Prescribed Norms: Women and Health in Canada and the United States since 1800 9781442686557

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PRESCRIBED NORMS

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PRESCRIBED NORMS Women and Health in Canada and the United States since 1800

Cheryl Krasnick Warsh

University of Toronto Press

Copyright © University of Toronto Press Incorporated 2010 www.utphighereducation.com All rights reserved. The use of any part of this publication reproduced, transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, or stored in a retrieval system, without prior written consent of the publisher—or in the case of photocopying, a licence from Access Copyright (Canadian Copyright Licensing Agency), One Yonge Street, Suite 1900, Toronto, Ontario M5E 1E5—is an infringement of the copyright law.

library and archives canada cataloguing in publication Warsh, Cheryl Lynn Krasnick, 1957– Prescribed norms : women and health in Canada and the United States since 1800 / Cheryl Krasnick Warsh. Includes bibliographical references and index. ISBN 978-1-4426-0061-4 (pbk.).—ISBN 978-1-4426-0359-2 (bound) 1. Women—Health and hygiene—Canada—History. 2. Women—Health and hygiene—United States—History. 3. Women’s health services—Canada—History. 4. Women’s health services— United States—History. I. Title. RA564.85.W37 2010

613'.042440971

C2009-906445-6

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Contents

List of Illustrations ................................................................................................................. vii Acknowledgements ..... .......................................................................................................... ix Introduction............................................................................................................................... xi

part i: rituals ...................................................................................................... 1 chapter One: Wendy’s Last Night in the Nursery: The “Disease” of Menstruation and Its Treatment ....................................................................... 3

chapter Two: Gladys, Take Your Medicine! The Culture and Business of Menopause ............................................................................................. 47

part ii: technologies ....................................... ..................................... 77 Chapter Three: Traditional Childbirth: Mothers and Babies ................ 79 Chapter Four: Modern Childbirth: Mothers and Doctors .................. 117 Chapter Five: Future Childbirth: Doctors and Babies ............................. 153 part iii: professions ........................................................................... 173 Chapter Six: Networks of Support, Networks of Opposition: The Medical Education of Women ........................................ ................................... 175

Chapter Seven: Nursing: The Science of Womanly Arts..................... 223 Epilogue: The Case for Chaos ..................................................................................... 271 References ............................................................................................ .................................. 275 Index . ................................... ....................................................................................................... 305

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Illustrations

Figure 2.1 Wicked Witch: Traditional Image of Aging Beggar-Woman ................ 50

Figure 6.1 Doctor and Patient, BC Cancer Institute, 1940s .................................194

Figure 6.2 Maude Abbott with Unidentified Nurse and Child ...........................195

Figure 7.1 Nurses Studying, Hôtel-Dieu Hospital, Campbellton, New Brunswick .........................................................................237

Figure 7.2 Unidentified Nursing Sister, No. 5 Canadian General Hospital, 1915–19....................................................................... 260

Figure 7.3 Jean Cuthand, Canada’s First Aboriginal Registered Nurse ............... 266

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Acknowledgements

The gestation of this book was way, way beyond that of any

known mammal on this planet. Its conception was an act of foolhardiness, occurring simultaneously with another research project on tobacco, a seven-course teaching load, the editing of an international journal, and the raising of a pre-schooler. On the other hand, researching tobacco sensitized me to issues of body image in marketing; lecturing on Canada, the family, popular culture, and health helped me to crystallize historical literature; and editing the Canadian Bulletin of Medical History/Bulletin canadien d’histoire de la médecine gave me the opportunity to read in fields beyond my own — ranging from medieval hospitals to Latin American epidemics to Galenic medical philosophies — and to make connections I otherwise would have missed. Even the pre-school environment produced insights, as I hope you will agree when reading my personal take on Disney’s The Little Mermaid (see Chapter 2). I was also helped by the continued support and wise counsel of many colleagues and friends. Many thanks to Veronica Strong-Boag, Wendy Mitchinson, Michael Bliss, Bill Seidelman, and Janet Golden, as well as to my colleagues on the board of the Canadian Bulletin of Medical History/ Bulletin canadien d’histoire de la médecine. Thanks also to Penny Tinkler, my collaborator from Manchester. Many thanks to my present and past colleagues in the Department of History, Faculty of Arts and administration at Vancouver Island University who have facilitated my research and who make this institution a very pleasant place to work: John Lepage, Steve Lane, Ross Fraser, Liz Hammond-Kaarremaa, Helen Brown, and the late Clarence Karr, as well as Stephanie Buckingham from Nursing and Laurie

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Meijer-Drees from First Nations Studies. Thanks also to my students, who have contributed their own stories. This project necessitated extensive assistance from support and library staff including Cheryl Coburn, Ros Davies, Faye Landels, Sheila Davidson, Lyn Makepeace, Jennifer Brownlow, and Jennifer Franklin, and student research assistants Wendy Cann, Mariah Moyen, Deb Stackhouse, Tim Percival, Beth McGarragher, Brian Donald, and Marine McDonnell. The support of my editors, Don LePan at Broadview Press and Michael Harrison, Betsy Struthers, Tracey Arndt, and Natalie Fingerhut at University of Toronto Press Higher Education, is appreciated. The generous research support of a Hannah Development Grant from Associated Medical Services Inc., the Social Sciences and Humanities Research Council, and Vancouver Island University is gratefully acknowledged. Portions of Chapter 2 were previously published in “Gladys! Take Your Medicine! Menopause in North American Popular Culture since 1800,” in Margaret C. Wiley, ed. Women,Wellness, and the Media (Newcastle: Cambridge Scholars Publishing, 2008): 230–50. This work is dedicated to the cherished memories of my mother, Ruth Rachel Broter Krasnick, and my father, Jack Gerald Krasnick; to my loving husband Michael Lawrence Warsh; and to my treasured daughter, Sarah Rachel Warsh.

Introduction

In the first decade of the new millennium, north american

women are facing very interesting and paradoxical times with respect to their health. The improvements in therapeutics and outcomes have been tremendous over the past 200 years. In 1800, a woman going into labour, whether she lived on a farm or in a city, did not know if she would live through the ordeal or if her child would survive his or her first year. Knowledge about her reproductive cycle — menstruation and menopause — likely would have been passed on from her mother or other female family members or friends, or from a midwife, or simply learned from personal experience. Certainly it was not a topic for discussion in mixed company nor debated in public outlets such as newspapers, magazines, or university classrooms. She might be involved in offering healing on an informal basis as part of her role as mother, daughter, or neighbour, or perhaps she worked more formally as a community midwife, as a monthly nurse in a town or city, or as a sister in a Catholic nursing order. Nevertheless, twenty-first-century North American society still provides challenges to women’s health. In 2007, 46 million Americans, or 18 per cent of the population under 65, were without health insurance.1 This has particularly negative impacts upon women, since they are more likely to have part-time or low-paying jobs that do not have health coverage plans; they may be covered by their spouses’ plans, which would be severed by divorce; and, if uninsured, they will postpone various diagnostic treatments such as Pap smears, which can catch cancers at an early stage.2 In Canada, Medicare provides basic coverage to all residents, yet rising costs and shifting priorities at the government and health administrative levels have chipped away at certain coverages (e.g., respite and other support xi

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services and long-term care facilities) so that supplementary insurance is required to access all necessary services. Lives can be extended through sophisticated surgical interventions following diagnoses in state-of-the-art MRI machines, but those lives can then be lost in understaffed, unhygienic nursing homes or in isolated apartments. While the neglect of the elderly affects both sexes, there are many issues unique to women. Therapies and technologies that were the stuff of science fiction 75 years ago may be interpreted and distributed to women in very traditional terms today. Models of linear progress, therefore, are not always appropriate and may be potentially dangerous to the health of women. For example, until recently menopausal, peri-menopausal, and post-menopausal women were prescribed hormone replacement therapies for extended periods, even decades. When a major American study determined the serious health risks involved, women were instructed, and many chose, to immediately cease taking the hormones. At the same time, younger women were advised that they could avoid menstrual periods altogether — the assumption being that it was an undesirable bodily function — by taking new forms of oral contraception, which would keep constant high levels of hormones in their bodies for years, even decades. The inherent contradiction in these events, and the underlying attitudes and motives that produce them, are discussed in this book. To give two more examples from February 2009: a single woman, living in her mother’s home in California, with six young children conceived through in vitro fertilization (IVF ), gave birth to another eight babies (their health status has not been revealed). She plans to pay for the octuplets’ upbringing through television interviews and a possible book deal.3 A 60-year-old Calgary woman, who had been rejected on the basis of age from local fertility clinics, travelled to India to have IVF and returned with healthy twins.4 The global free market of new reproductive technologies has triumphed at the same time as pro-life lobbyists place roadblocks to easy access to new technologies to prevent fertilization (“morning-after” pills). How governments and multinational corporations got so involved in the natural act of childbirth is also reviewed in the following pages. My interest in women’s health and women’s history was sparked by a little collection entitled A Not Unreasonable Claim: Women and Reform in Canada, 1880s-1920s (Kealey 1979), which I found in The Country Mouse bookstore in London, Ontario in 1979. Edited by Linda Kealey, it presented contributions by such other leading women historians as Wendy Mitchinson,Veronica Strong-Boag, and Suzann Buckley, and the reforms it spoke about included public health, women in medicine, and nursing. I went back to the store and asked if there were any more books on the topic; they said no, that was it. Thankfully, there was more to come.

introduction

The history of women’s health rose out of the women’s health reform movement, itself part of the second-wave feminism of the 1960s and 1970s. The American literature came first; when the Boston Women’s Health Collective published the best-seller Our Bodies, Ourselves (1973) as a selfhelp health manual, they were attempting to empower women at the most personal level.5 At the same time, they were echoing the critique of much earlier health reformers like Samuel Thomson, whose 1813 Every Man His Own Physician similarly espoused the cause of personal power through knowledge. Female sexuality, the experiences of menstruation and menopause, and the development of the American profession of gynaecology as a gatekeeper of patriarchal attitudes have been examined in lively critiques by Mary Daly (1978) and Barbara Ehrenreich and Deirdre English (1978), as well as in equally powerful historical studies by Carroll Smith-Rosenberg (1985), John and Robin Haller (1974), and, from a Canadian perspective, Wendy Mitchinson (1991). The role of childbirth in the perpetuation of patriarchal structures was examined by Adrienne Rich in her lyrical Of Woman Born: Motherhood as Experience and Institution (1976) and in the comprehensive overviews by Sheila Kitzinger (1995), Jean O’Barr et al. (1990), and Barbara Rothman (1989). Several American scholars, including Rima Apple and Janet Golden (1997; Golden 1996), approached childbirth at the individual level, situating it within the existing medical knowledge base, as well as at the structural level, relating it not only to the demarcation of women’s roles but to national interests (see also Ladd-Taylor 1994). Jane Donegan (1978) and Jean Donnison (1977) examined the elimination of midwives within the context of the professionalizing efforts of American physicians. Medical authority in this instance was created through the vilification of the female midwife. By the twentieth century, mothers themselves were subject to vilification, as discussed by Janet Golden (2005) and Molly Ladd-Taylor and Lauri Umansky (1998). Canadian scholars, including Katherine Arnup (1994) and Cynthia Comacchio (1993), similarly approached governmental, legal, medical, and religious directives affecting the childbirth experience (see also Arnup et al. 1990), while Andrée Lévesque (1994) and Denyse Baillargeon (1999) contextualized the shift in Quebec from being the province with the highest birth rate to one of the lowest. In the most in-depth study, Giving Birth in Canada, 1900-1950 (2002), Wendy Mitchinson crafted a balance between the state of medical knowledge and patient demand in the first half of the twentieth century. Reflecting contemporary movements to reintegrate midwifery as a legitimate profession, Cecilia Benoit (1991) and Lynn Bourgeault et al. (2004) analyze the practice from historical as well as present-day perspectives.

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Several collections, including those edited by Judith Leavitt (1999), Georgina Feldberg et al. (2003), Dianne Dodd and Deborah Gorham (1994), and Susan Sherwin (1998), cast a wide net concerning various aspects of women’s health and women in the health professions from historical, sociological, anthropological, and other perspectives, as well as across national borders. All maintain, however, the importance of gender in the development of medical theories, therapeutics, and technologies. This is especially true in the study of birth control, abortion, and new reproductive technologies. In several works, Angus McLaren has brought to light the much hidden practices of women in Canada and elsewhere to prevent conception and end pregnancies, despite the illegality of doing so and church condemnation (see, for example, McLaren and McLaren 1997). He and American scholars such as Andrea Tone (2001) and Rickie Solinger (2000) illuminate the human costs of turning private acts into political fodder. Many fine studies, including the work of Mary Fryer (1990), Gloria Moldow (1987), Regina Morantz-Sanchez (1985), Ellen More (1999), Barbara Sicherman (1984), Veronica Strong-Boag (1980), Mary Roth Walsh (1977) and Virginia Drachman (1984), recount the entry of women into the medical profession in the nineteenth century within the context of first-wave feminism and either overtly or subtly contrast the mutual support enjoyed by early feminist physicians with the lack thereof experienced by their later counterparts who adopted the male “objective” professional model. Nursing history, a particularly rich field in terms of scholarship in recent years, reflects professional concerns that remain consistent with those of a century ago. Historians such as Ellen Baer et al. (2001), Elizabeth Jamieson et al. (1966), Ellen Lagemann (1983), Sandra Lewenson (1993), Kathryn McPherson (1996), Susan Reverby (1987), and Janet Ross-Kerr (1998) deal with the problem of reconciling traditional female values such as caring, empathy, and sacrifice with professional goals such as status, autonomy, and material advancement, while Mary Carnegie (1995) and Darlene Hine (1989) add the factor of race to gender and professionalization.

About This Book Prescribed Norms is based on the contributions of hundreds of specialists in the fields of history, women’s studies, anthropology, medicine, biology, psychology, philosophy, literature, First Nations studies, law, and numerous other disciplines; it has been a fascinating and daunting adventure to digest and synthesize all of them. Particularly interesting has been seeing how the same event — the menstrual cycle, for example — has been viewed and

introduction

interpreted through the lenses of gynaecologists, granny midwives, public health nurses, and advertising agencies. The book is divided into three thematic sections — rituals, technologies, and professions — although certainly the themes are not mutually exclusive. In Part I: Rituals, Chapters 1 and 2 discuss the experiences of menstruation and menopause respectively, especially how these biological functions have been culturally interpreted over centuries and by peoples who inhabit North America. Menstruation has been both celebrated as a sign of maturity and fertility and dreaded as a taboo and indicator of a need to control female sexuality. Menopause, as a symbol of aging and the end of fertility, has incurred fewer positive connotations. In recent years, both female physiological functions have been medicalized and targeted for pharmaceutical, and occasionally surgical, interventions. Part II: Technologies examines the transformation in childbirth occurring over the last two centuries. Chapter 3 discusses traditional midwifery and early medical interventions that nevertheless relied primarily in “catching” rather than “delivering” infants. During this period, primarily in the nineteenth century but also later depending upon access to hospitals and physicians, childbirth was an event whose central focus was the mother and child, with the attending midwife or physician playing a supportive role. Chapter 4 analyzes the development of modern childbirth, in which medical intervention and hospitalization have become the norm for North American women and in which the medicalization of childbirth includes frequent prenatal visits and advice from a variety of experts. The role of the medical professional consequently has expanded so that since the mid-twentieth century childbirth can be conceptualized as a “partnership” between mother and physician. Chapter 5 presents many emerging trends stemming from advances in the biosciences that have extended medical intervention beyond childbirth and the prenatal period to conception itself. In this scenario, the role of the mother increasingly is diminished to that of an interchangeable vessel whose behaviours may be antagonistic to the needs of the foetus she carries. The obstetrician or genetic specialist therefore can be situated as having a direct relationship with the child. This relationship is a late twentieth- and early twenty-first-century phenomenon, but it has roots in the nineteenth century. Part III: Professions refers to women’s participation in medicine and nursing. Chapter 6 analyzes the efforts made by nineteenth-century North American women to enter the male preserve of organized medicine. The female pioneers were feminists and scientists, middle-class professionals, and radical trailblazers. They succeeded in making women a significant minority of the profession at the turn of the twentieth century, but these

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advances were stalled by a resurgence of the values of domesticity at the societal level and the institutionalization of quotas and other exclusionary policies at the professional level. Chapter 7 discusses the evolution of nursing from an informal, unregulated activity or religious calling to a profession whose demarcations have shifted depending upon financial constraints, hospital needs, and public perceptions. The epilogue presents a possible alternative to the model of linear progress in gynaecological therapeutics, a model that led and continues to lead to the development and prescription of one-size-fits-all medications, often to the detriment of women’s health. I argue that chaos theory, which recognizes that multiple factors, both direct and indirect, can influence a particular outcome, may be a future model for women’s therapeutics. It may not be the most efficient, cost-effective, or practical model for the development of drugs and therapeutics on a global level, but it may be more in keeping with the realities of female physiology and women’s lives.

introduction

Notes 1 2

3

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5

National Coalition on Health Care, “Health Insurance Coverage” (2009), http://www.nchc.org/facts/coverage.shtml. Molly M. Ginty, “US Women Lack Health Insurance, Access to Care,” Women’s E-News (2009), http://www.womensenews.org/article.cfm/dyn/aid/1757/ context/archive. Linda Carroll, “Too Many Babies: What Went Wrong? Birth of Octuplets Is Not a ‘Medical Triumph,’ Caution Fertility Experts,” MSNBC, 2009, http:// www.msnbc.msn.com/id/28902137/. CBC News. 2009. “Sixty-year-old Calgary Woman Welcomes Twins,” cbcnews.ca (5 February 2009), http://www.cbc.ca/canada/edmonton/ story/2009/02/04/cgy-twins-60yearold-mother.html?ref=rss. The Collective continues to flourish as an information clearing house and advocate of women’s health internationally. See their website: http://www. ourbodiesourselves.org/default.asp.

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rituals

Men Menstruation and menopause are natural bodily functions that have been overlaid with centuries of cultural, religious, medical, and sociob economic meanings. Diverse cultures brought to North America attitudes and rituals concerning the female reproductive cycle; nineteenth- and twentieth-century medicine provided new beliefs as well as physiological explanations of these processes. Many of these explanations were influenced by older presuppositions — also reflected in popular culture — regarding the nature of womanhood. Moreover, treating vast numbers of women for chronic functional discomforts and disorders presented economic opportunities for pharmaceutical companies by the middle of the twentieth century, with consequences that will be discussed below.

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C H A P T E R

1

Wendy’s Last Night in the Nursery THE “DISEASE” OF MENSTRUATION AND ITS TREATMENT

Introduction No function, status, or event defines womanhood so completely

and repeatedly as menstruation, and none, until the late twentieth century, has been so removed from “polite” conversation. Popular discourse has tended to be male and often profane, reflecting centuries of morbid fascination and revulsion towards this most natural of body functions. Menstruation is replete with euphemisms, including “falling off the roof, the curse, Aunt Martha’s coming to visit, my friend, my red-headed cousin, the bloods, riding the rag, flying baker (a male name, from the air force red flag for danger), my moons, that time of the month [and] my red-letter day” (Culpepper 1992, 277). Modern medicine divides the menstrual cycle into phases regulated by hormones. Days 1–51 are the menstrual or bleeding phase, when nonfertilization of the egg leads to a drop in the levels of the hormones estrogen and progesterone, followed by shedding of the top layers of the endometrium (uterus lining). Days 6–12 are the follicular phase, when the follicle-stimulating hormone produces ovarian follicles, each of which 3

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contains an egg. One of these follicles, which produce estrogen, will continue to develop. Days 13–15 are the ovulatory phase, in which a surge in the luteinizing hormone stimulates ovulation, or release of the egg. At the same time, estrogen levels peak and progesterone levels rise. Days 16–28 are the luteal phase, the last days of which are also referred to as the premenstrual phase, when progesterone levels increase and prepare the endometrium for the reception of a potential foetus. If fertilization does not occur, the menstrual cycle begins again (Asso 1983, 17; Rosenblatt 2008, 1–4). Millennia-old traditions and current attitudes, however, demonstrate that these phases and the physiological functions they represent are laden with meanings for both immigrants to North America and its Indigenous peoples. This chapter examines a variety of cultural meanings — both negative and positive — of menstruation, ranging from the persistence of blood taboos across societies to the mundane task of dealing with menstrual flow. It considers the event of menarche, or first menstruation, as a female ritual, a medical problem, and a marketing opportunity, as well as a mysterious epidemic — chlorosis. It examines the medical model of menstruation, the modern manifestation of which is rooted in classical Galenic therapeutics, and how it is used to justify the classification of menstruating women as disabled and the labelling of a natural bodily function as a disease. Finally, it explores premenstrual syndrome and toxic shock syndrome, two biomedical constructs influenced by cultural attitudes towards menstruation.

The Origins of the Blood Taboo Menstrual issue is bloody and only women excrete it; when it pauses, they may be performing the ultimate magic — creating life. For these reasons, menstruation has fascinated men. Anthropologists suggest that early man’s respect for menstrual blood was “greater than his fear of death, dishonor, or dismemberment” (Delaney et al., 1988, 7). North American Indigenous peoples discussed various taboos surrounding menstruation with seventeenth-century Catholic missionaries and nineteenth-century anthropologists. The Jesuit Relations, for instance, stated that The North American aborigines regarded a woman in her periodical illness as unclean, defiling all that she touched, but the latter race also cherished a superstitious belief that her look, or touch, or even the sight of her, had a malign influence — inducing disease, causing ill-luck in hunting or war, and bringing misfortune. In consequence, seclusion at this period was imposed by custom upon the woman,

part i: rituals

who must dwell apart from her family, in a small hut or wigwam constructed for this purpose. (Thwaites 1897, 308)

A nineteenth-century ethnographer observed that among the Omaha of midwestern North America, a menstruating woman lived apart from her family and supposedly emanated an odour children feared: “If any eat with her, they become sick in the chest, and very lean, and their lips become parched in a circle about two inches in diameter” (Thwaites 1897, 308). Many folk beliefs regarding menstrual blood persisted into modern Western culture as part of the “cultural baggage” of immigrants. Well into the twentieth century, North American women believed that a permanent wave in their hair “would not take if they were menstruating” (Delaney et al., 1988, 8). In modern Japan, a female Diet [Parliament] member was barred from an undersea tunnel “because workmen were afraid that the sea god would be angry.”2 An interesting counterpart to the male revulsion to menstrual blood is the male equivalent, in many cultures, of vicarious menstruation or blood-letting. Initiation rites, including circumcision, have been interpreted as a form of womb-envy (Brain 1988, 310). Canadian feminist Rabbi Elyse Goldstein puts this in non-Freudian terms: “Menstrual blood is women’s covenantal blood, just as brit milah, circumcision, is men’s. Women indeed have a brit inscribed in their flesh as an everlasting covenant. Women’s covenant of blood is not just once, at eight days, but every month ... This is the universal covenant which all women, not just Jews, experience” (1998, 113). The ancient practice of phlebotomy, or blood-letting, which enjoyed a revival in the eighteenth and nineteenth centuries, can also be associated with the benefits of menstruation. Its purpose was to release noxious humours through beneficial cleansing. According to Hippocrates of Cos (460–377 BCE), considered the father of Western medicine, human health was maintained by the balance of the four bodily fluids or humours, each of which was associated with a natural element: blood/air, yellow bile/ fire, black bile/earth, and phlegm/water. Imbalances caused illnesses, and therapies were developed to correct them.3 The periodical release of blood was interpreted as both a healthy purging for women and evidence of the superiority of the male physiology, since men had no need for such a purge. Some men, however, did not share that conclusion. The Jesuit fascination with menstrual taboos and practices among Indigenous peoples perhaps reflected the spiritual benefits of blood-letting, through self-flagellation and other means, in Western monasticism (Brain 1988, 312–13). Canadian and American Jews and Christians, whose liturgy includes the Hebrew Bible, have evidence of an ancient menstrual taboo in the Niddah laws, as related in Leviticus 15, 19–20: “When a woman has a dis-

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charge of blood which is her regular discharge from her body, she shall be in her impurity for seven days, and whoever touches her shall be unclean until the evening. And everything upon which she lies during her impurity shall be unclean; everything upon which she sits shall be unclean.” However, Rabbi Goldstein argues that this passage has been taken out of context and improperly translated: The Torah4 is vitally concerned with repopulation. In that sphere, sexuality is the conduit for birth ... sexual fluids need to be controlled in the same way that sexuality needs to be controlled.... Men and women stood equally on that tightrope. Our ancestors understood the highly charged power of the symbolism of both semen and menstrual blood. They were awed and disturbed by both of them equally. Those who discharged either substance ... were rendered ritually impure. (1998, 101)

The impurity, therefore, was not physical uncleanliness but lack of sufficient purity on the part of either sex to approach the sacred Temple. After its destruction and the increasing influence on Jewish society of Roman values (in turn influenced by the Greeks), menstrual blood was associated solely with female dirt or pollution. This taboo remained within the Judeo-Christian cultures that populated Canada and the US. The Jesuits and later ethnographers who observed Native menstrual rituals similarly misread them by not seeing “the element of holiness, retaining only the element of taboo” (Goldstein 1998, 110). Early agrarian societies celebrated menstruation as part of the cycle of birth, death, and rebirth, according to anthropological studies of North American Native practices: In spite of the taboos and the restrictions to which she was obliged to adhere, for a married woman the menstrual period provided a few days during which she could enjoy relief from routine and arduous obligations. She was in a sense an “untouchable” but not in a manner detrimental to her own well-being. She was free to relax and rest and to occupy herself in her days and nights of isolation with whatever pastime she favoured. (Terrell and Terrell 1974, 141)

Perhaps one reason the blood taboo has persisted for centuries is that in some cultures, the “victim” is barred from household labour, childcare, and other duties for a few days every month. Whether kept apart from their families or mobile in their communities, menstruating women dealt with their discharges in methods associated with taboo and hygiene. In many traditional societies they used pads

part i: rituals

devised from grass or root fibres to absorb the blood, while other women were isolated in huts and squatted on grass mats that would later be burned. Tampons have a long history. Ancient Egyptian women “inserted rolls of soft papyrus into the vagina” while Indonesian and Japanese women, among others, also rolled materials derived from vegetables, wool, and paper to function as tampons (Farrell-Beck and Kidd 1996, 331). In the seventeenth century, Englishwomen and their medical advisors devised pessaries from wool, linen, or silk, often containing herbs or other formulations for amenorrhea (lack of menstrual flow) or profuse menstrual bleeding (Crawford 1981, 55). North American Native women washed the “soft and pliable buffalo-skin smoke flaps from their lodges,” which they would then cut into small pieces (Terrell and Terrell 1974, 142). Many folk beliefs of the peoples who immigrated to Canada and the United States had vestiges of the humoral theory of beneficial purging, such as the concern with facilitating an adequate flow. Some Filipino women, among others, believe that bathing, especially in cold water, during menstruation would stop the flow and cause illness (Berger 1999, 7). At least until the 1970s, Newfoundland women living in isolated outport communities shared folk beliefs concerning the release of a plethora of blood. Heavy periods, for instance, were considered beneficial for women who suffered from “too much blood,” while those who had hysterectomies were prone to “high blood [pressure] because all the blood ha[d] nowhere to go.” Younger teenaged girls also were believed to have immature blood, and would be “susceptible to weak blood if they are pregnant” (Davis 1988, 135). This was similar to Welsh folk beliefs that the menstruation’s purpose was to “rid the body of bad blood,” which necessitated a heavy flow (Brain 1988, 314). Regardless of their views of the benefits of an adequate flow or the products they devised or used, every month women from diverse cultural backgrounds confronted the biological function of menstruation, layered over the centuries with taboos and restrictions upon their movements and their behaviours. It is small wonder that the transition through puberty, and the onset of a young woman’s reproductive career, should be particularly marked by ritual and stricture. The following section will examine traditional female rituals of menarche, or first menstruation.

