Friday, 30 August 2013

Part 1: The rise of the male medical professional in the field of midwifery: the work of William Gifford.

I am fortunate to have been alive at the end of the twentieth century and living in the United Kingdom when I gave birth to two healthy children. I was able to take full advantage of a National Health Service which offered professional midwives and doctors to attend both deliveries and provided pain relief in the form of a TENS unit, gas and air, pethidine and an epidural. In both instances I benefitted from medical staff skilled in the use of forceps and, when one delivery appeared to be going wrong, a surgical theatre was prepared for an emergency caesarean operation. How different things would have been in the eighteenth century: it is unlikely that I would have survived the birth of my first child.

For many centuries, midwives in Western Europe occupied a lowly position, while some were labelled as witches and others outlawed by the Church. At the same time the male medical profession avoided women’s diseases and childbirth, unless medical intervention became essential, and the majority of normal deliveries were left in the hands of untrained midwives. The licensing of midwives in England followed on from an Act of 1512,[1] which did not mention midwives specifically but placed the licensing of medical practitioners in the hands of the Bishops, in order to prevent the practice of witchcraft. As a result of which, a woman of good moral character might obtain a licence from a Bishop to set herself up as a midwife, although any training was generally gained by working alongside an established midwife.

Cases referred to below are taken from Gifford, William (1734) Cases in Midwifery, London: Edward Hody (The Wellcome Library)

An increase in scientific and medical knowledge and the professionalization of man-midwifery during the eighteenth-century had the effect of making the attendance of a man-midwife a necessity at difficult births. Amongst the social elite the attendance of a surgeon at normal deliveries became fashionable, even during normal deliveries:
Case XIV
8 April, 1726:  I was about eight a Clock called upon to go to the wife of one of the Prince’s Servants.
Case VI
Thursday 16 September, 1725: I was sent for to a Gentlewoman about six miles from London, whom some time before I was ingaged by her Husband to be ready to attend whenever there should be occasion, and as soon as they judged by her complaints, that her labour would come on, they sent for me. [A midwife had been in attendance leading up to the point of delivery].
William Gifford was a surgeon and man-midwife: his journal contains accounts of 225 cases in which he was called upon to attend women experiencing difficult births. Extracts from Gifford’s case notes set out below demonstrate a defensive manner towards his professional skills and contempt for those of the untrained or negligent midwife.

I could wish indeed to have found his language more correct; but it is with this Book, as it is with Men, we ought principally to regard the Use they are of to Mankind: and I dare venture to affirm, that whoever shall persue these Cases with an interest to learn the Practice of Midwifery, will not think his time ill spent.
Edward Hody, FRS.
Whether called to assist a male or female midwife, Gifford was outspoken criticisms when either failed to provide a satisfactory level of service:
Case V
I was fetched in a great hurry to the Wife of a Chairman ... Another Man-midwife …  had been there before me, who at first would not attempt anything without a Sum of Money was laid down; but upon assurances that he should be paid, he worked upon the poor Woman, and left her (as I had afterwards reason to think) in a worse condition than he found her, telling her he was not able to deliver her.
                                              A Man-Mid-Wife.[2]
                                             Coloured etching by I. Cruickshank, 1793
Lettering: A Man-Mid-Wife, or a newly discovered animal, not known in Buffon’s time; for a more full description of this Monster, see an ingenious book lately published entitled  Man-Midwifery ...
While midwives and patients recognised that skilled help was necessary in certain circumstances, some midwives resented the interference of man-midwives in their work and delayed calling for assistance:
27 March, 1729.  I rebuked her [the Midwife] for not sending at first, when she found it to present in a wrong Posture; but she in excuse, as is usual amongst them, told me that she had brought out many Children offering in that posture.  The Child from its having lain for some time so presented, was dead, which I told her was very probably owing to her neglect in not sending sooner, when she was satisfied the Child presented wrong.
As a result, in the battle between male and female midwives, female midwives were acquiring an increasingly poor public image:
30 November, 1728.  I was desired to go to a poor woman in Milford Lane .... I found things as represented; which in a great measure proceeded from the ignorance of the Midwife: ... I rebuked her for her carelessness.

I thereupon passed my Hand into the Vagina, and found the parts somewhat swelled, by the Mid-wife too rudely handling them.

