The Left Atrium ˇ De l'Oreille Gauche

History's labour Expiation and celebration Not just a pretty face Food for the soul Marrying the coats Mentor times two The Canadian Audubon Models of extravagance

Northern lights Failed utopia A pioneer in modernism Transformations Photography of place Art of persuasion Vancouver, Varley, Vanderpant

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

"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-midwife" William Smellie (1697­1763) 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 (1560­1631), 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.

Gynecology was largely an American construct, created in part to correct the ravages of obstetric — and midwifery — 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 (1771­1830). His unanesthetized patient was Jane Todd Crawford, 47, who travelled 60 miles on horseback bearing her ovarian cyst from her log farmhouse to McDowell's knife and, perhaps unsurprisingly, lived to age 78. James Marion Sims (1813­1883) 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 man-midwives, 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.

Philip F. Hall, MD, BScMed
Department of Obstetrics and Gynaecology
University of Manitoba, Winnipeg

Send a letter to the editor Envoyez une lettre à la rédaction

1. Rueff J. The expert midwife, or an excellent and most necessary treatise of the generation and birth of man. London: 1637. Translated from De conceptu et generatione hominis of 1554. Rueff was a surgeon who argued that midwifery was the "peculiar business of women ... only sacrificed to men by default of learning."
2. Fraser A. The weaker vessel: woman's lot in seventeenth century England. London: Methuen; 1985.
3. Hall PF. Rethinking risk. Can Fam Physician 1994;40:1239-44.
4. Diamond J. Guns, germs and steel: the fates of human societies. New York: W.W. Norton; 1999.
5. Sharp J. The midwives book, or the whole art of midwifery discovered. London: 1671.

[Contents]

Patients and doctors: life-changing stories from primary care
Edited by Jeffrey Borkan, Shmuel Reis, Jack H. Medalie and Dov Steinmetz
University of Wisconsin Press, Madison, WI; 1999
228 pp. US$24.95 (cloth) ISBN 0-299-16340-7

Patients and Doctors: Life-Changing Stories from Primary Care is an anthology of anecdotes contributed by no less than 47 authors. One or two of the authors are respected colleagues, several are friends and acquaintances, some have names so familiar to me it seems I know their owners although we have never met. The others have the kind of profile that tells me we could talk. Each one has an interesting story to tell. Each one has sought sense in an apparently senseless world, and I commend them for their highly readable, personal testimonies.

I believe that doctors write for two reasons, expiation or celebration. Expiation: seeking to exorcise a personal demon, searching for forgiveness of a professional error whether real or perceived. Celebration: recording with admiration the many facets of the human spirit it is our privilege to observe and the remarkable heights to which it soars.

When I was in practice in Glasgow many years ago I looked after two elderly sisters who lived together and seemed to get a lot of respiratory infections. They came to my office most of the time, and it was unusual for them to request a house call. They did on one occasion and I was surprised to see that the reason given was "both very sick." I've often said that you learn more about people in one house call than in a lifetime of office visits. This was one of the experiences that shaped that opinion. The sisters lived in a small but absolutely spotless home in a quiet cul-de-sac. I was ushered into the parlour and left for a few minutes while the ladies got themselves ready for examination. In a cage by the fireplace was Onan the budgerigar. Aloof and inscrutable, he ignored my efforts at conversation. There were pictures on the piano of two men in World War I uniforms. I found out later that both had been killed at the Dardanelles, one the husband and the other the fiancé of my respective patients.

The sisters had remarkably similar problems. Each gave a history of a few days of malaise, fever, cough and increasing chest discomfort. Examination of both found nothing but low-grade fever and a few crackles over the right middle lobe in the mid-axillary line. How very odd! Inspiration struck me and I went to some trouble to get blood samples from both ladies tested for psittacosis antibodies. This would have been around 1969; general practitioners had little access to diagnostic facilities in the National Health Service of the day, and the concept of atypical pneumonia as a specific syndrome hadn't quite reached communal consciousness, certainly not mine.