Menarche as Female Ritual Contemporary sociologists and psychologists conclude that proper education and preparation of pubescent girls for menstruation by the maternal figure will lessen the anxiety surrounding menarche. A loving but accurate introduction will set the groundwork for a healthy future mental and

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physical response to menstruation (Jackson 1992, 179). Many traditional societies understood the importance of menarche and incorporated ritual to mark it. It is a cornerstone of anthropology that ritual, in virtually all cultures, is integrated into the “great turning points of life — with regard to the individual (birth, puberty, marriage, death) and with regard to society as a whole (the rise and fall of governments, the turning of the seasons, the beginning of the new year)” (Lincoln 1981, 2). Among the Great Plains tribes, for instance, it was believed that whatever a menarcheal girl experienced would influence her entire life, and “that she had exceptional power over all persons or things that came near her at that period.” If she ate too much, talked too much, giggled, or lied during her first menstruation, she would ever afterwards be inclined to greed, garrulousness, hilarity, or prevarication. While the rituals of the various tribes differed in content, the substantive element — that physical maturity must be accompanied by maturity (or more precisely the rebirth) of character and personality — was constant. Hard labour, it was believed, was the best habit to instill. In four days of seclusion girls would chop wood and perform other arduous tasks while waiting to experience first visions. On the fourth night she was visited by the women of the camp; four of them, controlling spirit power, prayed for the girl, piled up the wood she had chopped, and pushed it over, whereupon each woman carried off some of it. The girl was led to her home ceremonially and was once more prayed for. A feast followed, and then the parents distributed presents among the guests (Terrell and Terrell 1974, 137, 139–40). The Apache female puberty ritual, dedicated to the deity White Painted Woman, also involved the counselling of young girls by mothers or female relatives. The four-day ceremony required extensive preparation and family expense, but ensured good health and longevity, and demonstrated the primacy of women in Apache society (Buchanan 1985, 15–16). Indeed, the puberty rite has been termed “the most important and ancient of all Apache rituals” (Boyer and Gayton 1992, xii). Among the Navajo, “(Goddess) Changing Woman was born to bring propriety, safety, and civilization into existence. Seen thus, she represents the triumph of cosmos over chaos, humanity over monsters, and productive, mature sexuality over the dangers of adolescent masturbation” (Lincoln 1981, 26). Among the Inuit in the pre-contact period, there was a similar balance of segregation and preparation for menarche. Young girls lived in isolation from all except their mothers for 40 days, during which time they learned to cook and acquired domestic skills. When they had completed this crash course in housekeeping, they were deemed marriageable (Boyle et al. 1996, 337). A nineteenth-century account of the puberty rituals of the British Columbian Carrier stressed the physical challenges and blood taboos.Young women were isolated, avoiding contact with any hunting or

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fishing grounds, and called “asta,” or “interred alive.” Females during this “primary condition [were] to eat as little as possible, and to remain lying down, especially in the course of each monthly flow, not only as a natural consequence of the prolonged fast and resulting weakness, but chiefly as an exhibition of becoming a penitential spirit which was believed to be rewarded by long life and continual good health in after years. These mortifications or seclusion did not last less than three or four years” (Morice 1889, 163). This early account clearly viewed the puberty ritual from a Western religious male lens, as the preoccupation with penitence and mortification indicates. Compare this with a report from the Jesup expedition in the same period to the Thompson (British Columbia) region under the auspices of anthropologist Franz Boas, which places more emphasis upon practical activities: On the first indication, and on each succeeding morning during her first menstruation, [the girl’s] face was painted red all over [and] she was wrapped in a heavy blanket ... She was then made to run as fast as possible to some goal, generally twice going and twice returning, until she sweated profusely.... Another morning ceremony was to run four times, carrying two small stones obtained from underneath the water. These were put into her bosom; and as the girl ran, they passed down between her bare body and her clothes, falling to the ground. As she ran, she prayed to the Dawn that it might come to pass, that, when she would be with child, she might be delivered as easily as she had been delivered of these two stones. (Teit 1900, 311)

While this narrative is more nuanced and reflective of the female viewpoint, it nonetheless remains a superficial account of physical acts that downplays their spiritual framework. In many tribes, menstruation was regarded as such a sacred power that women had no need for the sweat lodge since they underwent periodic purification on their own. Their monthly isolation was necessary “to keep the power contained.” Elder Adeline Wanatee stated simply: “Men have visions, women have children.” Even from a Native perspective, gender differences emerged in the perception of these rituals. Vera Martin, an Ojibwa Grandmother, recalled having to correct a Sun Dance leader who stated that menstruating women were “dirty”: Native people have always thought about menstruation as the sacred manifestation of a woman’s power, which is why we must abstain from participating in certain practices and ceremonies while “on our time.” The contemporary interpretation of many traditional prac-

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tices have been “distorted,” filtered or interpreted through Christian notions of sin as it relates to womanhood.... The way we deal with these situations is especially pertinent to women of our era because so many have grown up in residential schools where they were taught that they were dirty and evil.

Isabelle Knockwood, a Mi’kmaw and former inmate of a New Brunswick residential school in the 1950s, wrote, “The nun in charge of the girls’ side decided that the girls would no longer be provided with sanitary towels at night. Only those with exceptionally light periods were able to avoid bleeding onto the sheets. Every morning the sheets had to be held up for inspection. Some girls remember being sent to wash out the bloodstains. Others were beaten as well. For some girls, being beaten four days out of every month became a routine event” (Anderson 2000, 73, 37, 76; Bataille and Sands 1984, 36). Menstruation became one facet of the dehumanization to which inmates of the residential schools were subjected. In his classic study, Asylums (1961), Erving Goffman concluded that apparently disparate institutions, such as residential schools, insane asylums, boarding schools, penitentiaries, and concentration camps, had many similarities that were characteristic of “total institutions.” Upon arrival, inmates underwent mortifying rituals: they were stripped of hair and clothing, their identities were replaced by numbers or nicknames, and in other ways they lost their individuality as a process of submission to a central authority. Although they may have been founded with such lofty goals as educating the young or curing the insane, the daily realities of maintaining order and discipline in such total institutions, where the power of authority figures was unchecked and unsupervised, took precedence. In his works, Michel Foucault (1990, 2001) described how the body is often the terrain through which power is exercised. When a young girl at a residential school learned that even her most intimate bodily functions were policed and her menstruation was cause for punishment, she was alienated not only from her culture but her body as well. The pattern of violence and submission found in these institutions has parallels in other cornerstones of Western patriarchy. The experience of menarche was expressed in the Greek myth of the rape of Persephone, the daughter of Demeter, goddess of agriculture. Many ancient religions were based on the worship of earth goddesses in an association between human and agricultural fertility. To add rape to that association was to wrest control over fertility from women to men. Furthermore, to render defloration of a virgin a decision made by a man or among men was to transform the menarcheal girl into a commodity. Persephone was Demeter’s daughter and companion until she sexually matured; then

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she became a commodity desired by the gods. Patriarchal cultures, both Western and non-Western, which incorporated property ownership in women and the importance of virginity in determining bride-price, emphasized the sexual availability as opposed to the reproductive capacity of pubescent girls (Lincoln 1981, 79, 90). By the nineteenth century, the importance of bride-price diminished in industrialized societies as individual autonomy increased. However, the disjuncture between sexual maturity and psychological maturity was evident and newer (albeit centuries-old) myths, with which contemporary children are familiar, replaced the ancient ones in instructing appropriate behaviour. The period of adolescence between childhood and marriage, which could range from months to years, was a period of liminal status, in which the young girl had left her childhood but had not yet attained full womanhood (Lincoln 1981, 99). This liminal period was perceived as fraught with dangers in western European myths. Only deep sleeps and internments in glass coffins (symbolic homes) could protect a princess, and after crimson blood was drawn from her pricked finger, only the best prince on the market could wake her. Should she stray from the straight and narrow path, as did Red Riding Hood (an example of the dangers of too early a menarche), she would be eaten by wolves. The most popular modern menarcheal myth is James M. Barrie’s play Peter Pan, which was first performed in 1904. While most scholarship has concentrated on the title figure as the archetype of male immaturity, the character of Wendy, whose adventure takes place on “her last night in the nursery,” experiences many challenges and dangers as she tries out the roles of wife and mother she will assume in her post-liminal world. Some are innocent enough, such as tucking the Lost Boys into bed, but encounters with predators/ pirates warn that pubescent girls in their nightgowns should not climb out of their bedroom windows with strange boys. Contemporary social anthropologists note that the dearth of welldefined menarcheal rituals in American and Canadian society has rendered the puberty process more stressful and traumatic than in other cultures (Ulman 1992, 337). Japanese women, for instance, partake in a simple, beautiful ritual: “When a daughter has her first menses, the custom is to invite the family friends and celebrate. The guests are not told verbally the reason for the celebration. Instead, a candied apple or pear, with a small branch or leaves of bamboo, pine or other greens, accompanies the main tray. The guests, when they see the dyed fruit, understand that the daughter has become a woman and celebrate together” (Dan 1986, 7). By contrast, at least in the white mainstream, twentieth-century Canadian and American attitudes in the first half of the last century retained elements of Victorian prudery, silence, and denial. This has been blamed in part upon the disappearance of a domestic “women’s culture,” in which such knowl-

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edge would be exchanged across the generations, and its replacement with age-segregated public schools, in which girls were surrounded by equally ignorant peers (Brumberg 1999, 153). Information of a sexually explicit nature remained scarce in polite bourgeois conversation and was feared as corrupting “those tender shoots of purity which are the girl’s best attributes” (Strong-Boag 1988, 15). Instead, those tender shoots blossomed into countless misconceptions and traumatic initiations. A doctor’s 11-year-old daughter, growing up in interwar Thornhill, Ontario was informed by her mother that “once a month there would be ‘bleeding’ and that I had to wear a napkin while it lasted. I don’t think she mentioned what purpose it served, but just said that it was the lot of all women, and we had to accept it. During the ‘period,’ she said, we had to be very careful not to catch a cold, and we couldn’t take a bath or wash our hair.... I was left with the feeling that the whole thing was terribly unjust to females, and with the misconception that the ‘blood’ came from the nipples.5 Her contemporaries in Quebec were similarly kept ignorant. Québecois women married in the 1930s recalled that “as girls, they were not warned about the arrival of their menses and received no explanation once their periods started except that it would happen every month and that they ought not to talk about it with anyone” (Baillargeon 1999, 68). Countless young girls of every class, race, and ethnicity in Canada and the United States shared this experience. Fewer than 10 per cent of immigrant daughters in the United States prior to 1920 were given any advance knowledge of menstruation by their mothers. In many working-class homes in particular, communication regarding menses took place through the washing of rags (perhaps derived from flour sacks or discarded clothing) and bedsheets. Mothers could use the laundry as a form of finding out when menarche occurred and how regular the menstrual cycles were; daughters often experienced panic, humiliation, and confusion (Brumberg 1999, 159–60). In cultures with a particularly high premium upon chastity, such as Italian culture, mothers were loathe to share menstrual knowledge, either directly or through intermediaries such as public health nurses. Eastern European Jewish girls customarily were slapped by their mothers (either lightly or severely) at the first sign of menarche, although the meaning of the gesture had been long forgotten. It could have been either to prepare them for future travails in childbirth or adulthood, or as a warning to refrain from sexual activity (Culpepper 1992, 278). Young girls continued to lack knowledge at menarche even into the second half of the twentieth century, although there were some racial differences. American researchers estimated that 50 per cent of white women in 1961 entered menarche ignorant of their sexual physiology; by 1981 this figure had fallen to 33 per cent. In a study of African-American women published in 1992, however, it was estimated that only 33 per cent were

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“knowledgeable and prepared” for menstruation (Jackson 1992, 186). As will be discussed below, much, if not most, of the responsibility for sex education has been relinquished by parents to the school system and indirectly to the corporate interests of the sanitary protection industry. It is likely, then, that those communities with higher rates of poverty and lower rates of school attendance would experience a vacuum in terms of proper and early menstrual knowledge. Sanitary Protection in the Nineteenth and Twentieth Centuries Domestic production of sanitary napkins was part of the “great feminine underground.” Nineteenth-century health manuals, especially those written by female physicians, gave detailed instructions on the production and cleaning of pads from cotton batting and cheesecloth or other materials (Farrell-Beck and Kidd 1996, 330–31). The first commercially produced sanitary towel and belt was patented by Southalls of Birmingham, UK in 1880, followed by Lister’s Towels, sold by the American Johnson & Johnson Company from 1896. The latter, constructed from cotton wool and gauze, were the first disposable towels, but because the product was not considered respectable enough to be advertised, it failed to find a market. The modern sanitary napkin can be traced to products devised during the Great War by military nurses, who found the highly absorbent and light Gamgee material used in surgical dressings to be ideal for sanitary protection (Jones 1980, 407).6 The Kimberley-Clark Corporation entered the market in 1921 with its disposable sanitary napkin, Kotex, which was made from wood fibres. Once the social strictures against publicly advertising and exhibiting the product began to disintegrate in 1924 (with the first advertisement for Kotex in the Ladies’ Home Journal), it soon dominated the market. Mail order catalogues, such as Eaton’s in Canada and Sears, Roebuck and Montgomery Ward in the US, were ideally situated for distribution, while “Lady Agents” sold menstrual products “from their homes or door-to-door” (Farrell-Beck and Kidd 1996, 333). Johnson & Johnson re-entered the market with Modess in 1927. Such disposable sanitary products were welcome and necessary accoutrements for the new mobile lifestyle of North American women, particularly waged workers, from the 1920s onwards (Jones 1980, 407). They were now recommended and sold by pharmacists and other health professionals, reducing the stigma associated with menstruation (Farrell-Beck and Kidd 1996, 325). Conservative opinion, however, continued to find the public marketing of sanitary protection distasteful. In 1927 the Toronto and Saint John Local Councils of Women took “up the matter of the undue publicity of Kotex” (Light and Pierson 1990, 87).

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The hygiene movement also facilitated the widespread sale and use of disposable sanitary products. Health manuals emphasizing absolute cleanliness spread the message to the literate, while postnatal practices in lying-in hospitals and by visiting nurses exposed working-class women to the virtues of antisepsis as well (Farrell-Beck and Kidd 1996, 342, 344). Prudery remained long-lived, however. In 1950s Toronto, for instance, sanitary napkins were hidden behind the drugstore counters in brown paper bags. The sanitary napkin did not experience substantial innovation until the 1970s, when the belt was eliminated following the introduction of adhesive backing in such products as Stayfree and Libresse (Jones 1980, 408). Tampons have been used for centuries as medical tools. In 1776, a French physician reported the use of a “tightly wound linen cloth dipped in vinegar to control hemorrhage and leukorrhea” (Osterheim et al. 1982, 954). In the Victorian period, tampons continued to be used in “the treatment of diseases peculiar to women” and not to absorb menstrual flow. Tampons entered the marketplace in the 1920s with the introduction of Tampax or Hollypax, a product inserted by a plunger-operated applicator patented by Dr. Earle Haas (Farrell-Beck and Kidd 1996, 337). The product was extremely successful, although controversy arose over the mistaken conception that the insertion of a tampon ended virginity. The Roman Catholic Church, and other cultures which placed a high value upon virginity at marriage, long condemned its use (Jones 1980, 408). In 1969, the Tassaway, a reusable plastic cup which moulded to the vagina, entered the market. It was, however, never widely adopted. In the late 1960s, Tampax’s profits jumped 15 per cent a year, and other manufacturers entered the market. In 1972, the National Association of Broadcasters lifted the ban on the advertising of menstrual products on television (Lamb and Berg 1985, 217). Other alternatives to napkins and tampons include “period extraction [whereby] a suction cannula is inserted into the uterus, a procedure which could reduce menstruation to a 15-minute period” and the household sponge (Jones 1980, 408). By the turn of the twenty-first century, some organic products have entered the market in a marginal way as part of the natural health movement. These include 100 per cent cotton napkins and tampons, which eliminate chlorine and other toxic chemicals from the fibres, and sea sponges, although the latter may include the ocean’s pollutants and require repeated boiling. However, the use of these alternatives paled before the established sanitary protection industry, which since the 1980s has enjoyed an annual income of at least $1 billion (Lamb and Berg 1985, 217). Despite the fact that a handful of companies control products required by millions of women and containing possibly toxic substances, it is minimally regulated. It is, however, subject to federal tax in Canada,

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unlike medical devices. Stayfree may be one of the most popular brands, but Always is a more accurate description of consumer dependence. While those products that deal with menstrual flow are not considered medical, the conceptualization of menstruation itself as a disease requiring medical intervention has a long history.

The “Disease” of Menstruation Classical and Early Modern Antecedents The modern concept of the disease model of menstruation was rooted in classical Greek thought. The writings of the father of Western medicine, Hippocrates, and his followers first linked the uterus with women’s well-being and even their character. The Hippocratic School perceived the state of female health to reflect the proper positioning of the womb and its regular evacuation (menses). Illness in women was associated with a womb “wandering” from the centre of the body to other regions, and menstruation was necessary to “avoid the accumulation and putrefaction of superfluous fluids” (Cadden 1993, 19). Therapies, including intercourse and pregnancy, were recommended to reposition the itinerant organ and open the floodgates, so to speak. The Hippocratic treatise, On Generation, recommended that “if [women] have intercourse with men their health is better than if they do not.... Intercourse by heating the blood and rendering it more fluid gives an easier passage to the menses; whereas if the menses do not flow, women’s bodies become prone to sickness” (Cadden 1993, 19). The Greek philosopher, Aristotle, who regarded women as imperfect men, also did not grant menstruation much more significance than a “systemic plethora” or the monthly shedding of excess blood that the soft skin of women was prone to absorb. Menstruation ceased during pregnancy, according to Aristotle, because blood was diverted to feed the foetus (Valdisseri 1983, 66). That the ancients and their adherents, right up to the nineteenth century, associated menstruation with a healthful purging of fluids is apparent in medicine’s love affair with venesection (bloodletting). The use of leeches, probably derived from Chinese medicine and introduced to the West by Alexander the Great, was the most popular and graphic method of ridding the body of “bad blood.” Haemorrhoidal bleeding and nose bleeds were considered forms of vicarious menstruation (or loss of excess blood) which could be experienced by men as well as women (Brain 1988). Yet the ancients regarded menstrual blood with fear and loathing. In his first-century treatise, Historia Naturalis, Pliny the Elder of Rome described the menstruating woman as a harbinger of destruction:

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the herbs and young buds in a garden if they do but pass by, will catch a blast and burn away to nothing. Sit they upon or under trees while they are in this case, and the fruit which hangeth upon them will fall. Do they but see themselves in a looking-glass, the clear brightness thereof turneth into dimness, upon their very sight. Look they upon a sword, knife or any edged tool, be it ever so bright, it waxeth duskish, so doth also the lively hue of ivory. (Valdiserri 1983, 66)

These warnings, similar to those given in Native cultures, reflect menstrual blood’s perceived power. But the lack of menstrual flow, which was linked to infertility, greatly concerned pre-modern physicians. For instance, “a twelfth-century formulary recommend[ed] a powder of burnt deer’s horn to be taken with old wine, a thirteenth century source suggest[ed] a number of remedies, including pills, baths, herb drinks, phlebotomy, charms and pessaries.” Menstrual blood was seen in a positive light by Hildegard of Bingen, the twelfth-century German abbess and healer. She believed that her sex was protected from hernias and gout by beneficial monthly purges, and even used menstrual blood as an ingredient in a remedy “for the sort of leprosy which arises from excessive libido.” Other medievalists concluded that menstruation protected women from drunkenness and lengthened their lifespan (Cadden 1993, 174–76). By the seventeenth century, the intellectual ferment arising from the Reformation and Counter Reformation brought the study of the Hebrew Bible to the forefront, and the strictures of Leviticus became an important therapeutic as well as popular belief. A particular taboo was the practice of sexual intercourse during menstruation. This was believed to cause leprosy, epilepsy, or genetic defect in offspring. The offending male himself also risked leprosy, cankers, or sterility (Cadden 1993, 268; Crawford 1981, 49). Amenorrhea, or lack of menstrual flow, remained the foremost of women’s complaints, and was considered due to “the heat or the cold of the uterus or the heat or cold of the humors ... inside the uterus, or excessive dryness of their complexion, or being awake too much, thinking too much, being too angry or too sad, or eating too little” (Formanek 1990a, 6). The diagnosis of amenorrhea could (and was) used by women as a pretext for requesting abortions from physicians. In the seventeenth century, however, European women, for the most part, preferred the advice of other women, including midwives, to deal with gynaecological complaints, and the folk remedies were often spiritually as well as physically based, sharing much with traditional Native cultures. A remedy for excessive flow, for instance, was to cut a mulberry tree branch at the full moon and bind it to the woman’s wrist (Crawford 1981, 69, 71). The moon’s cycles were associated with femininity in pre-Christian European religions, vestiges of which

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remained as folk culture, and, like the red ochre painted on Native girls during puberty rituals, the mulberry branch had spiritual significance. By the eighteenth century, male physicians in Western countries began to wrest the practice of midwifery and gynaecology from traditional female healers and midwives. The continuing popular association of menstruation with most female disorders provided an excellent foundation for the new practice of “man-midwifery.” While the physicians used publicity, legislation, and community lobbying to prop up claims for the new, scientifically based discipline of gynaecology, it was still based upon ancient Aristotelian theories of female weakness (Lord 1999, 39–40). Clinical observation in the eighteenth century determined that menstruation occurred only in females, originated with the vagina or uterus, and should be differentiated from haemorrhoids and other periodic bleeding. The purpose and timing of menstruation were still imperfectly understood. In predominantly agrarian Europe, physicians and the public were familiar with animal patterns of menstruation and incorrectly extrapolated that human menstruation and conception occurred at the same time. Other medical theorists based observations upon charity hospital patients, who were malnourished indigents with higher rates of amenorrhea. Therefore, the menses was not associated with the proper functioning of the reproductive system but with the mysterious weaknesses of the “imperfect man” (Lord 1999, 41, 43). Menstruation occurred, it was argued, due to lunar forces (note again the association with the moon), “fermentation in the blood,” or (the most popular theory) too much blood — due to women’s inability to sweat as easily as men. After John Freund determined that a woman without a uterus would not menstruate, it was generally understood that this plethora of blood occurred in the uterus, and thus, ipso facto, only women menstruated. Medical theorists in the nineteenth century regularly related conditions of mysterious origins to contemporary social, political, and economic realities. By the late eighteenth century, a “sedentary” lifestyle in a pastoral environment was argued to be optimum for maintaining a regular menstrual cycle at a time when the Industrial Revolution was drawing more and more women into paid employment and social engagements in growing urban centres (Lord 1999, 44, 46). Current researchers and theorists attempt to relate conditions of unknown origin, such as breast cancer, endometriosis, and infertility, to environmental pollution and chemical additives to food and other domestic products. The onset of menstruation, or menarche, has also been associated with social and environmental factors for centuries.