7 February, 1728: I rebuked her [the Midwife] for staying so long before she sent for help; and I soon discovered her ignorance ... The Child was born dead, which I imagined to proceed from its lying so long in the posture I found it, and the Midwife’s too long rudely pulling the Arm.
            Notes to this case:
This is one amongst many Inconveniences that occur from the ignorance of Midwives: had I been sent for most of my troubles, and the Child’s Life, might have been saved.

6 March, 1728. The Midwife that was first with her, judged wrong, and thought it was the Foot that was fallen down;  but another being sent for ... I judged that the Midwife had been pulling out the Arm, for which I rebuked her; but she faintly denied it.
… the Arm which had been so long protruded, very much swelled, and very livid, and almost separated at the Shoulder; which proceeded from the Midwife’s too rudely pulling it.

20 November, 1728:  I was desired to go into Durham Yard, to a poor woman, the wife of a Porter ... the Midwife being a Novice in her Profession, was not capable of giving proper directions.  She should have advised the labouring woman to have kept as much as possible her Throws ... but the Midwife neglect[ed] to give this advice, or to act in this manner.

27 March, 1729.  I rebuked her [the Midwife] for not sending at first, when she found it to present in a wrong Posture; but she in excuse, as is usual amongst them, told me that she had brought out many Children offering in that posture.  The Child from its having lain for some time so presented, was dead, which I told her was very probably owing to her neglect in not sending sooner, when she was satisfied the Child presented wrong.
26 August, 1729:  I was called up about two a’clock in the morning to go to a poor woman in Westminster who was then in Labour ... The Child was born dead, which proceeded, as I Judged, from its lying in so uneasy a posture, and from the Midwife’s ignorance, in not knowing how to keep up the Arm, and letting the Shoulder be so pressed against the Os internum.
Case XC
9 November, 1729:  ... all which was owing to the Mother’s not sending for the Midwife in time: for as soon as the Midwife found, by passing her fingers, that the Hands presented, she sent for me.  This is what Midwives seldom do; trusting too much to, and depending on their own sufficiency, which very often occasions the loss of the Child, and sometimes of the Mother, and if not either of these, gives very great trouble and difficulty to the Man-midwife.

Several reports specifically specified problems that followed when a midwife failed to deliver the placenta, so that it was left in the uterus:
Case LXXVII Placenta in the Uterus
13 July, 1729:  I rebuked the Midwife for not sending sooner, telling her the danger she had exposed the poor Woman to by her delay.  She in excuse answered me that she had never had such an accident before, altho’ she had been Midwife above eleven years: however I found she was very ignorant. 
6 February, 1727.  Gifford reported that three babies had been safely delivered but that the midwife had been unable to deliver the placenta. When she was called away another midwife attended but would not attempt to deliver the placenta in case she was held to blame should the mother die.  Although a doctor was called, he did not attend but prescribed medicine which, in Gifford’s opinion: would of consequence encrease the Flooding, and so hastened her Death.

Nevertheless, even in this case, Gifford’s censure was reserved for the midwives:
... so that this woman fell a Sacrifice to the ignorance of one Midwife, and the timidity of the other, for had the Burdens been brought away at first, before she had lost so much blood, she had been in no danger of dying.
Case XCII  On the Placenta in the uterus, and the String torn away.
14 November, 1729:  I was called upon about three a’clock in the morning, to go to a poor Woman in Lutener’s Lane ... This is one among the many misfortunes that attend a Man-midwife, when he is sent for too late, proceeding from the Negligence, Supineness, Ignorance, or Self sufficiency of the Midwife.
Notes to the case:  Midwives have sometimes erred, by pulling the Navel-string they have endeavoured to bring away the Placenta, although another Child remained in the Womb.
Gifford attended the poorest women, including one resident of the workhouse and another who was unable to afford the attendance of a mid-wife:
23 January, 1728:  I was called … about two a clock in the morning, to go to a poor Woman in St. Martin’s Workhouse ... I told the Midwife, she was to blame in being so dilatory in sending [for me].

The Patient was so poor, she was laid on a hard bed on the floor, and had not common necessaries, so I ordered another Woman to take her legs in her lap.

There were few hospitals in the early eighteenth century able to provide maternity facilities and only a few lying-in hospitals were established during the second half of the century. Therefore, the presence of female relatives or midwives was essential for normal deliveries throughout the century.
Gifford was one of the first men to use forceps, outside the famous Chamberlen family, and this aspect of midwifery will be considered in my next blog.