The laboratory report came back just before I had arranged a return visit, and I was just tickled pink to find their psittacosis antibody titres sky high! They had both improved on the tetracycline I had prescribed but seemed less than impressed with my news that their budgerigar was making them sick and would have to go. That's when I was informed that his name was Onan. One of the sisters remarked enigmatically, "He's a very messy eater, doctor." I had expected praise and even admiration for an astute piece of diagnosis, but, to my chagrin, what was eventually forthcoming was a reluctant statement to the effect that they would change doctors rather than get rid of Onan. We eventually reached a compromise — my introduction to patient-centred medicine — and Onan went to the vet for a micro-dose of tetracycline or whatever sick budgies get.

I suppose that's by the way of both expiation and celebration. Education as well, as I found out later why the budgie was called Onan. My patients, observant Presbyterians who knew their Bible, pointed out to me that Onan was the second son of Judah and Bathshua, ordered to impregnate Tamar, his brother's widow. Whenever I feel that my ego is getting a bit too inflated, I remind myself of the beloved budgie who, like the Onan of Genesis 38:9, "spilled his seed upon the ground"!

Read Patients and Doctors. It is full of life-affirming stories that will challenge you to place your professionalism within the context of your patients' lives.

James McSherry, MB ChB
Professor of Family Medicine
University of Western Ontario, London

[Contents]

Making the body beautiful: a cultural history of aesthetic surgery
Sander L. Gilman
Princeton University Press, Princeton, NJ; 1999
396 pp. US$29.95 ISBN 0-691-02672-6

Gilman opens the book with the statement that "in a world in which we are judged by how we appear, the belief that we can change our appearance is liberating." Central to his thesis is the concept of "passing." Aesthetic surgery can allow a person to "pass" in a desired social group. It changes not only the present but also the future,"overrides the genetic code," and has been used on every conceivable part of the body.

"Passing" depends on many factors, including historical context, age and sex, and racial or ethnic issues. In earlier times, fat was perceived in some cultures as a positive sign of prosperity. By contrast, by the end of the 19th century it was usually perceived negatively, as a sign of poor health. Today the young and the old want to "pass" as slim and fit, and older people want to "pass" as younger.

"Passing" is often culture dependent. Breast size is cited as a classic example. Breast reduction has become commonplace among upper-middle-class Brazilian families to distinguish their daughters from the lower classes. "Brazilian breast reductions" are often given to young women as "sweet-sixteen" birthday presents, enabling them to "pass" as members of a more erotic cohort and find appropriate mates. By contrast, Argentinian women, who have the highest rates of silicone implantation in the world, are much more likely to pursue breast augmentation, fulfilling the "Spanish fantasy" of the large-breasted woman as the icon of the erotic. By comparison, standards of breast beauty in Europe shifted between the 19th and 20th centuries. Smaller breasts became associated with a new erotic image, enabling a woman to "pass" into the age of the "New Woman."

Gilman's many references to racial difference may seem somewhat provocative. Taken in context, however, they serve to emphasize the cultural determinants of aesthetic norms. Gilman relates that Israel has become the aesthetic surgery capital of the Middle East, where the most common procedure among both men and women is rhinoplasty. He describes a Jewish girl who undergoes the procedure to "pass" as more Gentile. In young men, aesthetic surgery is usually performed before compulsory military service so that they can look like their peers. In some instances, the urgency of disguising racial origins diminished with the dawning of ethnic pride and with greater racial tolerance. More subtle changes in ethnicity were in order. One can look different, but not too different. It may be desirable for Japanese people to appear Japanese, but not too Japanese. Thus, 32 different operations have been developed in Japan to create a westernized double eyelid-fold.

Throughout the book the evolution of aesthetic surgery is traced from the quack beauty doctors of the 1880s to the modern, board-certified aesthetic surgeon of today. The designation of this surgical specialty also changed, from "cosmetic" to "esthetic" to "aesthetic," as the specialty seemed to emerge with a classical lineage. Aesthetic surgeons overcame their low status to attain respectability and even adulation. Contributions from reconstructive surgery are recognized, particularly procedures to restore the collapsed syphilitic nose and the soldier's face ravaged by war. Surprising contributions are described from well-known figures not generally considered to be "aesthetic surgeons." These include Ambroise Paré, Theodor Billroth and orthopedic surgeon Jacques Joseph.