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Menarche as a Medical Concern The age of first menstruation or menarche was fraught with implications for control of sexual expression, behaviour of adolescents, and marriage prospects. That it could also be associated with possible physiological disorders greatly concerned practitioners, and indeed, the age changed considerably over the course of the last few centuries (and continues to change). In the seventeenth century, a late menarche was considered a good menarche, and girls from brisk northern climes (such as Britain, home of the medical writers) were considered superior because it was believed that their first menses occurred at about 14 to 16 years, considerably later than in the south (Brumberg 1999, 49). A late menarche was believed to be optimal for two main reasons. On a practical level, a later menarche gave parents fewer years to worry about daughters’ behaviour before marriage. On a medical level, physicians, who considered menstruation to be a “fundamentally unclean process” leading to a multitude of disabilities in women, believed the pre-pubertal state to be healthier. Not surprisingly, it was argued that early menarche could be precipitated by masturbation or other sexually precocious behaviour among girls: the “reading of [obscene] Books, [unchaste] touching, etc. for hereby the Subject becomes a woman as it were before her time” (Lord 1999, 50). By the Victorian period, the age of menarche in the United States was believed to be about 14 or 15 (Fenwick 18889, 8). By the nineteenth century and the flowering of the discipline of gynaecology, ancient precepts concerning the fragile state of menarcheal girls found new expression and authority in medical texts and practice, particularly since physiological functions remained largely mysterious. In Obstetrics: A Manual for Students and Practitioners, David Evans admitted that “the cause of menstruation is unknown. Many theories have been advanced; but all that can be said is that nervous influences proceeding from the sympathetic nerve-ganglia in the lower abdomen and pelvis periodically bring about a condition of congestion of the sexual organs.” Evans thereby married the Hippocratic principles of humours (menstruation was caused by congestion or a plethora of bodily fluids in the uterus) with nineteenth-century theories of nervous irritation. Despite some uncertainties about female physiology, he was more assured in reiterating that puberty occurred earlier in southern climates and in city-bred rather than in country-bred girls, and that it “had a peculiar odor, which is more marked in brunettes than in blondes” (Evans n.d., 17). The decline in the age of menarche generated much speculation regarding possible racial and social causes. Age gradation thus became a factor in the racial gradations so intrinsic to the Social Darwinist world. In his very popular manual, The Physical Life of Woman: Advice to the Maiden,

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Wife and Mother, George Napheys in 1871 picturesquely spelled out the racialist dicta to which Evans alluded: The females of certain races, certain families ... mature earlier than their neighbors. Jewesses, for example, are always precocious, earlier by one or two years. So are colored girls, and those of Creole lineage. We can guess the reasons here. No doubt these children still retain in their blood the tropic fire which ... their forefathers felt.... Those who will grow to be large women are slower than those whose stature will be small; that the dark-haired and black-eyed are more precocious than the light-haired and blue-eyed; that the fat, sluggish girl is more tardy than the slender, active one. (Napheys 1871, 33)

Napheys and his contemporaries also argued, as did their predecessors in the eighteenth century, that the conveniences and corruptions of modern life interfered with the natural course of puberty. His description of the life-long influence of the critical early years of puberty recalls explanations for many traditional menarcheal rituals: The two years which change the girl to the woman often seal forever the happiness or the hopeless misery of her whole life. They decide whether she is to become a healthy, helpful, cheerful wife and mother, or a languid, complaining invalid, to whom marriage is a curse, children an affliction, and life itself a burden. Idleness of body, highly-seasoned food, stimulant beverages, such as beer, wine, liquors and ... coffee and tea, irregular habits of sleep — there are the physical causes of premature development. But the mental causes are still more potent. Whatever stimulates the emotions leads to an unnaturally early sexual life. Late hours, children’s parties, sensational novels, “flashy” papers, love stories, the drama, the ballroom, talk of beaux, love and marriage [and the power of music can] awaken the dormant susceptibilities to passion. (Napheys 1871, 32–34)

Medical experts castigated mothers for failing to prepare their daughters for puberty. In 1900, William Gardner asserted that girls did not intuitively know how important the proper functioning of menstruation was to their present and future health. He related cases of girls who, frightened by the first discharge, attempted to remove it with cold water or others who tried deliberately to “arrest it” so that they could go to balls or pursue other pleasures. Gardner sang a refrain that still resonates concerning early sex education: “If the young girl has to learn of this matter from friends and companions of her own age, or from mature women other than her mother, she may also learn from them other things she had better

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not have known” (Gardner 1900, 9). The problem remained however, that daughters — and mothers — who consulted popular health manuals might well remain confused and misinformed. In 1896, the Ladies Book of Useful Information advised readers to warn their pubescent daughters that their menstrual cycle necessitated caution regarding exposure to wet or cold, and that many cases of consumption (tuberculosis) and other diseases were directly induced by folly and ignorance at the first menstrual flow ... The child is often kept in extreme ignorance of the liability of womanhood occurring to her at a certain age, and, hence, when she observes a flow of blood escaping from a part, the delicacy attached to the locality makes her reticent with regard to inquiry or expose; she naturally becomes alarmed, and most likely attempts to stanch the flow by bathing or applying cold water to the part, thus doing incalculable mischief.” (Ladies Book 1896, 135)

Euphemistic language lost in clarity what it gained in propriety. In Jules Michelet’s Love, published in 1859, girls learned that for the majority of each month, a woman was “not only an invalid, but a wounded one [always suffering from] love’s eternal wound” (Haller and Haller 1974, 107). The medical experts were on firmer ground when dispensing advice to mothers on managing pubescent daughters, or as Ruth Brumberg defined it, “in this new division of labor the doctor was the biomedical strategist, but the mother was the chief operative,” controlling exercise, hygienic practices, schooling, and leisure activities. The ever younger pubertal age and ever longer periods of adolescence must have kept concerned mothers busy. By the end of the nineteenth century, this liminal period averaged 9 to 11 years (Brumberg 1999, 156, 153). Therefore, physicians who advised that “pubescent girls [curtail] all activities outside the home,” eat bland foods, get only moderate exercise, rest frequently, and avoid strong emotions, “down beds, corsets, liquors and stimulating beverages” must have found a receptive and hopeful maternal audience (Cayleff 1992, 230). Other mothers were even more preoccupied with daughters who seemed to be contracting a strange disease associated with puberty. Chlorosis, The Green Mystery The disease of chlorosis, now accepted as an iron deficiency anemia affecting young girls, purportedly was common in the three centuries preceding the twentieth, at which point it mysteriously disappeared. Chlorosis was first recognized as a pathological condition in 1520, when Johannes Lange in his de morbo virgineo characterized its sufferer to be “a young lady who on reaching marriageable age, develops pale, bloodless cheeks

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and lips, suffers palpitations on minor exertion, has a visibly bounding temporal pulse, evidences dyspnea [difficult respiration] on dancing or climbing stairs, and develops food perversions.” Lange called the syndrome “white fever,” or love sickness, and instructed “virgins afflicted with this disease that as soon as possible they live with men and copulate.” In 1620, Jean Vavandal devised the term from the Greek word chloros (green) to signify the greenish tinge to the skin that physicians considered characteristic. The disease was common enough to be part of the cultural vernacular; in Romeo and Juliet, for instance, Shakespeare has Capulet yell at Juliet: “Out, you greensickness carrion!” while the Dutch masters added a greenish hue to the complexions of many young women in their portraits (Pannettiere 1973, 68, 70). By the mid-nineteenth century, advances in hematology demonstrated the association of chlorosis with iron deficiency, yet physicians still found its causation to be mysterious (Hudson 1977, 449). As late as 1850, its symptoms remained exotic and faithfully described: “The face and body lose colour, the face also swells; so do the eyelids and ankles. The body feels heavy; there is tension and lassitude in the legs and feet, dyspnoea, palpitation of the heart, headache, febrile pulse, somnolence, pica [depraved appetite] and suppression of the menses” (Hudson 1977, 450). Of particular interest was the “morbid appetite,” which included cravings for dirt, clay, chalk, and other substances not considered food. The incidence of reported chlorosis peaked in the later Victorian and Edwardian periods when, as Sir Clifford Allbutt averred, “The chlorotic girl is well-known in every consulting room, public or private” (1909, 701). It was a disease particularly characteristic of young ladies “of good breeding” and “great sensibility ... compounded of the cloistered virtues, who was pale, had no ostensible appetite, and who swooned at the slightest provocation. She was enveloped in clothing and her viscera was constricted by tight lacing. Custom and maidenly modesty forbade voluntary employment and anything like violent exercise” (Hudson 1977, 456–57). Tight lacing, which could lead to chronic malnutrition and lack of exercise, were breeding grounds for chlorosis. It was often regarded as inherited. Iron deficient pregnant women gave birth to children with limited iron reserves, called “larval chlorotics.” Deficiency would not become a problem until menarche, when young girls would suffer iron loss with each menstrual cycle at the same time as their bodies required iron for pubertal growth. The potential for anemia was exacerbated when many late nineteenth-century women did not eat animal products, such as meat, eggs, and milk, either due to poverty or to the contemporary belief that such foods stimulated the “animal passions” (Hudson 1977, 457). George Napheys’s health manual, however, stated that “modern” medicine dismissed anemia as the cause of chlorosis: “Green sickness never occurs

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except at or near the age of puberty, and was long supposed to be merely an impoverishment of the blood. Now, however, we have learned that it is a disease of the nervous system.... It can be prevented by a hygienic mode of life, and its most common causes are anxiety, home-sickness, want of exercise or over-work at school; nothing is so salutary in its early stages as a change of air and scene, cheerful company, a tour to the mountains or some watering place, and regular exercise” (Napheys 1871, 40). Perhaps part of the confusion for physicians regarding chlorosis was the fact that their own medical therapeutics may have caused the disorder. During the nineteenth century, when more and more mothers and daughters were consulting physicians for gynaecological and obstetrical concerns, the therapy of first resort was venesection. By lancet or by leeches, women were bled “for all the minor prenatal complaints such as headache, vertigo, nausea, vomiting, insomnia, apprehension, palpitation of the heart, muscle cramps, diarrhea, hemorrhoids, varicose veins, and swelling of the lower extremities.” The loss of blood ranged from 300 cc to 2,000 cc. for major complications, including haemorrhage. Furthermore, “since the procedure was also considered a way to prevent complications, it was not unusual for women to be bled six or eight times during the later months of pregnancy, even when no definite symptoms of disease existed” (Siddall 1982, 257–58). When the daughters of these pregnancies, likely born with limited iron reserves, presented themselves to gynaecologists and family physicians with their menstrual and other complaints, they also would submit to blood-letting. One standard medical textbook of the nineteenth century, William P. Dewees’s A Treatise on the Diseases of Females (1840), recommended the application of leeches for “inflammation of the vulva, uterus, uterine cervix and ovaries” (Siddall 1982, 259). Indeed, few ailments were deemed not to benefit from leeching. In 1846, an estimated 20 to 30 million leeches were used by French practitioners, while in 1863, 7 million leeches sucked patients’ blood in London alone (Brain 1988, 314). Hence the onset of the epidemic of chlorosis. Its disappearance was partly due to transformations in social customs such as the use of corsets, avoidance of meat, and restriction of exercise.Yet it would be the shift in therapeutics away from venesection which would have the greatest influence in protecting the iron reserves of generations of women and solving the green mystery. Victorian Views on the “Disease” of Menstruation As the nineteenth century progressed, advancements in surgery, medical technology, and chemistry gradually uncovered some mysteries of the female reproductive system.Yet theorists continued to rely on ancient precepts to explain not only physiological mechanisms but also to confront

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modern socio-economic transformations. As women in the United States and Canada, by choice and by necessity, increasingly entered the public spheres of paid employment and education, conservative elements of the medical community dusted off hoary notions of menstruation in defence of “traditional” values and privileges. According to social and medical theorists (often the same), Victorian women were to aspire to chastity, delicacy, modesty, and religiosity but were inevitably hampered by their “quintessentially sexual” animalistic nature. Women lacked bodily, intellectual, and emotional control, it was argued, because they were “driven by the tidal currents of [their] cyclical reproductive system,” rendering them eternally inferior to men (Smith-Rosenberg 1985b, 183). By focusing upon menstruation as uncontrollable, many physicians therefore were able to use the menstrual cycle to justify women’s continued subordination. Greek concepts of menstruation as the shedding of a plethora of blood were revived (Moscucci 1990, 18; Bullough and Vogt 1973, 66) to combine with other ancient concepts of female sexual voraciousness. In 1844, George Rowe wrote, “In God’s infinite wisdom ... might not this monthly discharge be ordained for the purpose of controlling woman’s violent sexual passions ... by unloading the uterine vessels ... so as to prevent the promiscuous intercourse which would prove destructive to the purest ... interests of civil life” (Rowe 1844, 27–28). Other physicians maintained medieval notions that the foetus was formed from the menstrual blood and that the moon’s influence upon the menstrual cycle was paramount. (Bullough and Vogt 1973, 66). Some of the most illustrious scientific minds of the Victorian age, including Charles Darwin, Sigmund Freud, and Havelock Ellis, subscribed to the latter view. As formulated by the distinguished British neurophysiologist, Thomas Laycock, the theory stated that all physiological occurrences were subject to the “law of periodicity” governed by the sun, moon, and seasons. Both menstruation and its non-gendered counterpart “vicarious menstruation,” or haemorrhaging, were considered products of the law of periodicity. Few medical theorists went so far as F.A. King, who viewed menstruation itself as an illness (albeit one contracted by virtually all women). King argued that menstruation was a “violation” of natural laws, since “no haemorrhage” could be natural. Therefore, blood that accumulated in the uterus had to be cured by pregnancy, not menstruation. Should pregnancy not occur on a regular basis, fibrosis of the uterus resulted (Valdiserri 1983, 69). A parallel theory concerning the origins of menstruation, reflective of the technological innovations of the Victorian Industrial Age, was the role of electricity. In the second half of the nineteenth century, theories abounded that much of human physiology, including not only muscle and organ functions but emotions and intellect, were controlled and

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transmitted through nervous stimulation similar to electrical charges. The evolution of theories offered a fascinating example of the workings of a Kuhnian paradigm, that is, that most researchers could only conceive of events and functions within the context of their own world views. Fascinated by the electrical power harnessed and applied to supply light and heat and to power engines, researchers extrapolated that human nerves flowed in a similar current and provided similar energy to the body. Turning their attention to menstruation, other researchers theorized that nerve function, rather than a plethora of blood, caused the monthly flow. They argued that periodic nervous stimulation, rather than the build-up of blood, forced the uterus to expel the monthly discharge. At the same time, researchers such as the English scientist John Power began to unlock the connection between menstruation and ovulation (Bullough and Vogt 1973, 67). Advancements in anaesthesia and antisepsis made complicated operations safer and permitted surgeons to develop a clearer understanding of the workings of the internal organs. The famed British researcher Lawson Tait found that the removal of the fallopian tubes would lead to the cessation of menstruation in “95 per cent” of cases, even when the ovaries were left intact (Webster 1897, 3). Yet the ovaries’ importance in menstruation remained elusive. In 1863, German researcher Edward Friedrich Pfluger advanced the first significant theory that menstruation was caused by the ovaries, and he formulated it in both plethoric and electrical terms. He proposed that the follicles of the ovaries enlarged, stimulating nerves that sent impulses to the spinal cord, causing in turn congestion in the pelvis and thereby menstruation (Valdiserri 1983, 68). Even as ovulation became increasingly linked with menstruation, the connection was not easily understood. Similar to F.A. King’s theories, Dr. Lowenthal argued that menstrual bleeding was “due to innumerable repetitions of an unnatural state of things, viz., the non-fertilization and death of the ovum.” He argued that “the swelling of the uterine mucosa is the result of the embedding in it of the last ovum discharged from the ovary” (Webster 1897, 5). The “ovular theory” of menstruation, popular in the 1850s, meant that countless Victorian women consulted their physicians concerning their fertile (and infertile) periods of the monthly cycle and were likely given incorrect information. The ovular theory held that “it was the spontaneous release of the egg which caused menstruation, and the onset of menses coincided not only with the fertile period, but also with the peak of sexual desire in woman” (Moscucci 1990, 34). Medical textbooks and popular manuals published this as well. In his Manual of Obstetrics, Gynaecology and Pediatrics (1889), Kenneth Fenwick stated that “It is immediately after the menses that ... impregnation is most apt to take place”

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(Fenwick 1889, 9).Young women consulting manuals when planning their wedding dates were advised, The Lady Should Select the Day —There is one element in the time that is of great importance, physically, especially to the lady. It is the day of the month, and it is hoped that every lady who contemplates marriage is informed upon the great facts of ovulation.... She will understand that it is to her advantage to select a wedding day about fifteen or eighteen days after the close of menstruation in the month chosen, since it is not best that the first child should be conceived during the excitement or irritation of first attempts at congress. (Jefferis and Nichols n.d., 202; see also Napheys 1871, 74)

By 1897, some gynaecologists, such as Montreal’s J.C. Webster, began to rethink woman’s fertile period: “For a long time it has been believed that ovulation and menstruation are so closely related that they occur at or about the same time, the former being the cause of the latter.... A careful examination of the evidence on which these statements are founded reveals their untrustworthiness” (Webster 1897, 2). The pattern of ovulation and menstruation outlined at the beginning of this chapter became accepted medical fact as the twentieth century progressed. However, there are glimmers in the early twenty-first century that at least some women’s bodies are not entirely orderly mechanisms and that perhaps, as will be discussed in this book’s conclusion, there are menstrual mysteries yet to be unlocked. The Education Debate For many nineteenth-century medical writers, however, menstrual mysteries were akin to menstrual disabilities. The publication in 1873 of Sex in Education by Edward H. Clarke, a professor of medicine at Harvard University, set off an international debate about the menstrual cycle, so silent a topic in polite society for centuries. Clarke wrote his book, a cautionary tale to some and a polemic to others, to rebut women applicants who were attempting to storm Harvard’s School of Medicine. He argued that not only did their reproductive system render women unable to withstand the rigours of higher education, misguided attempts to compete intellectually with men also rendered middle-class women unfit to perform their vital function: the creation of numerous, robust offspring. Citing the then-current theory of the conservation of nervous energy, Clarke asserted, as Aristotle had centuries earlier, that if woman’s vital force were diverted to and exhausted by the brain, the uterus would be starved, barren, and the source of chronic debilitating illnesses. His book

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so touched the nerve of a public confronted with rapid social changes that it went into 17 editions in 13 years (Cayleff 1992, 229). It also was quickly challenged by women at the centre of the storm — the new class of female physicians. Dr. Mary Putnam Jacobi in 1875 took on Clarke at his own institution by winning the competition for Harvard’s Boylston Essay Prize with her contribution, “The Question of Rest for Women during Menstruation” (Jacobi 1978; Valdiserri 1983, 69). Jacobi argued that the female constitution was hardier than Clarke and his followers would allow: “forced rest for women during menstruation was a result of custom and men’s wishes — not physiological necessity” (Cayleff 1992, 232). Other advocates of women’s education used that most “masculine” of disciplines, scientific method, to support their position. In 1883, W.L. Stevens sent questionnaires to the presidents of American co-educational institutions concerning their students’ health. Stevens found that “most women are more vigorous at their graduation than on their admission” (Cayleff 1992, 233). In 1905, Martha Carey Thomas, the president of Bryn Mawr College in Philadelphia, condemned the menstrual theories as “sickening sentimentality” and pseudoscientific, and her position was confirmed by John Dewey’s statistical study in 1886, which concluded that “female graduates of our colleges and universities do not seem to show, as a result of their college studies and duties, any marked difference in general health from ... women engaged in other kinds of work” (Cayleff 1992, 232). What the opposing conservative physicians could not match in verifiable evidence, they substituted with hyperbole, unfounded assumptions, and fear-mongering.T.S. Clouston of Edinburgh contended that the “overstimulation” of the female brain resulted in “stunted growth, nervousness, headaches and neuralgias, difficult childbirth, hysteria, inflammation of the brain, and insanity.” The female character is likewise altered by education; the educated woman becomes cultured, but “is unsympathetic; learned, but not self denying.” Clouston did admit, however, that his theory was “not founded on any basis of collated statistical facts” (Bullough and Vogt 1973, 72). Clouston was not alone in advancing medical theories based on speculation rather than fact. British, American, and Canadian physicians lacked, for the most part, the clinical training being developed in continental European centres like Paris, Berlin, and Vienna. They based their theories upon personal observations, which, over the course of a lengthy practice, could be quite perceptive and accurate. But personal observations of lesions, discharges, and other physical manifestations of disease were easier to verify than observations of behaviour or the operations of internal organs, and in these instances the written speculations were based more upon individual biases or accepted social norms. Many of Clouston’s contemporaries used phrases such as “It is commonly held” or “general

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knowledge” to develop sophisticated medical theories to “explain” social practices and equate tradition with health. In the popular journal, The Fortnightly Review, British alienist (psychiatrist) Henry Maudsley intoned, “Women are marked out by nature for very different offices in life from those of men, and that the healthy performance of her special functions renders it improbable she will succeed, and unwise for her to persevere, in running over the same course at the same pace with him.” The same journal published a rebuttal by Elizabeth Garrett Anderson, Britain’s first female physician, who emphasized the distance between these menstrual theories and real life, where women, particularly of the working classes, had to work every day and “as a rule, without ill effects” (Showalter and Showalter 1970, 86). Despite contrary evidence, conservatives were reluctant to give up the notion of biological disability with its physiological underpinning for the socio-economic realities of female subordination. Yet those on the left of the political spectrum used similar arguments to advance their goals. Dr. Azel Ames, a public health investigator in Massachusetts, published Sex in Industry: A Plea for the Working Girl (1875) in the same year as Sex in Education. Sex in Industry exposed the harsh working conditions in female-dominated factories. Ames argued that “this taxing of strength drained necessary energy away from the reproductive organs and was thus the causal factor in the development of too frequent and profuse return of the menses and other disturbed menstrual conditions.” His research led to the passage in 1874 of the Massachusetts maximum hours law for women and children (Harlow 1986, 40). The use of these arguments to pass protective legislation permitted legislators, union leaders, and employers to ameliorate the new working environment for women without having to admit full rights of citizenship. While some medical theorists attempted to label menstruation itself as a disease, the majority of physicians were dealing with a variety of diseases relating to the reproductive organs with which women presented them. Victorian Disorders of Menstruation Disorders associated with menstruation were recognized for centuries. During the Renaissance period, English physician James Primrose (c. 1598–1659) wrote, “If some women, before their periods, nevertheless suffered from headaches or pain in the abdomen or lower back, from restlessness, heart burn, palpitations and fainting, this was due to the peculiar, pathological quality of their blood” (Stolberg 2000, 305). The nineteenthcentury renewal of medical interest in menstruation produced detailed discussions of the various disorders associated with it, as well as reasons — both speculative and clinically proven — for their occurrence. One