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[1] 3 Hen. VIII, c.11 (1511/12) An Act concerning Physicians and Surgeons.
[2] Man-midwifery dissected, accessed 30 August 2013.

Saturday, 17 August 2013

Health Care and Mental Illness, now and then

“Vulnerable people deserve to be fully protected at all times, particularly when they need to be deprived of their liberty in their own best interests. However, there are still unacceptable variations across the country.”

Sadly, this is not an apposite quote found in the archive of State Papers, taken from an eighteenth or nineteenth century commission enquiring into the need for county asylums and workhouses. Instead, it is a Department of Health response to Charlie Cooper’s twenty-first-century investigation into reports that that doctors are sectioning mentally ill patients unnecessarily, as a means of gaining access to a bed in a psychiatric ward:, The Independent, 14 August 2013.

The article happens to coincide with my own research on responses to medical and mental health welfare of the poor during the eighteenth century, both at a community level (using poor relief records for Thames Ditton, Surrey) and within the legal system (based on quarter session and assize records for Yorkshire).

The Poor Relief Act 1601 made provisions for the general welfare of the poor, requiring each parish to make provisions, inter alia, for the care of its ‘lame, old and blind’.[1] Major developments in the establishment of voluntary hospitals occurred during the eighteenth century, which witnessed the opening of Guys hospital and the Westminster in London, the Edinburgh Royal Infirmary, Scotland, Addenbrooke’s hospital, Cambridge, and the Bristol Royal Infirmary in the first half of the century. In the second half of the century other voluntary hospitals opened in the new industrial cities, including the Manchester Royal Infirmary, the Birmingham General and the Glasgow Royal Infirmary.[2] While the country remained dependant on voluntary hospitals, until the creation of the National Health Service in the twentieth century, during the nineteenth century local governments were at least required to oversee the provision of isolation hospitals, asylums, workhouses and infirmaries for those in poverty requiring long-term care.

Wherever possible, the infirm were cared for within their own parish. Poor relief records for Thames Ditton during the eighteenth century provide evidence of medical payments to doctors and others who attended the poor and infirm. In May 1736, five shillings was paid for the expenses of engaging a midwife for a pregnant woman; £1 1shilling to Dr Waterhouse for setting a boy’s collar bone; and 6s 2d for burying a man. As there was no infirmary in Thames Ditton, one shilling was paid to carry a boy to the hospital in neighbouring Kingston upon Thames, presumably for a more serious ailment than could be managed locally.[3]

The parish was equally responsible for those in its community who suffered with mental illness. People with a mental illness might be cast out by their families, in which event those who were deemed harmless might be left to cope as best they could. Those who were considered dangerous could be confined in gaols, poor houses or private homes, where they were likely to receive little care and controlled or restrained through the use of physical force and chains. Private asylums became increasingly common during the eighteenth century, housing both the relatives of the rich and paupers boarded out by their parishes. As with the early poor houses, asylums were unregulated and might be concerned in the care of only one person or the housing of a hundred patients. Nevertheless, whatever their size, asylums were intended to be run for profit and were reliant on public donations for their existence.

The Hospital of St Mary of Bethlem (Bedlam) in London was founded in 1247 to shelter and care for homeless people and by the early fifteenth century it began to focus on the mentally ill. Bedlam became a popular visitor attraction from at least the late sixteenth century and was notably portrayed in a scene from William Hogarth's ‘A Rake's Progress’ (1735). Public visitors were allowed as means of raising hospital income and donations from hospital visits to Bedlam raised between £300 and £350 per annum between 1720 and 1770.[4]

Just as an increasing number of voluntary hospitals were established across the country during the eighteenth century, likewise the first hospitals for the insane opened in Norwich (1713), St Luke’s in London (1751), Manchester (1766), Newcastle (1767), York (1777) and Liverpool (1790).[5] However, until the early nineteenth century there was no system of county or borough asylums for the insane in England. In the meantime, those in need of support for temporary or long term mental health issues were reliant on the many provincial madhouses established during the eighteenth century. One such establishment was situated in Great Foster House, Egham.[6] Parish records for Thames Ditton in August 1759 record payments totalling £4 12s 6d incurred in escorting Robert Pryor to Egham madhouse.[7] Running a private madhouse must have been a fairly profitable business, as Daniel Defoe estimated that in 1724 there were fifteen private madhouses in just the London metropolitan. Defoe was, however, a critic of the ease with which people could be confined in madhouses and was an active lobbyist for their regulation.[8]

