final recommendation calls for public spirited physicians to share their specialized knowledge with the female midwives:

On the limitations of men-midwives, she continues:

With all too certain justification, Nihell accuses men-midwives of a particularly inexcusable arrogance: prescribing general physic though they have never studied medicine.

The justice of this accusation Smellie himself confirms in his report of a patient whom he found under the "care" of just such a man-midwife.[18]

In 1748, Smellie tells us, a lady asked him to visit a woman who had formerly been her servant. "On my arrival," he reports, "I found another practitioner there, who seemed much surprised, and with a very surly countenance scolded the husband for bringing another without his knowledge" (III, 486). From the ensuing report, it becomes clear that Smellie as much as Nihell despised the pretensions of untutored practitioners who insolently exceeded their capacities. The man-midwife's dress, Smellie says, "was as forbidding as his countenance, consisting of an old greasy matted wrapper, or night-gown, a buff broad swordbelt of the same complexion round his middle; napkins wrapped round his arms, and a woman's apron before him to keep his dress from being daubed. At the same time, to make him appear of consequence, he had on his head a large tie periwig" (III, 486).

Smellie pacified the man-midwife by apologizing and explaining his presence. The husband, too, excused himself, explaining the lady's interest in his wife. Somewhat mollified, the man-midwife blamed the lady who had summoned Smellie and "began to abuse the lady's ignorance of his importance, and damned all midwives for ignorant b[itche]s" (III, 487).

Having pacified the fellow, Smellie "begged he would tell me how his patient was, that I might inform and satisfy the person who had desired me to call" (III, 487). "By this calm reasoning," Smellie continues, "his surly aspect unbended. He told me he was just going to deliver his patient, and, if I pleased, I was welcome to be present at the operation; for he could wait no longer, as he had already lost one patient by waiting two days on this; and now he was called to another" (III, 487).

In other words, this unnamed practitioner was about to use instruments to hasten dangerously the birth of one child in order to enhance his income. He then admitted to Smellie that two nights before the woman had gone into labor, "but as he was then uncertain how the child presented, and she had got little sleep for two nights before, he had ordered her repeated doses of opium, which had produced little or no effect; but that last night she Page  138had been quite stupid and often convulsed; and that nothing could save her life but present delivery" (III, 487).

Eventually, having described the woman's condition in detail, and excusing himself for a time, the practitioner invited Smellie to examine his patient. This Smellie did, and found the woman much as she had been described, except that the head of the fetus had descended to just above the Ossa Pubis, which the practitioner had not observed. The practitioner left for a while, and in his absence, the apothecary, who was also present, advised Smellie that the patient had taken a total of about 15 grains of opium; "this was the occasion of the convulsions and stupidity" (III, 487).

On the quack's return, Smellie tactfully convinced him, considering the patient's stupor and her convulsions, that the case was no longer straightforward midwifery, and that "it would be proper, for the safety of all concerned, and in order to prevent reflections, that the husband should go to the lady, and beg of her to send her own physician to our assistance" (III, 487).

This all agreed to, and when the physician came he inquired, "minutely about the quantity of opium which had been administered.... The man-midwife and the apothecary disagreed in their accounts," and when the latter went for the bills as proof, the man-midwife suddenly remembered another patient elsewhere, and asked Smellie to take over. This Smellie declined to do. The physician enraged the fellow by telling him that "if the woman was kept quiet, she would sleep off her large dose of opium" so that "he left the house muttering revenge against the apothecary." (III, 487). Smellie and the physician agreed that as the opium wore off the woman would resume labor. They therefore sent for a female midwife to attend the birth. Unfortunately, though the mother survived the overdose of opium, the child was born dead.

Frequently, as previously noted, Nihell blames the foolish whimsicality of the French (a national characteristic she thinks) for introducing man-midwifery as a fashion to which the gentry have at their peril subscribed.