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of the more common complaints which women presented to their physicians was amenorrhea, or absent or very delayed period. Personal journals and letters revealed that the female perspective was consistent with the ancient humoral theory, in that women “wanted a copious flow to release bad humors ... Any delay, reduction or total ‘suppression’ of the menstrual flow ... aroused great concern” (Stolberg 2000, 316). Amenorrhea therefore figured large in health manuals. Fenwick’s Manual of Obstetrics (1889) advised that it could be caused by “congenital malformation” or was “usually due to some constitutional disorder, as phthisis [tuberculosis], chlorosis, Bright’s disease [kidney malfunction] ... sudden cold, bodily or mental shock, fevers and severe disease” or to life changes such as travel. Fenwick recommended that in most cases a hot hip-bath and foot-bath, hot drinks, and an “aloetic” purge just prior to the expected date of the period should suffice, followed by “a mixture of iron and aloes ... with exercise and fresh air” (Fenwick 1889, 144). The publications of the eclectic physicians (those who prescribed to both orthodox medical practice and the competing therapeutics of the naturopaths and homeopaths), such as John King’s American Dispensatory, recommended unicorn root, life root (also termed “Squaw-weed” and the “Female Regulator”) and black cohosh for amenorrhea, as well as for dysmenorrhea and other menstrual complaints, and these roots were basic ingredients in patent medicines like Lydia Pinkham’s Vegetable Compound (Stage 1979, 90). Dysmenorrhea (painful menstrual or premenstrual symptoms) was probably the most common complaint. It was believed to be caused by “taking cold during the period, fright, violent mental emotions, obstinate constipation, sedentary occupations [and] the smallness of the mouth and neck of the womb” (Ladies Book 1896, 138). In the latter cases, it usually occurred “in young girls or in sterile married women, and in those of a nervous, delicate constitution.” Dysmenorrhea took many forms, such as “neuralgic, congestive, mechanical, membranous and ovarian,” and its symptoms ranged from fevers, severe “paroxysms” [cramps], back pains, and “aching in the limbs.” Membranous dysmenorrhea (endometriosis) “where the superficial layer of the mucous membrane of the uterus is cast off as a coherent triangular sac, or else in shreds of a more or less firm consistence [was] accompanied by intense uterine pains like those of labor.” Physicians were cautioned “not to mistake it for abortion.... Its true pathology is unknown, and its prognosis is unfavorable” (Fenwick 1889, 145). Victims of dysmenorrhea were assured that “this trouble is generally relieved by marriage” and that hot poultices, laxatives, hot ginger tea, and cycling could help to relieve symptoms (Ladies Book 1896, 138; Mitchinson 1991, 65). More serious remedies, particularly concerning addictive substances, were debated. The Ladies Book recommended “three

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grains of calomel [mercury] and one grain opium or Dover’s Powder” before and at the onset of the menses, while Marion Harland’s manual, Eve’s Daughters (1882), considered the use of opium, laudanum, or paregoric (opium derivatives) “strictly forbidden.” She did allow, however, “gin and water as a last resort” (Showalter and Showalter 1970, 86). Fenwick’s manual, which was written for medical rather than popular use, prescribed “morphia, hot brandy, or even chloroform” (Fenwick 1889, 146). Electrotherapy was another external remedy. In 1846, Robert MacDonnell claimed to be the first physician in Montreal to use “electro-galvanism” to treat amenorrhea and dysmenorrhea. Mindful of the sensibilities of his middle-class Victorian clientele (and probably his own reputation), he held one electrical pole at the base of the patient’s spinal cord, but “the other button is applied by the patient herself, or by a female attendant, immediately over the os pubis” (Mitchinson 1991, 245). Mary Putnam Jacobi made an unusual association between dysmenorrhea and celibacy, commenting that “the proportion of married women who learned to suffer at menstruation was 11 percent, while that of unmarried was 84 percent.” She blamed this on the perception that celibacy implied “social failure [causing] depressing moral emotions,” which subsequently starved “the nerve centers.”7 Complaints less common than dysmenorrhea included leucorrhoea (painful white mucous discharges), caused by “cold, violence, high living and excessive sexual indulgence,”8 and menorrhagia (excessive menstruation). Menorrhagia was blamed upon “frequent childbearing, abortion, high living, too prolonged and frequent suckling” and was considered more common among the working classes, whose young females had to “work hard, running up and down stairs, or using the sewing machine” (Ladies Book 1896, 138; Fenwick 1889, 146). The growth in the field of gynaecology in the late nineteenth century, coincident with the revolution in relatively safer surgical technique, resulted in extremely radical solutions to menstrual complaints. Gynaecological surgery for nervous and mental disorders was a regular procedure from the 1870s to the end of the century. Thousands of young middle- and upper-class women in Canada and the US, usually in their thirties, underwent bilateral ovariotomies on healthy organs for the treatment of amenorrhea, dysmenorrhea, and any other form of “pelvic pain, hysteria or convulsive disorder.” By 1906, an estimated 150,000 women had undergone Battey’s Operation, so named for its originator, Robert Battey. Even if this figure was inflated, the number of operations was still extremely large, particularly given a purported mortality rate of 30 to 33 per cent. In 1876, Lapthorn Smith, gynaecologist to the Montreal Dispensary, believed that the acceptance of the operation “would alone suffice to stamp our age as one of great progress in the treatment of those affections which are peculiar to women.” The centres of surgical work

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in ovariotomy in Canada were the Montreal General Hospital and the Royal Victoria Hospital in the same city. At the former, five ovariotomies were performed in 1884 and 21 in 1900, while 45 such operations were performed at the Royal Victoria in 1895 alone. Ovariotomies also were performed at the Victoria General Hospital in Halifax and at the University of Toronto medical school. Some Canadian physicians were more cautious. “The removal of the normal ovaries is always a question in morals as well as in medicine,” the Canadian Practitioner asserted, “and cannot be evaded in either relation without evil results” (Goodell 1882, 295; Mitchinson 1984, 135; Warsh 1989, 55–56). Did women suffer from more menstrual disorders in the nineteenth century? Clelia Mosher, an American researcher who investigated the menstrual experiences of college women from the 1890s to the 1920s, concluded that women in the earlier period may indeed have suffered more severely, due in large part to dress fashions. Until the 1910s and particularly the 1920s, women squeezed themselves into “tight corsets, banded clothing, and unsupported heavy skirts,” totalling up to 30 pounds in weight (Bullough and Vogt 1973, 79–80). Such garments, part of women’s wardrobes for years, compressed and contorted body organs and probably added to the menstrual discomfort of their wearers. The flapper fashions of the 1920s loosened up the internal organs as they dropped the waistlines. Yet many twentieth-century medical theories echoed nineteenth-century beliefs, and much technological advancement continued to be detrimental to women’s menstrual health. Modern Conceptions of Menarche Freudian psychoanalytic theory took popular culture by storm in the 1920s, and words like “ego” and “complex” became part of the vernacular. In Freudian texts published for the American and Canadian audiences, old conceptions were simply relabelled. Helen Deutsch’s influential The Psychology of Women, published in 1944, was an example of this. Deutsch hypothesized that pubescent girls perceived the maturing process as “a threatening danger,” and even if extensively prepared about the biological event, they would experience the first menstruation “as a trauma.” She traced female anxiety to “primitive unconscious ideas that menstruation was dangerous, unclean, and to be avoided,” even though, as we have seen, genuinely “primitive” cultures often celebrated the experience (Deutsch 1944, 156–57). The progressively declining age of menarche continued to be of medical and possibly environmental concern. The age in Canada and the United States and most of Europe ranged from nine to 17 years, with an average of about 12.5 years. The age has been determined to be directly

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related to body weight; more precisely, when fat tissue reaches a critical level, the subsequent change in metabolic rate triggers menarche. Given North America’s increasingly rich diet, the age of menarche, not surprisingly, continues to fall (Asso 1983, 16). Of particular concern to contemporary researchers, however, are increasing examples of extreme precocity in age, as low as six or seven years, and its possible association with food additives. Dairy products, especially milk, have become a significant element of children’s diets over the past 100 years, and milk cows, “unlike nursing human mothers, are almost continuously pregnant. Hormonal levels in their milk must be quite high.... More recently, the use of anabolic steroids to increase weight gain in cattle and poultry has become nearly universal” in North America. A diet rich in animal products may well be exposing children to high levels of artificial hormone consumption (Burdick 1969, 1483). Nineteenth-century young girls became “chlorotic”— suffering from iron deficiency anemia — when parents curbed their exposure to the “animal passions” associated with a meat diet. Ironically, the twentieth-century love of the animal protein diet may be causing health problems of its own. Menarche as a Marketing Bonanza As the twentieth century progressed, both female rituals and medical directives associated with menarche were eclipsed by the corporate agenda. The ancient “unclean” taboo was stripped of associations with crop failures and the emasculation of warriors. Only the most superficial meaning of “unclean” remained. With the proper products, girls could be assured that vulvas would sparkle and shine like kitchen floors and shirt collars. As explicit sexual information was withheld from young girls in the 1920s and 1930s, “feminine hygiene” products were advertised in magazines and catalogues. Kotex and Modess sanitary napkins were marketed as pseudomedical items, and Ortho-Gynol douches were available to any Canadian farm girl to whom the Eaton company delivered (Strong-Boag 1988, 15). Menstrual “preparedness” also became part of the post-World War I curricula in schools and in groups like the Girl Scouts and Canadian Girls in Training (CGIT), where the focus was personal cleanliness rather than sexuality. From the 1930s, the sanitary products industry, led by Proctor & Gamble, began creating and mass-distributing increasingly sophisticated educational materials directly to schools, public health nurses, and girls’ groups as well as to mothers, effectively transforming pubescent daughters into incipient 40-year consumers. In the 1940s, the industry sponsored the Walt Disney animated feature, “The Story of Menstruation,” seen by almost 100 million North Americans. By the 1950s and 1960s, the focus of the publicity materials was upon “adolescent awkwardness and the embar-

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rassing specter of stained clothes [i.e., the taboo],” feeding upon the angst of junior high-schoolers in order to hawk thinner, whiter, more absorbent, and more chemically riddled sanitary products (Brumberg 1999, 163–64;Vostral 2010).Yet in many ways, the corporate model of menstrual preparation, by separating the plumbing from womanhood, motherhood, and the various dimensions of sexuality, was ultimately as insubstantial as the euphemisms of the Victorian health manual. A recent study of adolescent girls and their mothers found that the adolescents “were more likely to view menstruation as debilitating, bothersome and unsanitary, and less likely to view it as a positive event than their mothers” (Stoltzman 1986, 97). The birth control pill is used in many instances not just to protect against unwanted pregnancies but to eliminate menstruation. The American Food and Drug Administration (FDA ) in 2003 and Health Canada in 2007 approved the drug Seasonale, an extended-cycle birth control pill, which gave women only four menstrual cycles per year.9 Seasonale was tested for less than two years before it was placed on the market, with assurances that it was no different from standard oral contraceptives. Its side effects are increased risk of blood clots, stroke, and heart disease if taken by a smoker, as well as possible sudden numbness, migraine headaches, chest pain, confusion, and depression if taken by anyone. As birth control, Seasonale’s effectiveness may be limited by the use of acetaminophen (Tylenol) or ascorbic acid (Vitamin C), as well as antibiotics and other medications.10 Women who need painkillers or even eat oranges cannot depend on Seasonale to prevent pregnancy. Women who took the medication to lessen menstrual cramping or to limit periods and who responded to a website that noted patient satisfaction with the medication listed a series of negative side effects, including hair loss, severe menstrual cramps, insomnia, depression, and irregular menstrual cycles more than a year following cessation of the medication. One respondent wrote, The fatigue and depression have gotten increasingly debilitating. I never napped before taking the pill but for the last three weeks I have physically needed a nap everyday! I cry at the drop of a hat and am extremely irritable towards everyone around me.... The depression has gotten in the way of my nursing school studies and even my friendships. I can’t wait to be my normal self again! I would take the heavy bleeding and cramps to this any day!11

Many women at the beginning of the twenty-first century are endeavouring to dissociate menstruation from the cleaning of a toilet bowl and reclaim it as a rite of passage. There are various rites, ranging from Native practices of women’s circles to the orthodox Jewish ceremony of “bagrut.”

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These are all a similar initiation to the community of women, used to reintegrate the menses into the modern woman’s life (Amberston 1991, 30; Miriam’s Well 1986).

Premenstrual Syndrome Once a month Queen Victoria would become unaccountably enraged at Prince Albert, screaming accusations and hurling any object that came to hand across the room. If the royal consort tried to reason with her, she would only shriek loudly and vituperatively. If he remained silent, he would be accused of insulting the royal presence. If he withdrew to his room,Victoria would pound on the door with her tiny fists.12 (Clark 1981, 74; see also Markens 1996, 48)

It is entirely appropriate that Victoria, who placed her imprimatur not only on towns, provinces, hospitals, and schools throughout the British Empire but also upon manners, anaesthetized childbirth, and the AngloAmerican Industrial Age, should have displayed classic symptoms of premenstrual syndrome (PMS). She would not enjoy the releases of her royal predecessors: fox hunting, spirits, and varying degrees of debauchery. The Good Wife and Mother of her brood and her people had hormonal justifications for her nasty moods. Nineteenth-century alienists, such as J.C. Pritchard, described cases of “dysmenorrheal affections” that they encountered among mental asylum inmates in terms virtually identical to later characterizations of PMS: “Some females at the period of the catemenia undergo a considerable degree of nervous excitement: morbid dispositions of mind are displayed by them at these times, a wayward and capricious temper, excitability in the feelings, moroseness in disposition, a proneness to quarrel with their dearest relatives, and sometimes a dejection of mind approaching to melancholia” (Richardson 1995, 761). In the 1930s, another generation of psychiatrists formulated the conception of premenstrual tension or syndrome as a psychological disorder. In 1931, Robert T. Frank wrote of a large group of women who complain of a feeling of indescribable tension from ten to seven days preceding menstruation which, in most instances, continues until the time that the menstrual flow occurs. These patients complain of unrest, irritability, “like jumping out of their skin” and a desire to find relief by foolish and ill considered actions. Their personal suffering is intense and manifests itself in many reckless and sometimes reprehensible actions. Not only do they realize their own suffering,

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but they feel conscience-stricken toward their husbands and families, knowing well that they are unbearable in their attitude and reactions. (Frank 1931, 1054)

Also in 1931, leading American psychoanalyst Karen Horney first published her assertions that the appearance of menstrual blood awakened “cruel impulses and fantasies of both an active and a passive nature” in women. Furthermore, PMS occurred most often in childless women who developed intense defences against a “particularly strong desire for a child.” Her hypothesis corrected Freud’s theory that motherhood did not represent a primary instinct, arguing that the wish for a child fulfilled all of Freud’s postulations concerning what constituted a “drive” (Horney 1967, 99, 104, 106). In 1939, Karl Menninger, another leading psychoanalyst, followed Horney’s lead, theorizing that victims of menstrual disorders had rejected their femininity. In 1961, PMS was blamed by Natalie Shainess on bad mothering (Brown and Woods 1986, 27). Frank and Horney formulated their theories at the same time that endocrinologists were refining their understanding of sex hormones. Hormones were first discovered in 1905, and in 1921 Austrian physiologist Ludwig Haberlandt theorized the possibility of a hormonal contraceptive (Marks 2000, 147). The psychoanalysts, however, were skeptical about the utility of hormone therapy for PMS (Stolberg 2000, 314). As late as 1984, psychoanalytic researchers Roger Greenberg and Seymour Fisher supported Menninger’s hypothesis with their own questionnaire of 50 women, concluding that “a woman who has a strong acceptance of herself as a female will experience fewer of her somatic symptoms as menstrual.” They based their findings on the premise that women who could separate their menstrual symptoms from their other body problems were making use of “masculine mode externalizing defenses” (Greenberg and Fisher 1984, 643–48). By this reasoning, a woman who woke at 3 o’clock in the morning with severe abdominal cramps the day her period was due and concluded she had menstrual cramps had rejected her femininity (apparently logic and experience, not to mention the ability to read one’s own body, are masculine traits). Within the traditional psychoanalytic model, which supported traditional gender roles, career women or childless women were overly masculine. A feminist reading of the case may be that working or other multi-tasking women were more conscious of their menstrual discomforts because they couldn’t take a day or two of every month to lie in bed with a heating pad and ice cream and watch soap operas, in psychoanalytically proper feminine style. By the end of the twentieth century, PMS remained misunderstood yet generally (in fact, too generally) accepted. The number of its victims wildly varied from estimates of 25 to 90 per cent of all women (Rodin

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1992, 51). (One wonders, of course, if a “disorder” contracted by 90 per cent of the entire female population should be perhaps termed “normal.”) By 1968 over 150 different symptoms were cited as somehow associated with PMS , although without any precise or objective clinical evidence (Johnson 1987, 341). The severity of symptoms also was not established; should occasional yawning have been classified in the same category as migraine headaches? Since PMS came to include all symptoms that can in any way be attributed to the menstrual cycle, it could in fact occur in up to 17 days out of every cycle (that is, in most women most of the time). The medical establishment has come to regard PMS “as a legitimate disease category (by applying for research funds, proceeding with research, treating patients, and maintaining PMS clinics) despite the lack of an agreedupon definition and contradictory research findings” (Rodin 1992, 52). How has this mysterious syndrome become an established “fact”? Perhaps the diagnosis of PMS serves personal and social needs beyond the purely medical. Speculation in this regard has crossed academic disciplines. Anthropologists have approached premenstrual syndrome as a “culture-bound syndrome,” that is, “a constellation of symptoms categorized by a given culture as a disease; the etiology [cause] of which symbolizes core meanings and reflects preoccupations of the culture; and the diagnosis and treatment of which are dependent upon culture-specific technology and ideology.” Moreover, the “disease” of PMS is also unique to Western culture; an examination of studies on psychiatric disorders in other societies reveals no mention of it (Johnson 1987, 338, 347). In 1928, Margaret Mead noted that Samoan women experienced bodily discomforts associated with menstruation but did not make any connections to emotional upheavals (quoted in Gottlieb 1988, 10). A more recent World Health Organization (WHO) study found that the incidence — or, more precisely, identification — of mood swings in the premenstruum varied widely across cultures, ranging from 23 per cent of Sudanese women living in Indonesia to 73 per cent of Muslim women living in the former Yugoslavia (Richardson 1995, 763). What then is different about Western culture? From an anthropological perspective, in contemporary Western culture, PMS reflects “conflicting societal expectations that women be both productive and reproductive” while its appearance denies both alternatives (Johnson 1987, 337). In other words, if women were premenstrual, they were not fulfilling their reproductive role, and suffering the symptoms of PMS prevented them from working to their full capacity either in their domestic tasks or in paid employment. PMS thus can be seen as a “cultural safety valve” for women to relinquish temporarily either role demand. Women have been depicted alone (without husbands or children) and without the trappings of paid employment (that is, not in uniforms or in

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office settings) in popular journal articles and advertisements regarding PMS and its medications (Johnson 1987, 348). That is, women who consult their physicians and take medication to combat PMS symptoms are viewed as women who are trying to look after themselves and temporarily abandon all the other roles and responsibilities they perform daily. Further to the safety-valve thesis, the emotional behaviour associated with PMS appears as an inversion of traditionally approved feminine conduct, including a loss of control leading to aggression, anger, and “lashing out,” usually directed towards immediate family members (Gottlieb 1988, 11). These behaviours are not generally approved for women, yet understandable/forgivable/tolerated in terms of an occasional illness and subjection to the unstoppable waves of female hormones. By removing our focus from our own time and culture, we can better comprehend this point. As Natalie Zemon Davis noted, the Early Modern European folk tradition of misrule, or charivaris, were opportunities for the peasants to display their disapproval for those breaking societal norms (such as the marriage of older women to younger men) without challenging the state or religious authorities. Halloween rituals such as wearing masks, throwing eggs, and demanding candy from strangers are vestiges of charivaris. The salient point is that these inversions of accepted behaviour are temporary (Davis 1975, 103). While contemporary Western women in the premenstruum do not, as a rule, throw eggs at windows, they can yell at their husbands during a socially prescribed and accepted period of the month. Once this ritualistic inversion is over, “life reverts to its prior state and continues as if uninterrupted” (Gottlieb 1988, 13). A closely related Marxist analysis argues that PMS constitutes an “unconscious” rebellion by women against the ever-increasing demands of work efficiency on the job as well as at home (Gottlieb 1988, 10). This interpretation evokes parallels with the nineteenth-century disease of neurasthenia, where adopting the sick role was a socially acceptable (and ultimately self-defeating) form of rebellion against dampened personal aspirations. Both disorders arose from an “incomplete and inaccurate” understanding of menstruation; a “protean” variety of symptoms were described for both, without physical evidence of disease; the subjective nature of the diagnosis meant that many patients consulted a series of physicians, without obtaining an accurate diagnosis or symptom relief; “polypharmacy” was customarily administered, with patients receiving the popular remedies of the day, many of which created other problems such as addiction; and once the diagnosis of PMS or neurasthenia was made, “women’s behaviour was confined by the personal, professional and societal explanations of the diagnosis” (King 1989, 2). Some of the psychosocial factors alluded to above related to the medical model of PMS as it was synthesized and circulated to the public

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through the mass media. During the 1980s and 1990s, American popular periodicals ranging from women’s magazines like Mademoiselle, McCall’s and Ms. to health periodicals like Health and Women’s Sport and Fitness to general news magazines like Newsweek and U.S. News & World Report all negatively portrayed PMS. Women were described as suffering from “the blahs ... snapping, irritability ... bloating ... bitchy [leading to] strained relationships [and] feelings of despair” (Gottlieb 1988, 13). The “normal” woman (Madonna/Saint) was contrasted with the “abnormal” one (Eve/ Virago/Premenstrual) whose body had lost control of its “out-of-kilter” hormones (Markens 1996, 47). By maintaining a disabled, inferior view of female physiology, structural inequalities such as inadequate financial resources, a double or triple daily workload, and a lack of autonomy that also create stress and exhaustion are ignored. In this fashion, the medicalization of menstruation, and the related labelling of womanhood as disability, continues to support gendered socio-economic and political inequities. Womanhood as Disability A highly controversial social manifestation of the “disability” of menstruation is the debate over work-time loss. In the nineteenth century, concern over working conditions in factories resulted in paternalistic legislation to protect female workers. From the 1920s onwards, studies were conducted as large numbers of young women entered the paid labour force. Three early American reports — released between 1922 and 1931 — concluded that dysmenorrhea had no significant impact upon work time or efficiency and that “only 4.4 percent of women working in a department store experienced sufficient discomfort to remain home” (Harlow 1986, 42–43). A 1946 report estimated that probably “not over 10 percent of women employees suffer sufficiently from dysmenorrhea to cause lost time” (Harlow 1986, 43).Yet these results, flying in the face of widely held beliefs of female incapacity, received little publicity. Instead, sources such as Novak’s Textbook of Gynecology still asserted in 1981 that dysmenorrhea was “the most frequent cause of lost work time, and that each year dysmenorrhea is responsible for 140 million wasted work hours.” This statistic was not referenced and, even if true, accounted for only three hours per woman per year. While there is little evidence that female employees’ menstrual cycles adversely affect the workplace, the reverse may not be true. Changes in the menstrual cycles of many women in a specific workplace may be a possible bellwether for environmental hazards. Bleeding abnormalities might warn of “chemical poisoning, disruption of the circadian rhythm,

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disruption of steroid metabolism, or changes in blood chemistry” (Harlow 1986, 43, 46), all of which could be evidence of a toxic workplace. Despite the lack of evidence, menstrual disability and irritability have been cited as handicapping women from attaining positions of authority. The most famous American example was the misguided comments of Edgar F. Berman, a physician and leading supporter of Hubert Humphrey’s presidential campaign, who in 1971 asserted, “If you had an investment in a bank, you wouldn’t want the president of your bank making a loan under those raging hormonal influences at that particular period. Suppose we had a menopausal woman President who had to make the decision of the Bay of Pigs, which was, of course a bad one” (cited in Cox 1976, 27; see also Cayleff 1992, 233). Perhaps a more constructive method of dealing with female workers would be to follow the example of Japan, which provides employees with the option of leave during menstruation. Part of the Labor Standards Law of 1947, this regulation “permits leave for any woman worker under either of two conditions: 1) if a woman suffers heavily from menstruation, making it hard for her to work, or 2) if the work itself is injurious to her body during menstruation. It does not specify the number of days or whether the leave is to be paid” (Dan 1986, 1). A highly publicized and controversial conception of PMS in the late twentieth century was its classification as a psychosis and subsequent employment as a legal defence for criminal action. Echoing the clinical reports of nineteenth-century alienists, contemporary psychiatrists have cited cases of “puerperal psychosis,” where psychotic episodes occur or are aggravated in the premenstruum. In 1975, one study concluded that these episodes were more common than “would be expected by chance” (Stout and Steege 1992, 15). One patient with a “strong family history” of schizophrenia was treated not only with chlorpromazine and electroconvulsive therapy but also with Danazol, an ovulation inhibitor that staved off attacks (Dennerstein et al. 1983, 524). Depression, often accompanied by suicide attempts, was also linked to PMS, but in most cases the women seeking treatment for PMS-related symptoms manifested more continuous depression (Stout and Steege 1992, 19). The first or menstrual week of the cycle also was found to be the week most favoured for suicide attempts and possibly for criminal behaviour (Baca-Garcia et al. 1998, 32; Asso 1983, 70). This finding was a correlation rather than cause and effect; that is, women suffering from suicidal depression may act upon it during that week. There might be similar precipitating hormonal factors for men.13 It would appear then that some women who exhibit anti-social behaviour may be more at risk during the premenstruum and menstrual week. In three separate homicide cases before British courts, medical testimony of

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severe PMS was considered an adequate defense for a plea of “manslaughter with diminished responsibility” (Richardson 1995, 765).