Wornham Daniel first appeared in the overseers’ accounts for Thames Ditton in 1750, details of which are set out in Table 1 below, following which the parish bore the costs of keeping him in London’s Bedlam for almost three years and subsequently paid for his care in the community.
Table 1. Cost of carrying Wornham Daniel to Bedlam hospital.
1 July 1750
Expenses for Wornham Daniel getting him to Bedlam as follows:
Taking him in custody
Dame Oxley attending him
Keeping him 7 days
A journey to London to get petitions
Paid to the clerk
Paid for getting the petition signed by justices
To London to attend the committee with the petition
Mr Dean to London with a letter to attend the committee
Myself a journey to London for Bondsmen to give their names
Paid to the treasurer
Paid to the clerk
Paid to the steward
Expenses upon the road to London
Mr Deans journey to London
Paid for a key and mending a chain
Myself and two horses and cart carrying Wornham Daniel to Bedlam
3 trusses of straw for his use

Daniel spent intermittent periods in Bedlam between 1750 and1753 during which time additional expenses were incurred on his behalf by the parish, including payments for clothes, bedding and board. In September 1752 Daniel returned to the parish for a short period and payments were made to Mr Keel for his board in the poorhouse, otherwise used for the care of pauper children, and to Mrs Keel for making two shifts for him. In 1753 Daniel returned to Bedlam and then back to Thames Ditton, at which point he lodged (at the expense of the parish) with Mr Gardiner for five shillings a week until May 1756. It is possible that Daniel went through a period of greater lucidity between June 1756 and July 1760, when he received a direct pension of four shillings a week. After that date it is likely that he was admitted to the workhouse, as he disappears from the parish records.

What care would Daniel have received in Bedlam? James Monro held the post of Bethlem physican from 1728 to 1752, following which other men from the Monro family held the same post, without interruption, until the 1850’s. The hospital regime was a combination of punishment and prayer and, while it was considered a religious duty to care for people afflicted by mental illness, cold bathing, isolation and corporal punishment were believed to cure certain conditions.[9] The hospital inventory for this period includes chains, manacles, locks and stocks, although the use of physical restraints may not have been considered particularly unusual at a time when similar items appear in the inventories of private gaols.

Public concern for the mad and the bad.

Just as John Howard voiced concern about the state of England’s gaols in the 1770’s,[10] similar unease about the state in which many of the insane were kept resulted in the passing of a statute in 1774 which required five commissioners from the Royal College of Physicians to inspect private asylums in London, and justices of the peace to visit and license provincial asylums.[11]


The Hospital for Lunatics. Bethlem Hospital, London: the incurables being inspected by a member of the medical staff, with the patients represented by political figures, Drawing by Thomas Rowlandson, 1789. © Wellcome Library, London.

Mental illness and the legal system.
 According to Michael Spurr, NOMS (National Offender Management Service) Chief Operating Officer, 2010, at any one time ten per cent of the prison population have ‘serious mental health problems’[12]
An emerging awareness of insanity during the eighteenth century required a new vocabulary in the courts to describe mental states, which in turn affected gendered interpretations of criminal responsibility.[13] However, as in many areas of life, gendered interpretations were often overlaid with issues of social class and the deserving versus the not so deserving poor. For example,  although there was an increasing awareness of temporary insanity arising from pregnancy and childbirth, it is likely that until the 1770’s a defence to a criminal charge based on the mental health of a new mother was more likely to be available for a married woman than a single mother.[14]

At a time when prisons were run privately, for profit, the conditions of prisoners were very much dependant on their ability to pay for the removal of shackles, the provision of bedding and sufficient food beyond a basic diet of bread and water.

The Felons court-yard … is too small, and has no water … The cells are in general about seven feet and a half by six and a half, and eight and a half high’ close and dark’ having only either a hole over the door about four inches by eight, or some perforations in the door … In most of these cells three Prisoners are locked up at night; in winter for fourteen to sixteen hours: straw on the stone floors; no bedsteads.