There are many graphic descriptions of early surgical procedures. In 1892 Robert Weir brought a live duck into the operating theatre, killed it, and used its fresh sternum to rebuild the collapsed syphilitic nose of a 26-year-old man. There are vivid reports of paraffin being injected into breasts, faces and other anatomical areas, resulting in dreadful complications. There is a memorable story of a German lad who, after winning a lottery, consulted an aesthetic surgeon with the hope of surgically creating artificial duelling scars so that he could pass as a man of honour. The surgeon refused. Subsequently, the man sought treatment from a barber, who obliged with a straight razor, causing severe damage to the salivary glands.

This is a well-informed and engrossing study of a hot contemporary subject. It will be valuable to plastic surgeons and to other physicians who are interested in a comprehensive history of the cultural and aesthetic side of plastic surgery.

Walter Peters, PhD, MD
Professor of Surgery
University of Toronto

[Contents]

Doctors afield
Edited by Mary G. McCrea Curnen, Howard Spiro and Deborah St. James
Yale University, New Haven, CT; 1999
264 pp. US$27.50 (cloth) ISBN 0-300-08020-4

There are two biographical sketches that don't fit the model: those of Carlo Levi and Gertrude Stein. Levi practised medicine, under duress, for only a short period long after his graduation. Stein failed obstetrics in her final year at Johns Hopkins and never graduated. Some people should never go into medicine, but this is not the book's message. Thus I would have much preferred that those spots be given to a couple of star physician­writers who could reflect on medicine and creativity. That would have maintained the central theme and provided a much better counterpoint. So, the field in Doctors Afield is a little spotty, but there are some very fertile patches.

Eli Newberger is a pediatrician who does weekly sessions on the tuba with the New Black Eagle Jazz Band. He tells us about creative inspiration, the magic of improvisation and its prospect of mistakes. Mistakes in medicine can destroy lives, but in jazz improvisation they become a platform for new ideas and redemption. Eli's music has the power to transport him into a state that is not, "strictly speaking, a conscious process." We learn that the joy and release of his music enables him to deal in his professional life with issues such as child abuse and family violence.

In "A Prescription for Poetry," internist Rafael Campo provides a window on specific medical problems versus much larger, more complex societal problems. While trying to concentrate on radiographs of a battered woman's facial fractures he finds instead that he hears the soft, impatient tapping of her husband's foot outside in the emergency room. "Poetry is there when the last of our gizmos and gadgets fail us; ... it helps us gauge that which cannot be assayed in the blood, to see what cannot be imagined."

In "The Singing Endocrinologist," Alice Levine tells us that early in her training she observed the energy and efficiency her two careers provided: "diversions made studies easier, not more difficult." Like Anton Chekhov, who saw medicine as his lawful wife and literature as his mistress, Levine likens a career in music to climbing in sand, whereas medicine is always there, reliable. Both careers are about communicating, and she successfully fuses them into a rewarding life.

The section on spirituality is timely, moving and courageous. In the 19th century, Oliver Wendell Holmes argued strongly for a rational base for medicine that excluded religion. Today in Boston, Ray Hammond and Gloria White-Hammond, with a mission to "serve others as we are led by the Holy Spirit," have transcended barriers of class, gender and race to produce a modern-day miracle. Among other things, their coalition adopts gangs. Guess what has happened to the murder rate in Boston? I am sure that Holmes would be impressed.

Alan Mermann, in "Looking for the Red Line," and John Young, in "Priest in the Prison," are equally convincing on the need to appropriately access the soul to sustain the doctor and heal the patient.

There are lessons to be learned from careers in the visual arts. Andrea Baldeck, an anesthesiologist, was so fulfilled by her photography career that medicine lost out. Sir Roy Calne, a pioneer transplant surgeon, used his surgeon's eye for anatomy as a stepping stone into the world of art and then got lessons from one of his patients, a noted Scottish artist. Wayne Southwick discovered the connection between orthopedics and sculpture and used his second career as a successful bridge into his retirement.

"Getting Famous," by Michael LaCombe, an internist from rural Maine, is the piece that I liked best. His journey as a physician­writer has not been smooth and effortless. He reveals this in a wonderfully literate manner and packs in a whole lot of good advice along the way.

Read Doctors Afield. You will be nourished and renewed.

Ian A. Cameron
Department of Family Medicine
Dalhousie University, Halifax

© 1999 Canadian Medical Association or its licensors