Other Menstrual Complaints By the end of the twentieth century, all physiological as well as emotional changes associated with the menstrual cycle were included under the rubric of PMS. As most women know, a litany of symptoms is associated with the various stages of the menstrual cycle. In the premenstruum, common symptoms include water retention and weight gain, craving for sweets, “skin eruptions.” and a lower tolerance for alcohol. Negative mood swings — increased anxiety, tension, and depression — may occur to varying degrees, but there may be positive mood swings as well. Menstruation usually brings generalized feelings of relaxation and increased energy, while the ovulatory phase at mid-cycle is often accompanied by an “increase in self-confidence, assertiveness, competitiveness and dominance, feelings of well-being and pleasantness, enhanced cheerfulness, energy, outgoingness, and a peak in feelings of elation and vigour” (Asso 1983, 63). Mood swings, the foundation for the view of female monthly “disability,” must be viewed with some caveats. One research study that examined couples, rather than just women, found that the women’s moods were “affected less by the menstrual cycle ... than by variation in the social environment” and that the men were equally affected by mood swings (LeFevre et al. 1992, 81). Dysmenorrhea, which may commence immediately before or on the first day of menstruation, ranges from pelvic cramps of varied intensity to aching back and leg pains, headaches, and fatigue. These symptoms in recent years have been blamed on excessive amounts of hormones known as prostaglandins, which regulate the contractions of the uterus during menstruation and the amount and duration of the menstrual flow. There are, occasionally, mid-cycle spasms known as Mittelschmerz, which can accompany ovulation (Asso 1983, 35). Despite the extreme variations in symptoms and moods among women and during their cycles, contemporary researchers continue to focus upon the most negative. The British expert, Katharina Dalton, asserted that “there are few tissues in the body which may not on occasion be affected by menstrual variations and premenstrual exacerbation,” and her list, including asthma, hoarseness, haemorrhoids, varicose veins, spontaneous bruising, and palpitations, emphasizes the similar generalized weaknesses of womanhood used to justify inequitable policies centuries earlier (quoted in King 1989, 15). Perhaps, in some imaginary matriarchal culture, women would be placed in positions of

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power and authority to make the best use of their heightened energies during the ovulatory phase of their cycles! A form of dysmenorrhea, which has stymied medical science for centuries, is endometriosis. Described as “the disease of theories” (Thomas 1995, 151), endometriosis is characterized by the growth of endometrial lining outside the uterus and often by serious complications (Lamb and Berg 1985, 215). While it is, in many ways, a mysterious disease, it is not a new discovery. It was first described in 1690 by a German physician, Daniel Shroen. His book Disputatio Inauguralis Medica de Ulceribus Ulceri noted ulcers that could be distributed “throughout the ‘stomach’ (the peritoneum), the bladder, the intestine, the broad ligament, and the outside of the uterus and the cervix” and which was “a female disorder, characteristic of those who are sexually maturing” (Knapp 1999, 10–11). Early writers recognized that endometriosis could lead to frequent miscarriages, sterility, and exceptionally terrible pain —“the most continuously painful disorder in the medical lexicon” as described in 1776 by the Scottish physician, Louis Brotherson: “In its worst stages, this disease affects the well-being of the female patient totally and adversely, her whole spirit is broken, and yet she lives in fear of still more symptoms such as further pain, the loss of consciousness and convulsions” (Knapp 1999, 13). Contemporary gynaecology has not found a cure for endometriosis, although its description —“an intellectual and therapeutic challenge [which] should be regarded as a recurrent problem” (Thomas 1995, 149) — certainly is drier. Modern treatments include surgery, ranging from laparoscopy to remove and cauterize growths, to total hysterectomy; hormonal therapies (Danazol and progestogens, gonadotropin-releasing hormone agonists) to produce amenorrhea (cessation of menstruation) so as to “halt proliferation of implants and to facilitate healing”; and the advocacy of pregnancy, which is a venerable recommendation, albeit impracticable for many women (Lamb and Berg 1985, 215–16; Thomas 1995, 149). Amenorrhea is another venerable disorder with contemporary theories regarding causation that are similar to those of the Victorian period. These range from “acute psychic trauma (rape or death of a loved one) to chronic emotional stress (internment, attending medical school)” to events that “seem inconsequential (travel, examinations, a change of schools)” (Lamb and Berg 1985, 215–16; Thomas 1995, 149). Modern researchers have added a new category —“sports amenorrhea,” which they relate to anorexia nervosa and which involves “the desire to win in competitions and the emotional stress of training” (Smith-Rosenberg 1985b, 132). Striking about this categorization is the gendered presuppositions of athletic achievement. Bobby Orr, the great hockey player from the 1970s, has been virtually crippled by repeated knee injuries and surgery as a result

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of his sport; the African-American icon, Muhammad Ali, is a shadow of his former self due to head injuries incurred from boxing. But these male sports figures are regarded as battered yet ennobled heroes. When aspiring female champions in gymnastics or figure skating, however, become amenorrheic due to the low body weight required for their sports, they are deemed to suffer from a psychological disorder, despite the fact that, unlike male heroes, their condition may only be temporary. For a woman to voluntarily lose her reproductive capacity, even temporarily, is still viewed as so unnatural that it must be mental illness. A special category of menstrual disorders are those that are environmentally or iatrogenically based (or directly resulting from medical treatment). It has been estimated that anywhere from 1 to 10 per cent of American women were exposed to diethylstilbestrol (DES ), a synthetic estrogen, during pregnancy in the 1950s (Barnes 1984, 654). The negative consequences of this exposure continued to plague their daughters, who have greater difficulties in conceiving and successfully maintaining a pregnancy to full term. They are more likely to suffer from cycle irregularities such as anovulation and oligomenorrhea (scanty menstruation) and abnormalities of the uterine cavity (Schmidt et al. 1980, 21).Young women exposed in utero to DES report infrequent cycles (more than 35 days apart), “a higher proportion of premature births, spontaneous abortions, and [especially] ectopic pregnancies” (Herbst et al. 1981, 1009).14 Other diseases arose from the use of sanitary products to manage menstrual flow. The American Food and Drug Administration (FDA) has classified tampons to be “medical devices” of “middle-risk,” enabling it to create and enforce “minimum product standards.” Yet it has never done so (Rome and Wolhander 1992, 261). As a result of this neglect, in 1978, a study team headed by American physician James K. Todd introduced the term toxic shock syndrome (TSS ) to describe “an apparently new multi-system disease characterized by the rapid onset of fever, hypotension, erythroderma [rash], and delayed desquamation [shedding of skin] of the palms and soles.” Of 2,107 reported cases of TSS in the United States, the team identified death occurring in “10% before 1980, 5% in 1980, 3% in 1981 and 1982, and 5% during the first 6 months of 1983. The reported incidence of TSS in 1980 ranged from 6 to 14 cases per 100,000 menstruating women. Ninety-seven percent of such cases have occurred in whites, who make up 83% of the United States population” (Chesney et al. 1984, 316, 320).Young, white, middle-class women were more likely to use a new product and were therefore most susceptible to the TSS inducing tampon lines (Lamb and Berg 1985, 218). By 1980, cases of TSS were linked to tampons, particularly the “superabsorbent” kind. The culprits were the synthetic fibres used in tampons, particularly rayon polyacrylate (its use was discontinued in 1985) and viscose rayon

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(still in use) which enhanced “the toxin production of Staphylococcus aureus, a type of bacteria believed to be responsible for TSS” (Rome and Wolhandler 1992, 264). It was deemed possible that microscopic particles of these chemicals could enter the body’s lymph system and spread the toxicity. The FDA persuaded the Proctor and Gamble Corporation to remove the worst offender, the Rely tampon, from the market, although it was not the only product linked to TSS. Other companies were persuaded to insert TSS warnings on the boxes or as inserts and to include in the warning that women should use the lowest absorbency necessary. Unfortunately, since there are no standard measures of absorbency — one company’s regular tampon had more absorbency than another’s superabsorbent brand — this warning was of no help. Despite the deaths and disabilities caused by TSS, and despite the lingering questions concerning the long-term health effects of the synthetic fibres and chemicals used in tampon production (the leading American expert, Dr. Philip Tierno, Jr., concluded that only all-cotton fibres are safe), there remains no substantive regulation of the immensely profitable sanitary products industry, which has “refused to measure or limit these fibres and particles” (Rome and Wolhandler 1992, 263–64). There are no statistics available for Canadian cases of TSS because physicians are not required by law to report them. There are also no Canadian regulations concerning the levels of dioxins in tampons; these deadly chemicals, which can affect the reproductive and immune systems, are used in pesticides sprayed extensively over cotton crops. Health and Welfare Canada has set out regulations concerning the absorbency of tampons, consistent with the American and British standards, since tampons are imported from these two countries.15

Conclusion Medical experts found it simpler to list symptoms than to discover causes for menstrual complaints. Robert T. Frank, the first twentieth-century physician to label premenstrual tension (PMT), speculated that an excess of estrogen caused by the malfunctioning of the kidneys was responsible for PMT , but this theory was discounted by G.E. Abraham (1980, 170), who noted that the liver would have rendered the estrogen inactive before reaching the kidneys. Raymond Greene and Katharina Dalton blamed water retention associated with the premenstruum and the subsequent bloating as the consequence of abnormal shifts in the ratio between estrogen and progesterone. S.L. Smith countered that estrogen and progesterone levels fluctuate throughout the menstrual cycle without producing continual mood swings. Researchers have, in fact, found no direct causal

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relationships between hormone levels and mood swings. Other theories include a deficiency in pyridoxine (vitamin B6), “high levels of monoamine oxidase activity, high levels of prolactin, or a withdrawal reaction to beta-endorphin,” yet no clinical studies have produced effective or consistent treatment results relating to any of these. That “psychosocial” factors may have much to do with premenstrual symptoms appears supported by the fact that in one study, “94% of the control subjects reported an overall improvement in their premenstrual symptoms as the result of an inactive placebo, and 84% considered it to be more effective than other forms of treatment that they had tried” (Richardson 1995, 762). If sugar pills can be this beneficial, perhaps the chocolate women crave is not a symptom but a cure! By looking beyond the box of female hormones, researchers have found that in some women menstrual disorders may stem from social pathologies, such as violence. At risk for gynaecological disorders are women who have suffered physical or sexual abuse at some point in their lives, and this number is tragically substantial. A 1996 study found that “an estimated 21% of [American] adult women were sexually abused as children, an estimated 20% to 25% of women are likely to be raped in their adult lifetime, and a nationally representative survey estimates that 8% to 11% of all married and cohabitating women are physically assaulted by their spouses each year.” Sexually transmitted diseases are strongly correlated with serious menstrual problems and/or chronic pelvic pain and abuse, and this association crosses class and ethnic lines. These rates may well be conservative, since African-American women are less likely than others to receive a diagnosis of a gynaecological problem, and divorced or separated women fell out of the purview of the studies. (Plichta and Abraham 1996, 903, 904, 906). Causes of menstrual disorders have been wide-ranging and uncertain; so too have been their cures. Native peoples had a variety of remedies to deal with amenorrhea, dysmenorrhea, and other menstrual disorders. The Arikara women of the Upper Missouri River basin, for instance, used an infusion of wild sage (Terrell and Terrell 1974, 142). Contemporary North American women have a plethora of remedies from which to choose, including “diuretics, sedatives, tranquilizers, antidepressants, amphetamines, antihistamines, bronchodilators, analgesics (aspirin, narcotics, prostaglandin inhibitors, phenylbutazone), ergot, propranolol, muscle relaxants, steroids, progesterone and progestins.” More radical alternatives have included hysterectomy and oophorectomy (surgical removal of the ovaries) (King 1989, 17, 18). Wellness advocates note that some of the best results have been achieved through non-medical means, including “rest, exercise, dietary changes, especially eliminating refined sugar and flours and caffeine, frequent meals, vitamin B-6, oil of evening primrose, reorganizing schedules,

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meditation, relaxation exercises, biofeedback and acupuncture” (Rome 1986, 145). As long as the medical model (and its attendant profit-making apparati) of the normal functioning of the female reproductive system prevails, however, pharmaceutical solutions to its monthly complaints likely will remain at the forefront. How women should deal with the whole notion of PMS is extremely perplexing. On the one hand, the disease model legitimated and supported mood fluctuations that had previously been dismissed as imaginary or neurotic ranting. It also provided a growing area of interest for a medical establishment that had not ranked female complaints as high priorities. On the other hand, the sweeping range of symptoms and duration of the “disorder” served to raise once again the argument that womanhood, in and of itself, is an abnormal, ill state. Aristotle conceived as normal everything static, stable, and male, and this conception continues to cloud and denigrate female physiological experience (Markens 1996, 43). This debate reached a climax in 1987 when the American Psychiatric Association included PMS —“labeling it luteal phase dysphoric disorder”— in the last edition of its Diagnostic and Statistical Manual (DSM ). Terming PMS a psychiatric disorder appears to be a throwback to the Victorian female neurotic condition. However, since modern psychiatry has become strongly based in biochemistry, a hormonally based disorder and a psychiatric condition are no longer mutually exclusive. The lack of precision in the diagnosis and symptomatology of PMS has kept it mired in debate. It is significant that after a storm of protests from feminist health activists, the DSM designation was qualified as being a controversial diagnosis (King 1989, 14). What lessons can be learned from the PMS story? Women must be wary of relinquishing normal bodily functions to a medical establishment that purports to be objective and value-free but that still operates within the paradigm of masculinity equalling health. Female irritability is “understood” and tolerated one week of the month, but the content of that irritability — overwork, stress, lack of money, time, autonomy, and so forth — is dismissed with the excuse of hormones. Male irritability, on the other hand, is acceptable any week of the month, and its content — overwork, stress, lack of money, and so forth — is respected. PMS and all uncomfortable, intrusive, or painful menstrual symptoms should be approached as individual, unique events to address rather than as part of a protean mass characteristic of an inherent disability. Women must not allow the cultural manipulations of their hormones, their wombs, and their blood to cloud their understanding of their real grievances or to stifle their personal and societal aspirations.

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Notes 1 2

3

4 5 6

7 8 9

10 11 12 13

14

These are averages since the length of the menstrual cycle varies according to the individual woman and over the course of her life. Dan 1986, 7. It is probably inaccurate to term this attitude typical of “modern” Japan. Traditional societies are characterized in part by their submission to the forces of nature, and tunnel workers in the depths of the ocean, similar to sailors, miners, and others subject to the constant possibility of impending disaster, have more in keeping with traditional cultures than with modern societies, which have at least the pretension of control over their environments. “Hippocrates on the Humours.” In The Writings of Hippocrates and Galen. Epitomised from the Original Latin Translations, ed. John Redman Coxe (Philadelphia, PA: Lindsay and Blakiston), http://oll.libertyfund.org/ title/1988/128099. The Torah, or five books of Moses, is the first five books of the Hebrew Bible or Old Testament. Interview with Helen Elizabeth Coleman, in Strong-Boag 1988, 15, n.57. I have primarily used the term “Great War” instead of “World War I” throughout the text. World War I was a term used only after World War II began. For people who survived the Great War of 1914–18, particularly during the 1920s and 1930s, it was a shadow that coloured their lives. It led to pacifist movements, the Great Depression, the rise of Adolf Hitler, and Neville Chamberlain’s political concessions that permitted Hitler’s march through Europe, culminating in World War II. The Great War also led to maternal and child-saving movements and legislation, cited in the text, as governments and individuals endeavoured to replace the lost generations, not just the estimated 16 millions who died from the war itself, but the additional 20–40 millions who died from the worldwide influenza pandemic, which also struck cities and towns across Canada and the United States. In the interwar period, the Great War was a term of intense sadness. For a superb introduction to the meaning of the Great War, see Fussell 1975. Valdiserri 1983, 70. Jacobi’s conclusions would find resonance in the psychoanalytic writings of Helene Deutsch in the 1940s. That would be indulgences leading to sexually transmitted diseases. Fenwick 1889, 146. Michelle Magnan, “Health Canada Approves Seasonale,” 6 July 2007, http://www. canada.com/topics/bodyandhealth/sexualhealth/story.html?id=af6f4a7b-fc744433-816d-7fc5862745da&k=10868. “Seasonale,” http://www.drugs.com/seasonale.html. “Seasonale: Side Effects, Ratings, and Patient Comments,” 15 December 2008, http://www.askapatient.com/viewrating.asp?drug=21544&name=seasonale. Matt Clark with Dan Shapiro, “The Monthly Syndrome,” Newsweek (4 May 1981): 74. See also Markens 1996, 48. A 2007 Boston study found that obese men had a much lower risk of suicide, possibly due to their higher production of insulin and other mood-affecting hormones; see Denise Gellene, “Obese Men Less Prone to Suicide, Study Finds,” Los Angeles Times, 13 March 2007: A-13. Other studies, however, have found no significant correlation between in utero exposure to DES and ability to conceive. See Barnes 1984, 651.

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15

“Toxic Shock: When Tampons Can Kill,” Canadian Press Newswire, 14 September 1994: 1; Adair 1999, 15; Health Canada, “Draft Guidance Document: Guidance for the Labeling of Medical Devices, Section 21 to 23 of the Medical Devices Regulations, Appendices for Labelling: Prolonged Wear Contact Lenses, Menstrual Tampons, Contraceptive Devices, and Medical Gloves,” 11 January 1999, http://www.hc-sc.gc.ca/dhp-mps/md-im/applic-demande/guide-ld/ labl_etiq_dv10-eng.php.

C H A P T E R

2

Gladys, Take Your Medicine! THE CULTURE AND BUSINESS OF MENOPAUSE

With so much of female identity bound up in reproduction,

it is not surprising that the last stage of the reproductive cycle — the menopause — should be an experience fraught with socio-cultural meanings. The menopause refers to the cessation of the menstrual cycle, but its common usage, more accurately termed the “climacteric,” concerns the yearslong period of transition. Before 1900, female life expectancy tended not to exceed the menopause by more than a decade, if that, so that it has been associated with death and old age and all of the cultural demarcations of that life course event. By the end of the twentieth century, greater numbers of Canadian and American women could expect to survive their menopause by 20 or even 30 years; social attitudes concerning the status, capabilities, and value of aging women, however, have been slower to change. This chapter discusses the cultural characteristics of aging over the last 200 years with reference to the significance of reproduction, visual symbolism, and economic dependence. It will look at the menopause as experienced by many of the cultures that have contributed to the population of North America, differentiating between the physiological realities and social understandings that have developed over time. The medicalization 47

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of the menopause, which began in the Victorian period and triumphed in the twentieth century, did not replace the social experience with scientific rationalities; rather, the medical model often merely added another layer of patriarchal attitudes to further obfuscate biological realities. The menopause also has become a financial bonanza for the pharmaceutical industry, which has billions of dollars at stake in the maintenance of the menopause as an illness requiring long courses of medication, preferably for all women.

The Cultural Guideposts of Aging Like all aspects of human experiences, the demarcations of age are culturally determined. In early modern English society (the attitudes of which would find resonance in colonial Canadian and American communities), male age transitions took place every seven years with “perceivable decline” commencing at 49 and “old age apparent” at 63. For women, age was (and arguably still is) based not upon chronology but reproductive status and commonly divided, as Lynn Botelho argues, into the three stages of “maid, wife and widow.” However, it was not the biological fact of the cessation of menses that signified popular perceptions of old age but the coinciding visual changes, such as growth of facial hair, dowager’s hump (osteoporosis), wrinkled skin, age spots, and toothlessness. Many of these signifiers were class-related, since upper-class women had access to “beautifying waters, oyls [and] oyntiments” (not to mention a lifetime of better food and less hardship) to conceal or mitigate the effects of aging (Botelho 2001, 45, 51–53). Consequently, old age had the appearance, as well as more often than not the reality, of poverty. The guideposts of reproductive status, visual symbolism, and economic (in)dependence remained paramount in determining middle and old age over the course of the last two centuries. Reproductive Status In demographic terms, reproduction was an essential ingredient in establishing chronological markers because childbirth itself was so dangerous. In 1871, life expectancy for a 20-year-old Canadian woman was 67.3 years; once she reached the age of 40, her life expectancy jumped to 73.6 years. In comparison, life expectancy rates for these two age groups in 1971 were 78.18 and 78.99 years respectively (Leacy 1983). By the 1920s, Canadian women were beginning to overtake men in life expectancy. While American life expectancy figures from 1900 onwards note that women have consistently lived longer than men (46.3 and 48.3 more years

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for 20-year-old men and women respectively in 1900), the post-World War II era was the pivotal point in terms of extending that difference to five years. In 1946, American life expectancy rates were 64.4 years for men and 69.4 years for women. This reflects a substantial decrease in maternal mortality rates. In 1915, there were 60.1 maternal deaths per 10,000 live births among white Americans and 105.6 among African Americans. The rate dipped below 10 per cent for white women in 1948 although not for African-American women until 1960. The increase in life expectancy over the course of the twentieth century extended the average date for entry into middle age from about 30 to 40 or even 45 in both the United States and Canada (Banner 1992, 280; Kurian 1994c, 43–44; Kurian 1994b, 41–42; Strong-Boag 1988, 180). As a reproductive life-course event, female aging is associated with loss of fertility and sexuality and to some extent with the loss of femininity itself. For this reason, older women who bore children were considered both blessed — as was the Hebrew Bible’s Sarah and the New Testament’s Elizabeth and Anne — and dangerous, since such babies ran higher risks of suffering from deformities and their mothers of death in childbirth (Banner 1991, 185, 35). In the 1990s, much publicity was given the successful pregnancy, through in-vitro fertilization, of an Italian woman in her mid-sixties, although societies with very high birth rates, such as outport Newfoundland, record such events as being natural, albeit rare occurrences (Davis 1988).1 In Western culture, attitudes towards the sexuality of aging women are ambivalent but generally negative. Postmenopausal women are expected to lose interest in and “be past” sexual expression, yet there is also a tradition of alleging rampant sexuality among a few (deviant) older women. This contrasts with and challenges the “privilege of aging men to form relationships with younger women,” a privilege that Banner suggests “lies at the heart of patriarchal inequalities between the sexes.” Freudian theory, which gained prominence in North America in the 1950s, considered the lust for younger men to be common among menopausal women, and “so prurient that ... it fell within the prohibitions of the incest taboo” (Banner 1992, 59, 5, 9). The belief that menopausal women lost their sexual urges, was, however, more common in the twentieth century. Marion Hilliard, head of Gynaecology and Obstetrics at Toronto’s Women’s College Hospital from 1947 to 1956, contended that “Most married women would like to announce to their husbands that they are giving up on their love life for a while! But this is very unwise. Life goes on. And this indifference is temporary. Once a woman has passed the menopause, her interest in her sex life comes back, usually in all its glory and sometimes even more so” (Hilliard 1960, 108; for more on Hilliard, see Light and Pierson 1990,

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FIGURE 2.1:

iStockphoto LP.

Wicked Witch: Traditional Image of Aging Beggar-Woman.