Women-felons are kept quite separate: they have two courtyards, but no water.

The county pay an inspector to weigh and deliver bread to the prisoners twice a week.[15]

Nevertheless, in the 1720’s Yorkshire, a pregnant woman suffering from possible epilepsy might be committed to gaol pending her trial for a felony. A magistrate for Beverley wrote the following note to the gaoler at York Castle: “I send you two women one of them big with child & troubled with fits so if you should let her have the use of a bed for a while I will set you a reasonable allowance for it”.[16] It is notable that no mention is made of any additional allowance for a supplement to her diet.

It is possible that judges and juries paid attention to mental states when seeking extenuating circumstances which might mitigate the harshness of the ‘Bloody Code’, that is, the rising number of capital offences created between 1680 and 1820. The defence of insanity was not a solution readily sought, as it first required an admission to the crime alleged in order to minimise the ensuing sentence. However, if the defence failed, an admission of guilt resulted in the defendant being sentenced for the full offence alleged. The test for criminal insanity was not fixed until McNaghten’s case in 1843. Before then, courtroom vocabulary varied from case to case in the attempts to negate an accused’s ability to form the necessary ‘intent’ or mens rea for the crime alleged. For example, when a coroner’s jury in Yorkshire identified Robert Barker as having caused the death of Mary Issott by beating, they further determined that at the time of the incident Barker was “of insane mind and memory”.[17] Barker was acquitted of murder at the following assizes on the grounds that he was incapable of forming the intent for either murder or manslaughter.

However, Barker’s case cannot be taken on face value as evidence of a changing attitude to mental illness. Barker was described in the coroner’s records as ‘a gentleman of Beverley’. It is impossible to say whether his plea was genuine or if his social status, combined with an ability to pay for legal advice and representation, was the reason for the success of the plea of temporary insanity, thus avoiding a capital conviction.
Sadly, 300 years on, too many people with mental illnesses continue to be sent to prison rather than receiving treatment, while Stephen Dorrell (Health Secretary, 1995-1997) acknowledges that mental health services are under disproportionate pressure from local healthcare cuts.[18]

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[1] 43 Eliz., I c.2 (1601) The Poor Relief Act.
[2] The voluntary hospitals in history,, accessed 17 August 2013.
[3] Surrey History Centre, Woking (SHCW) 2568/8/1-4 Overseers’ Accounts, 1704-1808.
[4] Andrews, Jonathan, Asa Briggs, Roy Porter, Penny Tucker and Keir Waddington (1997) The History of Bethlem, London and New York: Routledge.
[5] Bewley, Thomas (2008) Madness to Mental Illness : A History of the Royal College of Psychiatrists, London: R.C. Psych. Publications.
[6] MacKenzie, Charlotte (1992) Psychiatry for the Rich: A History of Ticehurst Private Asylum 1792-1917, Abingdon, Oxfordshire: Routledge.
[7] Surrey History Centre, Woking (SHCW) 2568/8/1-4 Overseers’ accounts 1704-1808.
[8] Defoe Daniel (1697) An Essay upon Projects, London: Cockerill.
[9] Scull, A C MacKenzie and N Hevey (1996) Masters of Bedlam: The Transformation of the Mad-Doctoring Trade, Princeton University Press; From Bethlehem to Bedlam  - England’s First Mental Institution,, accessed 12 August 2013.
[10] Howard, John (1777) The State of the Prisons in England and Wales, Warrington; 14 Geo. III, c. 59 (1774) Health of Prisoners Act.
[11] 14 Geo. III, c. 49 (1774) Madhouses Act.
[12] Prison Reform Trust (2010) ‘Mental Health Care in Prisons’, accessed 17 August, 2013.
[13] Rabin, D.Y. (2004) Identity, Crime and Legal Responsibility in Eighteenth-century England, Basingstoke: Palgrave Macmillan.
[14] Rabin, Identity, Crime and Legal Responsibility, pp. 97, 103.
[15] Howard, John (1777) The State of the Prisons in England and Wales, Warrington, pp. 397-398
[16] East Riding of Yorkshire Record Office, QSF 48/04, letter from Thomas Stillington to Mr Ward, keeper of York gaol, 29 March 1720.
[17] The National Archives, ASSI 44/54, coroner’s report on the death of Mary Issott, 22 April 1739.