Based on the misjudgments of even the most famous and fashionable men-midwives, however, the gentry sometimes came to share Nihell's views. In May 1755, Mrs. Delaney wrote to her sister of Lady Gore's unhappy time as a patient of Sir Richard Manningham, one of the best-known London accoucheurs:

In her scorn for the entire profession of man-midwifery, Nihell tars the learned and the quasi-learned with the same brush:

Nihell expands her attack to include the parishes for their allegedly insidious practices with respect to orphaned children. She accuses the parishes, which were responsible for the support of the children, of regularly substituting dry-nurses for wet-nurses with the result that the child dies and that the parish is spared the expense of its sustenance. She then links this "Violence offered to Nature" with that of the men-midwives as both attributable to "exactly the same common parent, interest," with "exactly the same common effect, the destruction of infants" (200). And she reminds the public of the sheer numbers of ill-trained male practitioners that the physicians have loosed upon the public:

Nihell is clearly a highly skilled debater. In part I of her book, she uses the medieval method of questiones—the statement of an objection and the answer to it—to argue her case. Her arguments are full of understated irony—a much more effective weapon that the broad slapstick of Thicknesse's treatise. She regularly gets her best arguments from the texts of her adversaries, Page  142and she employs both "difference" and "likeness" theory to argue her case against the men. When it comes to the question of aptitude for learning the necessary, the women are as capable as the men; when it comes to that of emotional suitability for the work, the women are by nature better suited than the men. Women are more patient, she argues, more sympathetic, naturally disposed to be care givers, etc. They are also, being smaller and more flexible, physically equipped to do the work better. Generally, she gets the best of the argument. As is so often the case, though, where power is involved, the better debater loses to the stronger opponent. Fortunately for the women who required the services of both female midwives and male physicians, the disagreement between the sexes often, at least among the competent of both genders, turned to professional cooperation in the lying-in chamber.

The Midwifery Debate Versus Midwifery Practice

Though feelings on both sides of the midwifery issue ran high, and though much invective both in print and in conversation was exchanged on both sides of the issue, the case books of physicians make clear that responsible persons, both male and female, both midwife and surgeon, in practice relied on one another to assist women in labor, to deliver the infants, and to preserve the health and lives of both mother and child, if possible. If that was not possible, if a choice had to be made, then saving the mother took precedence. To those ends, in fact, midwives like Nihell and obstetrical physicians like Macaulay, William Hunter, William Smellie and Christopher Kelly cooperated effectively within their capacities and to the degree that the science of their day allowed.

The Critical Review, edited at this date by Tobias Smollett and a company of anonymous reviewers, predictably savaged Nihell's book. Smollett was himself a physician. George Macaulay, though sympathetic with some of Nihell's positions, was also intimately connected with the Review, as we shall later see. William Smellie was a close friend of both men, and all were Scots.[20] The reviewer suggests that Mrs. Nihell take as her motto: "Nihilo ex nihil fit" (A recondite pun: Nothing can be made from nothing, and [Mrs.] Nihell can do nothing). Then for the next ten pages, he trashes everything she says. Page  143The combativeness of the reviewer's stance suggests that Smollett, who was renowned for his temper and bellicosity, may well have written this review himself. He faults Nihell's style:

We need not detail the sustained invective with which the reviewer treats the work. He suggests Nihell is ignorant, mistaken, verbose, self-interested, sexist, a threat to charitable institutions and unworthy of attention. Despite the reviewer's unflagging scorn, however, Nihell's suggestion that the doctors share their anatomical knowledge with the female midwives with a view to improving patient care reflects a position with which George Macaulay fully agreed. When, shortly after his arrival on staff, the British Lying-in Hospital became a teaching hospital and established a program to instruct midwives, only female students were accepted into the program. The sensitivity to female capacities and opinion that Macaulay elsewhere evinced was once again apparent in this decision. It may also reveal a tacit agreement with Nihell's concern that too many ill-trained men were taking up the art of midwifery.