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313; Feldberg 2003, 123–43). By the end of the twentieth century, as will be discussed below, “declining libido” was one more symptom for which hormone replacement therapy was prescribed (Li 2003, 109). Visual Symbolism Fears of the power and sexuality of aging women reached their zenith in the Europe of the Middle Ages, when thousands of older women were burned as witches seeking to control men and subvert the Catholic patriarchal order through the black arts (K. Thomas 1971, 530). This image was later homogenized and domesticated into the popular holiday of Halloween, whose stooped, gaunt, long-nosed hag is a distant reminder not only of the accused witches but of beggar-women in general (Banner 1991, 181–82). American essayist Susan Sontag argued that these ghastly images of old women constitute the “visceral horror felt at aging female flesh [revealing] a radical fear of women installed deep in this culture” (1972, 37). By the eighteenth century, femininity as embodied by older women who assumed the “grandmotherly” role was accorded respect, albeit not always power. The adoption of the grandmother role was not in keeping with strict chronology. Even as young as age 35, British and American “rural and conservative women donned white caps under which they tucked their hair, symbolically containing their sexuality.” In the twentieth century, the grandmother’s status and publicity ebbed and flowed with the primacy given youth. In the interwar years and in the 1950s, women in illustrations and advertisements portrayed maturity (Banner 1991, 17, 252, 50). In popular literature and commercial advertisements, older women offered advice and testimonials based upon their supposedly acquired wisdom. The denigrated “old wives’” tales were gold for Madison Avenue (Strong-Boag 1988, 180). To some extent, a similar pattern developed in the last decades of the twentieth century, as the baby boom cohort moved into middle age. Yet youth (even pubescent) culture remained a popular force as boomers seemed unable to surrender their identification with the young and the beautiful. It will be interesting to see what patterns develop in the early twenty-first century. Will there be a revived hunger for Grandma as cultural icon? Grandmothers aside, age has not fared well as an indicator of female beauty. With the notable exceptions of late nineteenth-century theatrical personalities Lillie Langtry, Lillian Russell, and Sarah Bernhardt, who remained popular icons of beauty despite advancing age and weight gain (Banner 1991, 283), standards of beauty emphasized youth, slimness, and fertility. Since female life expectancy increased after the Great War, women could look forward to spending a greater proportion of their lives in a

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life stage not valued and, indeed, increasingly termed an age of “mental and physical crisis” (Strong-Boag 1988, 180). Men could be compensated for the loss of youth with money, power, and wisdom, but the inexorable reality of their aging confronted women head on (Light and Pierson 1990, 313). Advice manuals, medical literature, and newspaper articles alike warned women that aging looks may well threaten their marriages and undermine their happiness, yet cautioned against narcissistic obsession (Light and Pierson 1990, 314). Narcissism is a patently unjust charge when levelled against participants/victims of a visual culture, who are rendered invisible “not only to the male gaze, but to the gaze of youth” for failing to measure up to youthful norms of appearance, health, and energy (Furman 1999, 12). Aging women were both expected to conceal their ages and thus the true body, and disparaged for doing so. As Sontag notes, “The body of an old woman, unlike that of an old man, is always understood as a body that can no longer be shown, offered, unveiled. At best, it may appear in costume”; the elaborate and expensive rituals of dressing, makeup, dyeing hair, and reshaping the body through dieting, implants, and surgical procedures was not so much narcissism but self-protection against the revulsion of woman’s body and, therefore, of woman herself (Sontag 1992, 36–37). These rituals carry the potential for both liberation and alienation. On the one hand, treating the body, and especially the face, as a canvas for perfectibility could have an equalizing effect to help those less fortunate in the gene pool. The disadvantages as beauty’s bar got lifted ever higher, however, were manifold. When the possibility of self-improvement became a necessity, women were ever more alienated from their own bodies in an atmosphere of rising intolerance for imperfection. Furthermore, the business of beauty has remained expensive, both in terms of money and time, and so has served to separate the “beautiful” rich from the “ugly” poor. Although the siren call of “reversing the age process” has been sung for at least a century and the various touted concoctions have been found wanting, this has not led to the conclusion that aging is inevitable and should be accepted; rather, generations of women have felt inadequate for failing to withstand the ravages of time (Strong-Boag 1988, 80). While the last quarter of the twentieth century saw the vista of opportunity expand for women, popular culture has not wholeheartedly accepted aging as one of the possibilities. “Ideal womanhood” was the ability to deal with careers, husbands, children, households, social lives, and volunteer work with serene competence and youthful grace (Barbre 1993, 31). Popular culture portrayed the menopausal woman as a “comic figure ... with a red face, erratic moods, and the ultimate parcel of female troubles” (Weideger 1976, 196). In one analysis of twentieth-century literature,

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menopausal women were found to be virtually nonexistent or merged with the stereotypical neurotic, repressed spinster (Kincaid-Ehlers 1982, 24, 29). Negative portrayals of aging women abound in films and television, ranging from the sexual predations of Gloria Swanson in Sunset Boulevard 2 to the harpies and insane caricatures of the older Bette Davis and Joan Crawford. Canadian literature has many examples of strong, although not entirely sympathetic older women, such as Adeline Whiteoak, the matriarch in Mazo de la Roche’s series, The Whiteoaks of Jalna, Hagar in Margaret Laurence’s The Stone Angel, and Marilla in Anne of Green Gables. Margaret Atwood characterized them as a “tough, sterile, suppressed and granite-jawed lot” (Atwood 1972, 199). A particularly vicious depiction of the menopausal woman is the character of Ursula the Sea Witch in the Disney animated film, The Little Mermaid. Ursula’s crimes range from attempting to regain her throne from Neptune (shades of the pre-patriarchal goddess religions?) to seducing the innocent mermaid’s prince by disguising herself as a young, beautiful woman. For our purposes, this is the far more interesting “crime” since it exemplifies the contradictory directives given to aging women to do (and buy) whatever they can to look youthful but not to compete with young women for male attention. Given the continued hegemonic grasp of the Disney Corporation on childhood, these images likely will remain strong well into the twenty-first century. The television comedy series Bewitched, popular in the 1960s and 1970s and revived in the 2000s, has a number of menopausal or postmenopausal characters. The protagonist is the witch Samantha, played by Elizabeth Montgomery in the original series. Samantha is beautiful, charming, eternally young, and never troubled by housework, child care, or money problems if she chooses not to be — she is the ultimate female fantasy figure. Samantha’s principal foil is her mother, Endora, played in diva-esque proportions (self-centred, mischievous, and vindictive) by veteran actress Agnes Moorehead. Similar to Ursula the Sea Witch, Endora uses her supernatural powers not for good but to infuriate her mortal son-in-law. Her character instructs the audience that the power of older women, if left unchecked, can destroy families. There is also the latent message that this is what Samantha will become when she finally ages. The other older witch character, Aunt Clara, shows signs of dementia and requires supervision. Two other female mortal characters are depicted as regularly using medication: Darren’s mother, for her “sick headache,” and the most memorable character, nosy neighbour Gladys Kravitz, the menopausal clown played by Alice Pearson. Gladys is shrill and irritating; through her snooping she witnesses many episodes of the witchcraft occurring at the house next door. However, her tales are dismissed by her husband with the admonition, “Gladys! Take your medicine!” In the 1960s,

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this medicine would have been recognized by the audience as being either benzodiazepines (e.g.,Valium) or estrogen for perimenopausal symptoms. Clearly, women of a certain age were — and are — not to be trusted nor believed. Economic Independence Images of aging and the realities of women’s health have been intertwined with issues of dependency and poverty. At the beginning of the twentieth century, mature women who were financially self-sufficient were occasionally portrayed. In 1903, Cosmopolitan magazine lauded “the woman of 50” and her “distinctive charm and beauty, ripe views, disciplined intellect, cultivated and manifold gifts.” Old maids or spinsters were to be called “bachelor” girls and women instead (Banner 1991, 276–77). This era was the beginning of modern consumer culture, and these “ripe” and “bachelor” women were literate readers of magazines like Cosmopolitan and increasingly in possession of disposable income to purchase whatever they advertised. It is telling that the change in labels was cited as an indication of the change in status. Originally, the word “spinster” referred to a woman who spun wool, a respectable occupation. By the 1790s, textile production was moving to factories, and respectability for adult women was associated with unpaid domestic housekeeping. “Spinster” subsequently became a synonym for “old maid,” both derogatory terms related to age and marital status rather than work status. But, as always, there were more poor than rich mature women, and as the number of aging women increased, so too did the numbers of those who became indigent and/or institutionalized in old age homes, poorhouses, and asylums for the insane. In Montreal in 1861, for instance, almost 10 per cent of the city’s widowed population in their seventies were in an “asile,” hospice, or general hospital. In Alabama, Kansas, Massachusetts, and Washington, among other states, admissions of patients aged 60 and over increased 300 to 400 per cent by the end of the nineteenth century. This trend continued; by 1940, 223 of every 100,000 patients admitted to Massachusetts psychiatric institutions were elderly (Bradbury 1998, 133; Tomes 1984, 324; Grob 1983, 180–83). The presence of the elderly in all manner of welfare institutions reflected not only the lack of social status of the aged but the dearth of options for families financially and/or physically unable to care for them (Reaume 2000, 46). The most vulnerable to institutionalization were those who had never married or had no children. In asylums ranging from the Sisters of Providence in Montreal to the Homewood Retreat in Guelph, Ontario, single women were admitted in disproportionate numbers to the general population (Bradbury 1998, 134; Warsh 1989, Chapter 5).

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It soon became evident that the elderly who had raised families also faced destitution. Testimony by public health officers, welfare workers, and government inspectors to Canadian parliamentary commissions in 1911 and 1924 concurred that “Under existing industrial conditions many men and women, especially married couples who have reared a family, have found it impossible to provide for their old age.... High rents, overcrowding in houses, make it difficult for the poor to provide for their aged parents....” And the result for the aged was “a hopeless, heartless life.... Women were particularly vulnerable, because of their lower wages. In 1951, 88 per cent of women, and 52.2 per cent of men over 65 earned less than $1,000.00 (the lowest income cohort). In 1961, the figures were 70.7 per cent and 37.4 per cent respectively” (Bryden 1974, 40–42). The institution of federal pensions did not end the poverty. A 1943 study of Toronto’s Welfare Department’s clients determined that the $20.00 per month maximum pension fell 18 to 50 per cent short of meeting minimum requirements. “Many of the elderly surveyed reported living only on bread, butter and tea for the last week of every month” (Struthers 1992, 252). In the United States, while households headed by a male over 55 years were consistent with the median wage of the general population in 1939 ($1,243.00 to $1,231.00 respectively), those households steadily lost ground; by 1970, they earned $8,402.00 annually while the median household income was $8,933.00. The incomes of households headed by females worsened to a much greater extent. In 1939, the figure was $909.00; by 1970, it was $4,797.00 or almost half of the median income (US Dept. of Commerce 1970, Part I , 303). The association of aging women with poverty, then, was real. Their association with disease, however, was more culturally than factually determined.

Menopause as Experience and Not a Disease The medical paradigm of the menopause is so entrenched in contemporary Western society that it is only through an examination of the experiences of other cultures and sub-cultures that the extent of its social construction can be fully recognized. Cultural anthropologists and sociologists have argued, quite convincingly, that the real “change of life” is the transition from the status accorded premenopausal women to that of postmenopausal women, and all of the benefits and disadvantages that may accrue therefrom. Whatever the role of women during the fertile years, it is reversed at menopause. It may signify freedom in cultures where childbearing women are isolated from public life and their behaviour is severely circumscribed (Griffen 1982, 249–50). In such cultures post-menopausal women may gain increased mobility (that is, less surveillance over their

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movements), authority, and statuses, such as holy woman or matchmaker (Brown 1982, 51). Having “become” men, they might accrue increased power “both secular and supernatural” (Griffen 1982, 251). As anthropologist Margaret Mead observed: “Where reproductivity has been regarded as somewhat impure and ceremonially disqualifying — as in Bali — the postmenopausal woman and the virgin girl work together at ceremonies in which women of childbearing age are debarred. Where modesty of speech and action is expected of fertile women, such behaviour may no longer be asked from the older woman, who may use obscene language as freely as or more freely than any man” (quoted in Weideger 1976, 206). The maintenance or acquisition of meaningful roles beyond the climacteric well might alleviate many menopausal symptoms. A Scandinavian study found that menopause was experienced more negatively by rural women who had fewer non-domestic role alternatives than by urban dwellers and by those of lower socio-economic status whose workload never appreciably diminished. Among Israel’s many ethnic groups, the only universal symptoms were vasomotor (hot flushes), and women with higher incomes and stable marital relationships coped best with menopausal symptoms (Millette and Hawkins 1983, 41). Older Native women in Canadian and American traditional communities were esteemed (the term “grandmother” signifies wisdom and respect), and this was reflected in attitudes towards menopause (Bataille and Sands 1984, 37). Among New Brunswick’s Maliseet, “the elder women were the ones to hold places in council and to guide the men” (Anderson 2000, 67), while in Inuit cultures older women were part of policy decision-making. In traditional Iroquoian society, the matriarchs of the Longhouse enjoyed significant political, domestic, and religious power; older women of the North Piegan (Blackfoot) were deemed “manlyhearted”: sexually expressive esteemed wives and skilled workers (Brown 1982, 54). The Mayan welcomed menopause as a respite from frequent childbearing and as a transition to a higher status as a respected elder (Martin et al., 1993). Contemporary Cree Elders use the metaphors of the moon and ocean waters to explain menopausal symptoms: “When that tidal wave comes in, that is when your feelings really get out of control. And when the tidal wave leaves, that is when you are calm” (Anderson 2000, 187). Elements of a folk culture either organically evolving or being deliberately re-imagined can be found in contemporary Canada. In Newfoundland, outport women interviewed by Dona Lee Davis claimed increased post-menopausal status: “Boys had to tip their hats to such women ... people feared them and children obeyed them” (Davis 1988, 69); their maintenance of active roles in the community eased the “change of life” transition. The outport culture also revealed a fascinating mix of folk

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remedies (many of which can be traced to the Galenic models of early modern European medicine) and contemporary public health campaigns. Outport women categorized disorders as emanating from too much or too little “blood and nerves,” a concept rooted in Galen’s humours; they equated a diagnosis of high or low blood pressure with too much or too little blood in the body. By this model, menopausal women were prone to “high blood” because “all the blood has nowhere to go,” although hot flashes were perceived to relieve this condition (Davis 1988, 133, 135). The concept of “nerves” also can be traced to Victorian (and older) medical models that placed emphasis on reproductive organs as ruling behaviour in women and for which over-the-counter remedies (such as Dr. Chase’s or Lydia Pinkham’s nerve pills) and later prescription medication were specified. The outport women did not distinguish between hormones and tranquilizers, considering both to be “nerve pills” (Davis 1988, 147). In Victoria, British Columbia, the Crone Circle Women celebrate their middle years in a ritualistic fashion. As one member relates, I believe there is a certain power in hot flashes. There is a purpose for them. In the old days I’m sure women knew that purpose, but we have lost that ancient wisdom. When you fight hot flashes and tense up against them, they, like menstruation, can be more uncomfortable than necessary. In my house, one advantage to hot flashes is warmth. It is very cold in the morning, so I wait in bed until I feel a hot flash coming on, then I get up and get moving. It’s great, and it saves on the fuel bill. (Amberston 1991, 168)

While the vast majority of Victorian literature on the menopause pathologized the event, a few physicians and reformers denied that the majority of aging women suffered much during it. In 1880, Dr. A. Arnold of Baltimore concluded that no pathology had ever been determined, a position supported by British physician William Playfair that same year (Mitchinson 1991, 94) and by his American colleague, Dr. Andrew Currier, in 1897 (Banner 1991, 277). The Victorian paradigm of the conservation of energy (vitalism3) also served to reverse previous notions of menstruation as beneficial purging; rather, the menopause represented the retention of life force (Banner 1991, 277). Hamilton Ayers, in his guidebook Everyman His Own Doctor (1881), noted that the benefits associated with the ending of childbearing and freedom of sexual intercourse led many women to welcome the menopause (Mitchinson 1991, 94). The eugenics movement, with its emphasis upon population control, gave other positive characteristics to the menopause (Banner 1991, 278). Female medical writers also approached the menopause positively. Dr. Emma Drake, in her 1902 advice book, What a Woman of Forty-five

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Ought to Know (one of the popular Self and Sex Series), soothed her audience by stating that those who experienced an uneventful menopause outnumbered the sick 50:1 to 100:1 and that cancer was not necessarily a concomitant of the menopause, as was commonly feared. She asserted that Native American and Jewish women passed through the menopause particularly easily but did argue, as was regularly related in the Victorian literature, that women who had been neglectful of their health in younger days were “inevitably preparing the way for a stormy menopause” (Drake 1902, 30, 53, 130). Mary Putnam Jacobi, the famed American gynaecologist, was less judgemental towards her female subjects. She blamed difficult menopausal experiences upon the sins of the fathers and the husbands, such as “alcoholism of the fathers; gonorrhea contracted by wives from husbands; sterility due to licentiousness in which the innocent woman may have no share [and] childbirths too close together” (Jacobi 1925[1895], 482). Nineteenth-century feminists, who considered health issues to be an important aspect of women’s subjection, also celebrated the menopause. In 1864, Eliza W. Farnham asserted that “Most women experience a secret joy in their advancing age but have been so overruled by the universal masculine judgment as to see in it only a loss of Power.... We shall soon cease the wailing and lamentation over the first gray hair and the first wrinkle at the eyes” (Formanek 1990a, 28). Such positive views about the menopause reverberated once again with the second wave of feminism in the 1960s and 1970s. This was signalled by the publication of the bestselling feminist health guide and manifesto, Our Bodies, Ourselves, by the Boston Women’s Health Collective in 1971. Our Bodies, Ourselves encouraged women to reject or at least critically examine the medical models of the menopause, as well as those of childbirth, menstruation, and sexuality (Carolan 1994, 195; Millette and Hawkins 1983, 38). Later scholars cautioned that swinging the pendulum too far the other way was also detrimental for women, since those who suffered problems during the menopause might feel inadequate (Kaufert 1982, 141–66) or even avoid seeking medical help on the basis of their politics.Yet studies continue to mount that for the vast majority of women, the menopause is not an illness (Mathews et al. 1990, 345–51). Not simply an absence of illness but a surge of positive power was another view of the menopause promulgated in the nineteenth and twentieth centuries. New role models gave support to Margaret Mead’s portrait of post-menopausal zest (Banner 1991, 279). Reformers such as Elizabeth Cady Stanton, Letitia Yeomans, and Nellie McClung in the nineteenth century, and politicians like Agnes McPhail, Golda Meir, Flora MacDonald, Indira Gandhi, and Madeline Albright in the twentieth century created a new archetype of energy, wisdom, and courage far removed from decay and decline. With such models on the political landscape, it

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is not surprising that writers began to note that many post-menopausal women acquired new vitality or “a second youth.”4 Unfortunately, these positive role models were overwhelmed by the centuries-old negative conception of the menopause and the women who experienced it.

Menopause as Taboo and Disease That the menopause is a negative event associated with despondency and impending death has been the norm, particularly in Western culture. In his Book of Secrets, medieval German theologian Albertus Magnus warned that the gaze of a menopausal woman would damage the eyes of an infant (Banner 1991, 193). Older women were perceived to be powerful because they were freed from many sexual taboos (Kincaid-Ehlers 1982, 28), but the humoral tenet that menstruation was a beneficial purging rendered its end suspect, as if the damming up of bodily humours would lead to the poisoning not only of the body but of the spirit and character of the woman (Banner 1991, 184). The labels of menopause varied; in seventeenth-century England, menopause was termed “the end of the flowers [womanly beauty].” In the eighteenth century, it was “the dodging time,” signifying the belief that women wanted to prolong their reproductive capacities. In the nineteenth century, the French, who are viewed as more appreciative of mature feminine womanhood, referred to the menopause as la crise de la quarantaine (the crisis of being in one’s forties) (Banner 1991, 266). There were, however, far fewer taboos on the behaviour of menopausal women than there were of those menstruating. Victorian Views In 1875, the term “menopause” was coined (Bullough and Bullough 1977, 122), signalling the commencement of the still-dominant scientific disease model. Like other Victorian models of female disorders, this biological event was transformed into an illness with cultural characteristics, being described in the medical literature as the “death of the woman in the woman” (Ehrenreich and English 1979, 111; Mitteness 1983, 162). The ovary was paramount in Victorian gynaecology. Practitioners of this new discipline followed Virchow’s edict that “Woman is a pair of ovaries with a human being attached; whereas man is a human being furnished with a pair of testes” (Weideger 1976, 207). The Greek humoral theories maintained their resonance in the etiologies of nineteenth-century menopausal disorders. In Domestic Medicine, the American physician William Buchan claimed that “the stoppage of any customary evacuations, however small, is sufficient to disorder the

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whole frame and often to destroy life itself ” (see Smith-Rosenberg 1985b, 192). But the mystery and imprecision of this functional disease (i.e., a disease with no apparent organic cause) lent themselves to far more appealing models of causation, which ran the full gamut of Victorian attitudes towards female behaviour and position. The menopause was Everywoman’s purgatory, when her physiology would sit in judgement of her earlier transgressions. If she had consumed or imbibed too much, loved too well, prevented a period or ended a pregnancy, even mounted a soapbox or tossed an egg at a suffrage rally, she would “find this period a veritable Pandora’s Box of ills, and may well look forward to it with apprehension and foreboding,” as William H. Kellogg, health reformer and cereal king, intoned (Haller and Haller 1974, 135). This Pandora’s Box encompassed the full range of diseases, from “dyspepsia, diarrhoea, severe vaginitis, vaginal inflammation, prolapsed uterus, rheumatic pains, paralysis, apoplexy, and erysipelas to uterine haemorrhaging, tumours, uterine and breast cancer, tuberculosis, scrofula and diabetes” (Smith-Rosenberg 1985b, 191). Yet Victorian women could not approach such a dangerous time as adults, according to the medical literature. Rather, their new physiological state rendered them psychologically akin to pubescent girls, thereby requiring medical guidance. In 1890, A.M. Longshore-Potts, an American female physician, concluded that menopause was “the transition of the (sexual) system from an active ovarian state to the quiet condition of a non-ovulating girl” (Longshore-Potts 1890, 94). This was also an oblique warning to menopausal women that they, like schoolgirls, must be removed from the sexual arena, since sexual urges at menopause were “morbid” impulses (Tilt 1882, 79). Should older women consult their physicians, as recommended in the medical literature, they sometimes encountered loathing and disgust. Edward John Tilt, a British gynaecologist, in 1882 described the menopausal woman as having “a dull stupid look” (Tilt 1882, 16), while students at Toronto’s Trinity Medical College were instructed that after menopause, “the genitals loose [sic] their size and become atrophied, hairs make their appearance on the face, the voice changes, the breasts dry up and the whole body assumes the masculine form.”5 Equally unattractive behavioural symptoms were other manifestations of the menopause. In his widely read popular health book, George Napheys noted that “Hardly any one has watched woman closely without having observed the peculiar tint of skin, the debility, the dislike of society, the change of temper, the fitful appetite, the paleness of the eye, and the other traits that show the presence of such a condition of the nervous system in those about renouncing their powers of reproduction” (Napheys 1880, 274).

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One aspect of the menopause that particularly interested Victorian physicians was its effect upon mental stability. As aging women, many of whom displayed symptoms of depression and other neuroses, sought help in greater numbers, filling insane asylums, clinics and waiting rooms, gynaecologists, neurologists, and other medical writers formulated models of psychiatric and neurotic disorders arising from the menopause. This fit in neatly with the Victorian paradigm of the ovarian influence in female physiology, or what was termed “reflex insanity in women” (Showalter 1985, 55). Since the ovaries were the seat of sexuality, medical writers were especially fascinated and repelled by cases of menopausal and postmenopausal “nymphomania,” which leading British alienist (psychiatrist) Henry Maudsley described as “a disease by which the most chaste and modest woman is transformed into a raging fury of lust” (Maudsley 1870, 74). In the February 1895 Dominion Medical Monthly, menopausal mania, or “climacteric paroxysm” was characterized by “hallucinations, sexual excitement, violence, phantastic ideas and obscene behaviour.... Widows, old maids of not very high morals, and, generally speaking, in persons with unsatisfied sexual cravings, or in such who have committed excesses in venery” were its usual victims (Mitchinson 1991, 297). Moral insanity arising from menopause also was cited as a legitimate defence in cases of “kleptomania” or shoplifting in the late nineteenth and into the twentieth centuries, absolving but also stigmatizing the culprit (Abelson 1999, 394; Barbre 1993, 29). The diagnosis of depression or “involutional melancholia,” so coined by the great European nosologist (disease classifier) Emil Kraepelin, was of greater influence and duration. An estimated one-third of all functional psychoses were a product of this disorder, the symptoms of which included “hypochondriasis, pessimism and irritability [leading to] a fullblown depressive syndrome” (Formanek 1990a, 28). Involutional melancholia was a useful diagnosis to explain, in medical terms, the commitment of aging women to institutions in a fashion that did not have to take into account economic dependency, patriarchal inequities, and the apparent growing unwillingness and inability of families to care for non-productive members (see Warsh 1989, Chapter 5). So influential was the classification that, despite the fact that no studies ever supported its existence, involutional melancholia was not removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of the American Psychiatric Association (as well as its Canadian counterpart) until the publication of the DSM III in 1980 (Formanek 1990a, 28). For those treated outside of the asylum, the physician’s consulting rooms were fraught with therapeutics ranging from the banal to the horrific. William Buchan in 1771 advised women to eat a healthy diet, “exercise in fresh air, and live in a protected setting” (Buchan 1771, 335),

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while in 1882, Edward Tilt recommended open bowels and weekly bathing (Tilt 1882, 131). Patients were cautioned against self-medication with alcoholic stimulants, for which there was often “a diseased craving” at this time (Smith 1849, 609; Napheys 1880, 280) and against exposing themselves to “lascivious pictures,” “love stories,” and any other sexual stimuli that might “cause regret for charms that are fled, and enjoyments that are ended forever” (Formanek 1990a, 21). Should such hygienic practices prove inadequate in alleviating menopausal symptoms, there were more drastic treatments such as cold water injections into the rectum or the “introduction of small pieces of ice into the vagina” (Smith 1849, 608). If all else failed, physicians threw leeches into the breach. Tyler Smith recommended leeching for both “cerebral” and “ovario-uterine” symptoms of the menopause, noting that “leeches draw blood more suddenly from the vascular os uteri than from any other part of the body to which they are commonly applied” (Smith 1849, 607). To twenty-first-century sensibilities, the leech reeks of barbarism and its employment in gynaecology the most overt form of misogyny (Showalter 1985, 75).Yet leeching, cupping, and other forms of bleeding were the cherished tools of therapeutics for centuries and, for many Victorian physicians, represented the limits of their medical implements. By the end of the nineteenth century, advancements in surgery allowed gynaecologists the opportunity to remove (healthy) ovaries as a pre-emptive measure supposedly to avoid the symptoms of menopause, although they would soon discover such radical surgery had the reverse effect (Mitchinson 1991, 269). It should come as no surprise that Victorian women began to shun the gynaecologists and seek less invasive treatments, such as those offered by homeopaths, hydropaths, and patent medicine manufacturers. Lydia Pinkham’s Vegetable Compound, the most successful patent medicine for decades, first came onto the market in 1875. Its formula of unicorn root, life root, black cohosh, pleurisy root, and fenugreek seed “suspended in alcohol” provided a timely alternative for women in Canada and the United States and later throughout the world through its ubiquitous advertisements and testimonials describing “that all gone feeling” and “that nervous irritable feeling” it purportedly would cure (Stage 1979, 88–89, 122). It would not be, however, until the 1920s that advancements in endocrinology would result in the replacement of surgery by medication as the central feature of the medical model of the menopause. Twentieth Century: Menopause as Mystery Throughout the twentieth century, the menopause confounded many middle-class women in its grasp and the physicians and psychiatrists whom they consulted. Because “menstruation and menopause are the only physi-

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ological processes in which mild to severe discomfort is a normal accompaniment to healthy functioning” (Weideger 1976, 44), women often found it unnecessary to visit a physician. In a study of 2,500 Canadian women in the mid-1980s, it was determined that only about one-third consulted physicians about the menopause. On the other hand, while the menopause itself is not life-threatening, its symptoms (such as variations in the menstrual cycle) may mimic “any one of an assortment of pathologies affecting the reproductive system, including cancer” (Kaufert 1982, 68, 75). Because the menopausal experience is so varied, modern researchers have approached it in a number of often contradictory ways — ways that reflect their training and wider cultural imperatives. Randi Daimon Koeske has divided the various approaches into biomedical, behavioural science, coincidental stress, and cultural relativist models, reflecting their origins in the paradigms of metabolic sciences, psychology, sociology, and anthropology respectively. Yet such divisions between bodily functioning and behaviour come up short when dealing with such a complex life experience: To treat all self-reported “symptoms” as either wholly psychological or wholly socio-cultural is to radically distort the complexity and variability of bodily functioning ... It is important to acknowledge that socio-cultural factors also influence the actual levels of important biological variable, thereby indirectly influencing bodily experience and behaviour: gene pools, diet, exercise, obesity, sleep, physical and emotional stress, parity, lactation, disease history, available medical care — all are influenced by social and cultural factors in complex and probably unknown ways. (Koeske 1982, 5–7, 12)

Because the menopause has been so amorphous an experience, and a disease with no organic pathology, physicians and researchers have relied upon the symptoms and complaints raised by the minority of women who consult them; in this manner, a menopausal model has been created over the last century, with far-reaching effects for all women. According to one study, women visit their physicians when they experience the following symptoms: “flushes of the head, face, neck and chest, profuse sweating, sensations of cold in the hands and feet, dizziness or faintness, headaches, irritability, depression, insomnia, pruritus (intolerable itching and tingling) of the sexual organs, constipation and increase in weight” (Weideger 1976, 58). However, universal symptoms are limited. In an exhaustive study of 15,000 American women, Nancy Avis et al. (2001, 345) found that across five ethnic groups — Caucasian, African American, Chinese, Japanese, and Hispanic — Caucasian women recounted more psychosomatic symptoms (depression, irritability, headaches, and nervousness) while

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the African-American women reported more vasomotor symptoms (hot flushes and night sweats). Indeed, the consensus of participants at The First International Congress on the Menopause, which took place in France in 1976, was that the “universal early menopausal symptoms were only three in number: hot flashes, profuse sweating, and atrophic vaginitis [dry vagina]” (Flint 1982, 364). Despite substantial ethnic and cultural variations in the experience of the menopause, the medical treatment of choice worldwide is very limited and largely based upon a North American Caucasian model. Menopause as Madness As the twentieth century began, portrayals of the menopause concentrated upon its associated psychological changes and problems, painting all women in midlife “more or less mad” (Michaelis 1911, 49). Such a casually all-encompassing statement reflected the growing acceptance of the psychopathological nature of the menopause and the corresponding necessity for intervention by both medical and psychiatric professionals (Banner 1991, 275). The psychological model found its greatest currency through the work of Helen Deutsch, an American psychoanalyst and student of Sigmund Freud, who specialized in the psychology of the female. Deutsch presented the menopause as a time of loss for women, while her student, Hana Klaus, termed it “a narcissistic mortification” (Klaus 1974, 1187). The Madwoman became a convenient catch-all label for psychological complaints such as depression and anxiety, which, as described in the literature, were often not based upon the menopause per se but upon life course and socio-economic realities. The popular and medical literature described the middle-aged woman as one “who is among the most pitiful of all the unemployed, because she has finished her job and does not know what to do with her idle hands”; “who was too busy rearing her family to develop other interests”; and whose “sense of uselessness is so acute” (Strong-Boag 1988, 183; Prentice et al. 1996, 390).6 Solutions for these structurally based problems were individually and medically centred. If the woman was so inclined, and wealthy enough, she could partake in a lengthy course of intensive psychoanalytic therapy. Should this be unsuccessful, or her symptoms particularly severe, she might be admitted to a psychiatric institution where radical measures such as hysterectomies and ovariotomies were being substituted with electro-convulsive therapy, frontal lobotomies, and injections with hallucinogens. For the vast majority of women who consulted their physicians, treatment involved medication — tranquillizers, narcotics, and stimulants were prescribed by the millions. To add a coda to Karl Marx’s paradigm, if religion was the opiate of the masses in the nineteenth century, then opium was the opiate of the

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female masses in the twentieth — that is, until mid-century, when a new “opiate” would eclipse all others. A distinctive form of middle-aged depression, which coincides with the menopause although cannot strictly be termed to be caused by it, is the “empty-nest syndrome,” as discussed by the American sociologist Pauline Bart in her influential study. Bart found that American Jewish women, especially those of the second generation (whose mothers were born overseas), displayed higher incidence of depression than Americanborn white (Anglo) and African-American women. She blamed the intense focus of these Jewish women upon the family and the subsequent loss of role once the children left home (cited in Seaman and Seaman 1977, 345). In later cross-generational and cross-cultural studies, she found that women whose lives were not “child-centered,” who maintained strong marriages, and whose children lived nearby, had easier transitions to middle age (Bart 1975, 159). By the third generation, when the Jewish women were fully assimilated into American society and when their language skills, employment opportunities, and social acceptance were consistent with other, native-born populations, their rates of this form of depression fell almost to the level of the other groups (Carolan 1994, 198). Bart and others extrapolated her findings to other women suffering similar role loss. The most extreme example of this was noted in Ireland in 1969: “It is commonly believed that the menopause can include insanity; in order to ward it off, some [rural Irish] women have retired from life in their mid-forties and, in at least three contemporary cases, have confined themselves to bed until death years later” (Griffen 1982, 253). By contrast with women whose lives are centred in the home, AfricanAmerican women have had dominant roles as folk healers, midwives, community activists, and upholders of family life (Banner 1991, 6). Bart hypothesized that African-American women who cared for grandchildren suffered fewer losses of the maternal role that comes with age and that their presence in the workplace offered them an alternative focus for their energies. Nonetheless, depression, illnesses, and violence could also accompany “forced” active grand-parenting, when children were delinquent, addicted, or otherwise absent.7 However, African-American and other marginalized women were less likely to seek assistance from health care professionals and therefore were not always reported in mental health statistics (Weideger 1976, 205). Bart’s explanatory model for the psychological stresses associated with menopause were confirmed and expanded for other ethnic groups. A study of Mohawk women in Canada, for instance, found that those accepting midlife changes with the most aplomb were in “synchrony,” that is, they “felt that their lives had evolved as they would have liked along appropriate and expected pathways.... Those who were out of synchrony

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discussed one or more areas of time imbalance that included a discrepancy between expected and actual experiences at midlife, a lack or excess of personal time, a sense of being behind schedule developmentally, and a lack in meaningful experiences” (Buck and Gottlieb 1991, 47, 49). Like African-American women whose life transitions were gradual rather than abrupt, Mohawk women experienced an easier or more difficult menopause based upon other structural aspects of their lives. Japanese women are another cohort who experienced loss of role and status upon the menopause. Western scientific influences were apparent in postwar Japan, where the menopause’s traditional description, “path of blood,” was changed to “damage of the changing years” (Rosenberger 1986, 16). Traditional attitudes altered more slowly. As sociologist Nancy Rosenberger concluded in her study of Japanese women in the early 1980s, socio-cultural influences in the symptomatology of the menopause were pervasive in Japanese culture. The menopause was blamed for an extraordinary range of complaints “such as extreme dislike of housework in the late 30s, frequent anger in the early 40s, stiff shoulders at 46, or bad headaches at 55.” The loss of status based upon function, similar to the empty-nest syndrome, was also part of the menopausal experience for Japanese women. Self-control was a symbol of maturity in Japan, and a depressed woman with no one at home for whom to care was considered to have fallen “victim to her own individual self-will” (Rosenberger 1986, 18). Her liminality — that is, not being fully part of public society nor in charge of a household — resulted in any complaints during this extended period (from ages 35 to 60) being considered menopausal. That this situation was limited to a specific cohort was made apparent by the fact that in recent years, those women who were better educated and/or had full-time careers were much less likely to consider the menopause to be particularly problematic (Rosenberger 1986, 21, 23).

Empire Premarin Whatever the causes of the myriad of symptoms associated with the menopause, the universal nature of the experience did not escape the attention of health entrepreneurs. The venerable Lydia Pinkham’s Vegetable Compound, a nineteenth-century artefact, found a new lease on life in the twentieth century. In 1925, the American Food and Drug Administration (FDA) banned the Pinkham Company from advertising the Vegetable Compound as a medicine for menopause, but this decision was reversed in 1941, when the Federal Trade Commission allowed it to be advertised as “a uterine sedative capable of relieving symptoms associated with menstrual aberrations and menopause.”Subsequent advertisements bore head-

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lines appealing to “Women Who Suffer from Hot Flashes,” and when the FDA demanded proof that there was indeed a medicinal background for their claims, the Pinkham Company began experiments with hormones and was delighted to muster up vegetable estrogens in licorice root. The FDA, however, was not impressed with their claims for what had been a flavouring agent added to the original formula and limited the extravagance of the company’s promises (Stage 1979, 198, 242).8 While Victorian medicine attempted to capture the menopause as a disease, its ephemeral and inconsistent etiology and symptomatology rendered it an imperfect diagnosis. This would change, however, in 1923, when advancements in endocrinology allowed scientists to identify the hormones produced by the ovaries (Bell 1987, 536; Mitteness 1983, 164). The female hormone estrogen was synthesized (an early version was stilbestrol) and distributed to women during the 1930s. The discovery that the menopause increases the incidence of atherosclerosis, a major cause of cardio-vascular disease as well as osteoporosis, justified a prolonged course of estrogen replacement therapy (ERT ) as essential to maintaining premenopausal protection against these diseases (Weideger 1976, 61). Despite reports in the 1940s that linked the new substances with cancer (Prentice et al. 1996, 289), ERT rapidly spread, especially with the distillation of estrogen in pill form, as physicians began to experiment primarily with diethylstilbestrol (DES) as a treatment for the menopause (Mitteness 1983, 164; Bell 1987, 536). By 1947, the hormone craze was in full swing. DES and other female sex hormones, some with thyroid, “were available, from dozens of companies, by mouth, by vagina, and by long-acting and short-acting injection” (Seaman and Seaman 1977, 349). ERT was publicized widely, and its touted benefits went far beyond the prevention of cardio-vascular disease and osteoporosis. In a 1948 issue of Chatelaine, Canada’s leading woman’s magazine, Robert Cleghorn and Karl Stern, psychiatrists at McGill University in Montreal, encouraged women to seek medical help for the menopause and suggested that estrogen replacement would “reduce emotional instability” and “clear up ... nervousness, excitability, irritability, depression, insomnia, fatigue, consciousness, decreased memory and power of concentration, and headaches,” although no empirical evidence supporting these claims existed (Light and Pierson 1990, 313). In other articles in the American popular press before 1950, the menopause was described in both positive and negative terms, with recommendations to seek medical treatment for health problems. After 1950, with the introduction of ERT in general medical practice, the emphasis in the popular literature shifted to negative views of the menopause, highlighting the loss of female sexuality unless menstruation was maintained (Mitteness 1983, 167–68). Problems with the treatment, however, continued to mount. In 1947, Dr.

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Saul Gusberg of New York’s Sloan Hospital and Columbia University reported that an alarming number of cases of women suffer from endometrial bleeding after being prescribed a course of oral estrogen; Gusberg termed this “stilbestrol bleeding” (Seaman and Seaman 1977, 349). This somewhat tempered the calls for widespread estrogen use in other than the most severe symptomatic situations of the menopause during the 1950s (Mitteness 1983, 164). Then the sixties began to swing, and while recreational drug use snared the headlines (and the jail sentences), it was the revolution in prescription medication that set the tone for the rest of the century. Estrogen was not only established as the drug of choice for menopausal women, it was packaged as a beauty care product, a veritable passport to the Fountain of Youth for older women who had to compete with mini-skirted teenyboppers for male attention and social esteem. The guru for this revolution was Robert Wilson, the self-styled “Youth Doctor” who in 1966 parlayed his health manifesto, entitled Feminine Forever, into a best-seller and himself into a media darling, profiled in the popular fashion magazines Look and Vogue and sponsored by several pharmaceutical companies (Seaman and Seaman 1977, 349; Mitteness 1983, 174). The decade subsequent to the publication of Wilson’s book was the height of the estrogen craze, with American prescriptions nearly tripling. The hormone was offered in a variety of exotic formulas, including tranquilizer, vitamin, testosterone, or amphetamine cocktails (Seaman and Seaman 1977, 337). New complaints associated with old age (and not necessarily gender-specific) were added to the popular list, including skin changes, memory loss and forgetfulness, indecision, and hair loss. The menopause was now referred to in overwhelmingly negative terms, with loss of sexuality and youthfulness eclipsing the end of reproduction as the most significant consequence (Mitteness 1983, 167–70). By the last quarter of the twentieth century, more women were in the paid labour force and the birth rate was falling, so that some of the “triggers” for menopausal depression should have been disappearing. Yet the numbers of women seeking medical help for psychological symptoms remained high and indeed increased. Other cultural pressures were impinging upon female acceptance of aging. In particular, there was a growing disjunction between cultural images of female beauty as young (and increasingly younger), (often pathologically) slim, and free from wrinkles, stretch marks, and other proof of life and the reality of the female body at 40 and 50 (Carolan 1994, 194). The allegedly decreased sexual attractiveness of aging women became an integral “symptom” of the menopause requiring medication. Estrogen’s association with female beauty, sexuality, and quest for youth only further infantilized women and undermined their right to complete and truthful information. Pamphlets,

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cartoons, and advice columns (often sponsored or written by pharmaceutical companies) encouraged women to ingest hormones for longterm — sometimes life-long — therapy for what had been reconstituted as a “deficiency disease, like diabetes” rather than a natural part of the aging process (Berger 1999, 23; Daly 1978, 249). Articles in American popular journals continued to focus upon the medical model of the menopause and suggested that only female sex hormones could remedy “changes so diverse as wrinkles and broken hips” (Gannon and Stevens 1998, 11). Three forms of estrogens in ERT preparations led the market. Each could have different side effects. First are “conjugated estrogens equine,” derived from the urine of pregnant mares. Premarin, the most popular brand, was the fourth most prescribed drug in the United States in 1975, with many women taking it in their thirties “just to prevent aging,” some simultaneously with the pill (Seaman and Seaman 1977, 338). By 1991, it was the second most prescribed drug in the United States, with annual sales of $560 million in that country alone (Braus 1993, 47). Second is “ethinyl estradiol,” also used in oral contraceptives and linked to heightened risk of blood clots and stroke as well as “weight gain, tenderness of the breast, headache, and nausea.” Third is “diethylstilbestrol” (DES), a drug used in the morning-after pill; during the 1940s and 1950s, it was also used to prevent miscarriages and suppress lactation after birth, with tragic consequences (Weideger 1976, 66; Seaman and Seaman 1977, Chapters 1–6, passim). The dark side of long-term, artificially raised estrogen levels continued to emerge. In 1971, the New England Journal of Medicine published a study linking DES with vaginal cancer (Seaman and Seaman 1977, 337), a finding which by 1975 was backed by other reports. Despite growing concerns, the medical model of menopause as a deficiency disease to be “cured” by ERT had become so entrenched in the medical profession that even researchers who had uncovered the carcinogenic properties of estrogen fell short of demanding its removal from the physician’s pharmacopeia. In The New York Times in 1975, Dr. Donald C. Smith stated that DES “is an extremely valuable drug and I hope they don’t take it off the market, but we have to start using it more cautiously” (Smith 1975, 1164–67). Amid the controversy, the American National Institute of Health held a major conference in Hot Springs, Arkansas in 1971, after which it published Menopause and Aging, a report that would be extremely influential in formulating government policy and standard therapeutics. Despite a century and more of medical claims to expertise, the report stated that there was a dearth of information about the menopause and female physiology in general, particularly relating to the effects of medication. Despite this, sales of ERT, particularly Premarin, were increasing. By 1973, the journal Medical Letter was cautioning physicians to prescribe Premarin very spar-

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ingly. There were no empirical data that Premarin could cure “melancholy, diminished sense of well-being, and decreased vitality,” as claimed by the manufacturer, and estrogens could in fact increase the risk of cancer. By 1975, a number of reports confirmed that estrogen increased the risk of endometrial cancer, with the danger heightening with each year of use (Seaman and Seaman 1977, 338). The earlier efforts by the Pinkham Corporation and other patent medicine companies to hawk their concoctions as cure-alls were amateurish compared to the well-oiled, well-financed marketing strategies and lobbying efforts of the pharmaceutical cartel. In 1973, Medical Letter had to warn physicians to ignore advertisements, flyers, and sales personnel who advised them to “Keep Her on Premarin” (Seaman and Seaman 1977, 338). Clearly, many physicians were absorbing not the warnings expressed in medical journals but the promises of their glossy advertisements and inserts. When, in 1975, the New England Journal of Medicine published a series of articles demonstrating that the risk of endometrial cancer was five to 15 times higher among ERT users than non-users, Ayerst Laboratories, the manufacturer of Premarin, countered with a letter to all physicians stating that “the studies were weak” (Seaman and Seaman 1977, 355). A year later, still another study confirmed that long-term users of ERT were twice as likely to contract breast cancer as non-users (Seaman and Seaman 1977, 410). Over the next several decades, evidence about the dangers of prolonged ERT use continued to mount. By the 1990s, studies established that endometrial cancer rates were up 820 per cent, and breast cancer rates were 25 to 30 per cent higher with estrogen use over ten years (Berger 1999, 29). One of the raisons d’être for prolonged ERT use was the protection it was said to offer against cardiovascular disease (CVD ), so in the 1980s and 1990s, women were prescribed combinations of estrogen and progestin, another female sex hormone, in courses of hormone replacement therapy (HRT), formulated to lessen the risk of cancer while maintaining the benefits against heart disease. Unfortunately, the studies were still inconclusive as to whether the addition of progestin actually decreased the positive effects of estrogen as protection against CVD. Women therefore faced Hobson’s choice: to risk “endometrial cancer with estrogen alone to prevent CVD, or to take HRT without truly knowing what the long-term effect of progestin on CVD and on her body, in general, will be” (MacPherson 1993, 154–55). As is the case with the risks of HRT (and with everything else to do with the menopause), the benefits of estrogen and progestin remain imperfectly understood. For instance, even the one accepted truth of the menopause — that the symptoms are caused by the loss of estrogen — has been placed in doubt. Women who have had ovariotomies before the

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age of 30 suffer much less dramatic menopausal symptoms than those who have their ovaries removed at 40. The reason for this discrepancy is unclear; one hypothesis suggests that cells become addicted to high levels of estrogen over time, which would render a later menopause more severe (Weideger 1976, 63). Osteoporosis Protection against osteoporosis was another purported benefit for prolonged HRT use. However, there appear to be ethnic as well as individual variations in its benefits. Among Native and non-Native women in the United States, similar patterns of CVD risks related to post-menopausal estrogen use were reported (Cowan et al. 1997, 447–48). But despite the fact that the Native women in the American study had a higher body mass index (obesity) and were non-smokers, they remained at a higher risk for post-menopausal bone loss. Their sedentary lifestyles and low calcium diets have been positively related to osteoporosis (Evers et al. 1985, 721, 724). Other studies called into question the universality of the efficacy of HRT. Among Mexico’s Pima women, “there was no significant difference between the serum cholesterol levels of the pre- and post-menopausal women” (Hamman et al. 1975, 166), while Mayan women of the Yucatan in Mexico, whose estrogen levels tend to be lower than that of American women, and who could expect to live 30 years after menopause, did not experience an increase in the number of cases of osteoporosis (Martin et al. 1993, 1839, 1842). Therefore, the maintenance of premenopausal levels of estrogen to protect against CVD and osteoporosis may not be a universal necessity. Osteoporosis has been estimated to affect one-quarter of all women, and one in eight men over the age of 50 in North America (Berman 1999–2000, 258). The term “dowager’s hump” has reflected its ubiquitous presence across the ranks through many centuries (Banner 1991, 182). An Alsatian pathologist, Jean Lobstein the Younger, labelled the condition osteoporosis (porous bone) in the 1820s, but it faded from interest in research circles until the development of bone density screening technology in the 1980s. Early studies discussed a wide range of physiological and social factors in the etiology of the disease in both sexes, yet North American researchers soon concentrated upon the use of ERT to treat osteoporosis in women (Berman 1999–2000, 257–61). Unfortunately, the protective benefits of HRT are not cumulative since bone loss will begin or resume should the treatment be ended (MacPherson 1993, 154). There may be cultural variations to the rate of bone loss. Inuit women, for instance, were found to lose bone tissue at a rate of 15 per cent per decade after the age of 40, while white women’s bone loss averaged 10

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per cent (Mazess and Mather 1975, 60). Some of the incidence of female osteoporosis in the twentieth century may have been the consequence of medical treatment. High rates of hysterectomies and ovariotomies, leading to artificial menopause, and the prescribing of the contraceptive “depomedroxy-progesterone,” which may lessen bone density, have contributed to the rate of osteoporosis (Berman 1999–2000, 265) as have such socio-cultural factors as the obsession with thinness, associated with a deficient diet and over-exercise, and lack of exercise due to sedentary lifestyles. As with other symptoms related to the menopause, therapies that do not involve pharmaceutical products, such as sodium fluoride and lifestyle changes, have been under-researched and publicized. The exception has been calcium. Promoted by the dairy industry and manufacturers of calcium supplements, additional calcium was found, in several studies in the 1980s, to have “had little or no effect in slowing bone loss, even when the dosage was as high as 3,000 mg per day” (Berman 1999–2000, 269–70). While no longer perceived as the miracle drug, an increase in dietary calcium, along with regular exercise, is still recommended as a preventative measure. HRT and Smoking Just as the monocausational approach cannot explain the “disease” of menopause, the association of menopause with CVD and osteoporosis — and the necessity to embark upon a long-term (or life-long) course of HRT as a precaution against them — is equally inadequate. The most significant risk factors for CVD (most of which are not gender-specific) are hypertension (the most important predictor), smoking, diabetes, high cholesterol, a family history of CVD , and the use of oral contraceptives (MacPherson 1993, 155). Most of these risk factors can be lessened or eliminated through lifestyle changes such as the long-term maintenance of a healthy diet, an exercise program, and the elimination of smoking. Osteoporosis also may be preventable through diet changes and regular exercise. The magic bullet in its pink wrapper may be easier to swallow than the prospect of dragging a sagging posterior to the treadmill or the swimming pool on a dark winter morning, but the potion is not all beneficent. While there are class, age, and gender issues related to the accessibility of health maintenance measures — private health clubs outnumber public facilities, and city sidewalks are not always safe or well-maintained for older women to traverse — the long-term benefits far outweigh the costs for individuals and governments. One notable risk factor associated with HRT is smoking, with its exquisite confluence of corporate interests, governmental acquiescence, and socio-cultural attitudes. It has been determined that women “who

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smoke one-half pack of cigarettes or one pack or more a day may have a fifty to one hundred percent increased risk of Cardiovascular Disease death ... compared to women who have never smoked” (MacPherson 1993, 150). Older women who are on oral contraceptives have a particularly high risk of CVD , as do smokers on HRT . So women who, since childhood, have been bombarded with the ideal of the Independent Woman (who smoked), the Sexually Active/Free Woman (who smoked and took oral contraceptives), the Sexually Desirable Thin Woman (who took oral contraceptives and smoked, starved, and took diet pills to lose weight ), and the Sexually Desirable Child/Woman (who used HRT to stave off the effects of aging) earned, as their reward for embracing these socio-cultural norms, the increased prospects of CVD, cancer, and osteoporosis. The End of the Empire? At the turn of the twenty-first century, the controversy over HRT continues to rage, and the profit margins for the pharmaceutical corporations continue to escalate. As the baby boom generation lumbers its vast cohort through middle age and beyond, the sheer volume of potential consumers of pharmaceutical products and lifestyle aids cannot fail to attract entrepreneurs. It has been estimated that between 1990 and 2010, the number of women between the ages of 45 to 54 will grow 73 per cent in the United States (Braus 1993, 44). In Canada, 15 per cent of post-menopausal women, 30 per cent in Quebec, were on HRT in 1991. From being a low-status discipline on the medical hierarchy, the gynaecology of aging has begun to attain respectability. When Dr. Wulf H. Utian, one of the new wave of menopause gurus and best-selling author of Managing Your Menopause, founded the North American Menopause Society, his organization had a membership of 800 physicians from 20 countries within three years of its establishment in 1989 (Braus 1993, 44). Like Helena Rubinstein in 1950, other manufacturers of cosmetics at the end of the century took the “beautifying” aspect of estrogen at face value; Bonne Bell’s Plus 30 Hormone Cream, containing 10,000 I.U. estrogen per ounce, is touted as a “natural E estrogen to help your skin have a smoother, softer, younger look.”9 The market reach for HRT products has become global. Ayerst, Squibb, Abbott Laboratories, Schering, Upjohn, Roche, and Lederle have become multinational entities that have amassed great fortunes from HRT sales. Premarin has become so inexpensive to manufacture that it enjoys an 80 per cent profit margin before taxes (Berger 1999, 16). The global elderly population for the year 2025 is projected to be over two billion (Berger 1999, 12), the majority of whom will be post-menopausal women. Alternative remedies to HRT have become popular, particularly with the increase in clientele for naturopathic medicines. One of the leading

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ones marketed at the turn of the twenty-first century is wild yam cream, which contains a phytohormone whose effects mimic those of progesterone. Unfortunately, the successes of natural remedies are often exaggerated, similar to many of the homeopathic and patent medicines of the Victorian era. Wild yam is hawked (like HRT) with wide-ranging claims not yet substantiated scientifically. Furthermore, like most naturopathic remedies, there are no quality standards, and drugs in cream form are difficult to standardize in terms of dosage. Increases of “anywhere from 400 to 20,000 per cent in normal progesterone levels” from using wild yam cream twice daily have been reported, resulting in symptoms ranging from weight gain to depression (Jensen 1999, 160). Other suggested therapies for menopausal symptoms include the E, C , and B vitamins, although scientific interest in such research remains minimal (Weideger 1976, 71). Over-the-counter vaginal lubricants, such as Replens and Gyne Moistrin, supply non-invasive remedies for at least one universal symptom of the menopause (Braus 1993, 47). The hegemony of HRT may be diminishing. In July 2002, the Women’s Health Initiative, a group of American researchers, stopped a large longterm study of HRT because it verified that the therapy increased the risk of heart disease, cancer, and blood clots. This was a terrific shock to the medical community as well as to menopausal women. As Dr. Utian admitted, “This is the biggest bombshell that ever hit in my 30-something years in the menopause area.”10 Should it have been? As noted above, the warning signs were present for decades. The FDA initiated an education campaign, including a website, advising women to curtail HRT use. Equally significant was the very limited number of symptoms FDA Commissioner Dr. Mark McClellan described as appropriate for HRT: “Our recommendation is that if you choose to use hormone therapy for hot flashes or vaginal dryness, or if you prefer it to other treatments to prevent thin bones, take the lowest dose for the least duration required to provide relief.”11 There are, therefore, no simple alternatives available at the present time to HRT, but there is much at stake for global capitalism in maintaining not only the medical model of menopause but, more insidiously, the construct that aging means a social and sexual decline that women should avoid at all costs. Moreover, the costs of cancer, heart disease, and other debilitating effects of prolonged HRT are at least as high as the astronomical profits. Women around the world may do well to remember that while growing old may have moments of unpleasantness, it can still be a walk in the park.

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Notes 1 2 3

4

5 6

7

8 9 10 11

Outports are the isolated fishing villages strung along the Newfoundland coastline. See a lengthy account of Sunset Boulevard in Banner 1991, Chapter 1. With the discovery and application of electricity in the nineteenth century, some British philosophers espoused the notion that people have an electromagnetically based life force, or soul. Medical theorists applied this “vitalist” theory to explain nervous exhaustion and other neuroses that seemed to be increasing among their middle-class patients, arguing that their life forces were being enervated, or drained, by modern technology, congested urban life, and bad habits such as masturbation, which drained semen, considered the purest concentration of life force. The theorists recommended rest, nourishing foods, and stimulants such as wine or brandy to rebuild the life force. A.G. Spencer, Woman’s Share in Social Culture (1912); see Banner 1991, 274. An argument could be made that the first recorded case of post-menopausal zest was the biblical figure Sarah who, when an angel promised her a child in her old age, dared to laugh at the Lord — and got away with it. Archy McCurdy’s lecture notes, 1873 in Mitchinson 1991, 95. “Emily,” one of her obstetrical patients in the 1950s at the Women’s College Hospital, described Hilliard as a “battle axe whom she feared and later loathed”; see Feldberg 2003, 137. See Holly S. Kleiner and Jodie Hertzog, “Grandparents Raising Grandchildren: Implications for Professionals and Agencies,” Purdue University Extension Service, January 1998, http://www.uwex.edu/ces/gprg/article.html. For more on the marketing of Premarin in North America, see Li 2003. “How Women over 35 Can Look Younger,” Life, 2 January 1950: 40; see Griffen 1982, 257. Gina Kolata and Melody Petersen, “Hormone Replacement Study a Shock to the Medical System,” The New York Times, 10 July 2002: A1, A16. M. Fox, “FDA Launches Hormone Therapy Campaign.” Reuters, quoted in MedlinePlus, National Library of Medicine, 10 September, http://www.nlm. nih.gov/medlineplus/news/fullstory_13942.html.

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3

Traditional Childbirth MOTHERS AND BABIES

Childbirth is a central, transformative event in the lives of

most women. It can be both empowering and constricting. Civilizations cannot be produced and reproduced without childbirth. Therefore, it is hardly surprising that women giving birth should face countless layers of social preconceptions, directives, and regulations. This has not been lost upon feminist scholars, who have approached the birthing experience from a variety of perspectives, yet who concur that this fundamental aspect of woman’s biology is also a fundamental element in her place in society.1 As an experience, Birth takes place in approximately only one day in a woman’s long life. But no other event encompasses so much pain, emotional stress, exhaustion, vulnerability, possible physical injury or death, and a permanent role change, including responsibility for a tiny, dependent, helpless human being.... The long hours of contractions represent a crisis of sorts, bringing her face to face with the deepest stressors she is likely to experience. (Simkin 1996, 251)

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This chapter will describe traditional birthing practices and the role of midwives among several groups of North American women: Native, African American, pioneer, urban, rural, Latina, and immigrant women. It will examine the arrival of physicians in the birthing room and the displacement of midwives, which, far from being a simple dichotomy of male physicians usurping female practitioners, was facilitated by a number of significant groups of women, including physicians, private duty nurses, public health advocates, and parturient women themselves.

Traditional Birthing Practices Both oral tradition and the fact that midwifery and traditional practices persisted where there was little or no modern medical care — in isolated regions like the Arctic or in impoverished regions like Appalachia or the American rural South — have provided us with vivid portraits of traditional birthing practices. The Inuit comprised small, scattered migratory groups who followed food sources, such as fish runs, caribou, and other game in an extremely inhospitable climate. Therefore, women often gave birth in solitude, or perhaps only with their spouse’s assistance. However, where groups lived in larger, more stable, or regularly visited communities there were recognized midwives. The midwives of Alaska’s Koyukon Athabaskans were respected within an egalitarian culture. Pregnant women were taught to emulate the useful behaviours of certain animals to ensure easy delivery: to be active like the female moose in order to “loosen” the placenta and to wear “porcupine cords” (decorated with quills), since this animal had easy deliveries. Women avoided eating the lower parts of the beaver, because it had difficult deliveries (Klein Kirsis 1996, 63, 66). The Koyukons, like virtually every recorded society, believed in the power of marking an infant, that is, that a pregnant woman’s diet, behaviour, and experiences could “mark” or shape the child’s character and physiology.2 Koyukon women avoided eating the feet of beavers and other clumsy animals to prevent their children from having birth defects such as pigeon-toes or club-feet. Although some received Western training in obstetrics from Episcopalian missionary nurses in the early twentieth century, Koyukon women maintained traditional practices for most of that century (Klein Kirsis 1966, 67, 65). The Koyukon birthing position was to kneel, holding on to a suspended stick, with an attendant squeezing the stomach from behind. Shamans were called in for difficult births. The fragility of a newborn’s existence was recognized by a stricture against either parent using knives or other sharp implements for a few days following the birth to avoid cutting “the imaginary thread of the life of the child.” Koyukon women who

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gave birth in the mid-twentieth century compared traditional village to modern hospital births: “If a woman goes to a hospital she lays on a cold table, her feet in cold [stirrups]; to me it’s very uncomfortable. When the midwife took care of me it wasn’t uncomfortable even though the pain was the same. Later in a birth she might let you lay back, she supports both your knees ... More comfortable than the flat table.” (Klein Kirsis 1966, 67, 70). Native American traditional birthing practices shared many similarities with those of the Inuit. Oglala (Lakota) pregnant women were advised to remain near home in order to avoid frightening situations that might mark the baby. They were also to shun rabbit and duck meat lest the infant be born with a harelip or webbed feet. Pregnant women were to keep clean habits and sew finely embroidered clothing for the infant (Powers 1986, 54). Assisted by female relatives or other women, a Navajo woman gave birth kneeling, holding on to a red sash suspended over her head. In protracted labour, the midwife kneaded her abdomen, or the attendants would turn her upside down and shake her. Throughout the labour, a singer chanted the Navajo creation song. Apache women likewise gave birth in a kneeling position, grasping a door post. While most matrilineal Native peoples did not allow men in the birthing room, the Hopi permitted male family members to assist. Following childbirth, Mexican American women, like their Apache neighbours, tied a faja, or heavy cotton band, around their stomachs to protect the stretched abdomen muscles (Melcher 1999, 182–84). Before 1940, Arizona’s Native women (who included the Navajo and Hopi) and Mexican American women did not go to the hospital unless there were serious complications, such as, frequently, the retention of the placenta. Because of the poor outcomes of these cases, the people associated the hospital with death, much as urban Americans and Canadians had done before advancements in antiseptics and therapeutics reduced hospital mortality rates (Melcher 1999, 184).3 Many Native women preferred the services of traditional midwives, who were esteemed in their communities. Oglala women, for instance, were assisted by hoksiicu (“takes the baby”), skilled women noted for having “the highest character” (Powers 1986, 55). Midwives and Preventing Conception and Birth The functions of the midwife were not limited to assistance in birthing. Preventing unwanted conception and births was an essential component of practice within the traditionally women-centred realm of reproduction. Nineteenth- and twentieth-century physicians, strongly supported by the Catholic Church, attacked midwives partially on charges that they

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performed abortions and dispensed birth control and abortion knowledge.4 Women desperate to avoid or end an unwanted pregnancy, however, viewed this knowledge as a vital part of the midwife’s health services, as generations of women had before them.5 The remedies were varied, albeit not always successful. Since medieval times, midwives from Europe to China collected the black fungus from rye and barley, which produced ergot, and used it to curtail postpartum haemorrhaging. It also was used as an abortifacient.6 Alberta’s Blackfoot medicine women gave their patients a piece of clothing, an amulet, or a bracelet to wear next to their skin to prevent conception. The women were to stand over sweet grass before bed and to paint their bodies with red ochre. Magical objects were often decorated with the symbol of snake or butterfly, which were agents used in both the prevention and facilitation of conception. While such methods have been dismissed as superstition by observers, some historians have argued that psychological influences, including belief in magic, upon physiology cannot be dismissed (Burnett 2006, 242–44).7 In the brutal world of American slavery, preventing births could be an act of resistance. The breeding of workers was essential for the maintenance of the southern plantation economy, and slave-owners attempted to keep their African-American slaves, and their own white wives for that matter, from acquiring birth control and abortion knowledge. Pregnant slaves were given lighter duties and more rations, and infertile slaves were sold to “unsuspecting buyers.” Despite the “incentives,” slave women resorted to abortion and infanticide to prevent their offspring from sharing their fate. After the end of slavery, local granny midwives continued to offer abortifacients and birth control methods, including “alum water,” a mixture of petroleum jelly and quinine dabbed over the mouth of the uterus. Turpentine and pennyroyal and papaya seeds, which produced severe cramps and contractions, were also familiar abortifacients (Ross 1997, 262–63). In the southwestern United States, traditional emmenagogues (substances to bring on menses) and abortifacients used by women of Spanish and Mexican origin included cotton root bark, poleo chino, rue, and wormseed. Rue has been used as an abortifacient in a number of cultures, but it can be very toxic. Cotton root bark was also used for the same purpose by African-American slaves. These remedies were still provided by herbalists within Spanish-American communities in the 1970s; so was the herb Pazote or Jerusalem oak, as a Santa Fe herbalist recounted: “Women will frequently bring in their teenaged daughters, who look like they have just been chastised. The daughter’s menses will generally be two or three weeks late at the time, and mother will dose daughter with Pazote” (Conway and Slocumb 1979, 241, 243, 251).

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In pioneer Canadian settlements in the late nineteenth and early twentieth centuries, the health advice many white women received from Native female healers included birth control and abortion information. As one pioneer later recounted, I guess the priests didn’t approve, but the woman figures that’s the Indian way, not the white man’s way. They sewed a black bag from the bladder of a bear. They’d dry it, then mix it with some liquid, and then they’d lose the baby. There must be some medicine in that. They figure that’s okay. It’s from the land they figure it didn’t do any harm. Well the priest didn’t know about it. Nobody told him about it. (Burnett 2006, 96)

White women, like their sisters of colour, found childbirth a dangerous as well as exhilarating enterprise requiring much physical, psychological, and ritualistic preparation.

White Birthing Experiences For most North American women of European origin, childbirth and childrearing were a constant of their early adult lives. Women in the North American British colonies on average had their first child within 16 months of marriage at 22 and continued to give birth approximately every 18 months until about 40. North American white women were more fertile than their European sisters, due to better nutrition and living conditions, and most breastfed their children for at least one year (Sterk and Hay 2002, 11). How women dressed when they were pregnant reflected their class, region, and mobility needs. In urban America in the first half of the nineteenth century, upper- and middle-class women wore corsets and tightlacing well into later pregnancy, despite the objections of physicians and health reformers. New York physician Valentine Seaman speculated in 1800 that a popular belief held that a corset artificially forced the foetus lower in the womb, resulting in an easier delivery (Hoffert 1989, 32–33). If this was indeed a folk custom, it resonated with Native American and other ethnic childbirth customs such as tying a rope belt around the woman’s abdomen during labour. By the late nineteenth century, women on the Nebraska frontier altered current fashions with extra side lacings and fabric to fit their changing figures and wore shawls and scarves to hide their bellies. Tea gowns and “Mother Hubbards” (loose, flowing wrappers) were popular models for women of wealthier and ordinary means respectively,

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and both met the approval of health reformers (Funderburk 2000, 61–62; Hoffert 1989, 33). North American women of European origin, like those of Indigenous cultures, shared folk beliefs, such as the power of infant “marking,” well into the mid-twentieth century. In rural Tennessee, for instance, it was believed that birthmarks were the result of maternal prenatal experiences: a woman who had been frightened by a snake while pregnant saw a snake-like birthmark on her son’s forehead (Lane 1982, 56). While they attended most births, midwives ranged greatly in terms of training and expertise. Quebec midwives, for instance, were legally recognized and preferred by most women well into the later nineteenth century, despite the appearance of physician-run hospitals. This was the legacy of a structured and educated midwifery system developed in France (Laforce 1990, 36–-41). Midwives were brought to North America with each wave of immigration; their training varied, depending on the traditions of their home countries. North American-born midwives either apprenticed, formally or informally, with midwives in their respective communities or became midwives after they had successfully attended local births and were recommended to other women.8 Midwives performed a variety of practices in the birthing process. Some used massage and lubricants and stretched the labia to expedite dilation and delivery. Analgesics such as laudanum and belladonna were often administered. Birthing positions varied according to local custom and personal comfort, ranging from “crouching, kneeling, standing, sitting in another woman’s lap or on the birth stool provided by the midwife.” While traditional midwifery is portrayed as non-intrusive, midwives took active measures, such as using scissors, pins, or fingernails to puncture the amniotic membrane and pulling whatever part of the child presented itself. Since these activities all took place with minimal regard or understanding of hygiene, infections such as puerperal fever and lacerations could ensue. The major causes of maternal mortality were haemorrhaging, eclampsia,9 and puerperal fever (Sterk and Hay 2002, 14). Following childbirth, women had a lying-in period of days or weeks, depending upon their ethnicity, and socio-economic circumstances. Navajo women rested three or more days after giving birth (Melcher 1999, 183). In some nineteenth-century white American communities, after the initial rest period there was an “upsitting” when the mother would entertain female visitors (Sterk and Hay 2002, 15). Canadian health literature of the 1920s advised mothers to remain in bed for at least two weeks following childbirth. Ten years later this was reduced to ten days and by the 1940s to five days, as the benefits of light exercise and the dangers of embolism from extended bedrest were recognized (Arnup 1994, 82). Certainly many working-class, rural, and indeed all busy mothers

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could not follow the prescription to avoid chores. On the other hand, the reduced time was likely a response to the increasing mechanization of the household. By the 1940s indoor plumbing, washing machines, and other household appliances were cropping up in an ever-increasing number of homes, thereby lessening the extremely heavy domestic labour common earlier in the century. However, new mothers still craved and needed considerable rest following childbirth. Death was an ever-present shadow over childbirth. In 1900, the maternal mortality rate in the United States was one death per every 154 live births. According to Judith Leavitt, if the average number of children were five, then one out of every 30 women could expect to die in childbirth (Leavitt 1986, 25). In family letters in the American antebellum (1830s-50s) period, the fear of death of oneself or one’s newborn coloured the anticipation of birth. In a letter to her husband in 1852, Elizabeth Underwood of Kentucky, who would give birth to eight children, characterized childbirth as “the event most dreaded and terrible to the inexperienced young wife,” while Ellen Green outlined the disposal of her property when she feared dying in childbirth during her third confinement. Miscarriages also were cause for sorrow, even when there were several living children. In their letters, expectant mothers used euphemisms about “coming events,” or “juvenile strangers,” or one’s “disease” (Baird and Crowe-Carraco 1992, 371, 374). Childbirth and childrearing advice passed through the circle of women in preliterate societies. Childbirth was a female-centred event witnessed by local women or “gossips,” a corruption of the phrase “godsib,” or witness to a baptism (Sterk and Hay 2002, 12). In white communities, these circles were the first to be stretched and sometimes broken by increased geographical mobility, intermarriage, rapid socio-economic changes, and extended childhoods in which young girls are decreasingly exposed to and responsible for the care of their younger siblings. Prospective mothers searched for alternative forms of advice and knowledge (Whiting 1974, 9). Occasionally they received information from other mothers. In 1914, the Grain Growers Guide, a Canadian prairie newspaper, published a letter from a Norwegian wife who wanted to share both her advice and her grief after the loss of her baby boy: Dear Mothers All:— Perhaps I am not what you would consider an experienced mother, as I have not been married quite three years, yet in that short space of time has been crowded considerable experience for me. I have had two children, the first is now a big, rosy girl of nineteen months, the second a boy, I have just lost, and have not yet grown strong since the great trial. In both cases I was very ill and had to have a great deal of help from doctors, nursewomen

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and hired help in the home, and the advice and help they gave me I would like to pass on ... Good care of the mother during confinement, and until she can be about at her work again, goes a long way in helping her to regain her old strength and energy ... Let the help in the house be a married woman, if possible, then she will understand how her patient feels and give her genuine sympathy, and bear patiently with her when she is in pain and when she seems hard to suit ... Try to keep the sick one from worrying. Keep her cheerful and interested, and make her feel you are longing to see her back in her old place as mistress in the home ... Well, we live to learn, and I am learning a great deal from the experience of other mothers. I wish someone could be helped by my experiences, then I will not feel I have suffered in vain. (Wife of Norwegian 1914, 14)

To avoid such heartbreaking results of childbirth experiences, many women and men in the late nineteenth century, who now enjoyed the benefits of mass literacy, sought the advice of the new theorists of science, efficiency, and progress. The scientific age manifested itself in every aspect of life, and an ideology of “scientific motherhood” was promulgated by teachers, physicians, and public health reformers and was transmitted through the mass media. Features and advice columns in popular magazines and newspapers, self-help books and university courses, consulting doctors and nurses — all trumpeted the importance of a mother well versed in modern theories and practices in carrying, delivering, and rearing a healthy, happy child (Apple 1995, 161–62; see also Arnup 1994). However, as Rima Apple noted, by the twentieth century, reliance upon modern experts, through the advice literature or through health professionals, was constructed as a necessity, not as a choice, for proper motherhood. Scientific motherhood ideology rendered women “both responsible for their families and incapable of that responsibility” (Apple 1995, 162). Thus in the nineteenth century, educated, primarily urban women turned to the medical profession to ensure a happy outcome to their pregnancy.

Early Obstetrics Prenatal Care By the early nineteenth century, North American physicians, many of whom were developing practices in highly competitive urban markets, began to move into the field of obstetrics. While commonly regarded as tedious work with unpredictable hours, obstetrics was attractive because it provided an excellent entrée for a physician into a family of potential

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patients. The challenge, however, was that the physicians’ ambitions often preceded their knowledge and expertise in the field, which previously had been the purview of women. Heroic medicine was the therapeutic paradigm. Benjamin Rush, one of the leaders of early American medicine, recommended in 1803 that physicians bleed expectant mothers to relieve the symptoms of their “disease” (Hoffert 1989, 21). Most women during this early time period, however, were unlikely to seek prenatal care from physicians, since pregnancy was considered a natural event, not a disease. Medical prenatal knowledge also was murky, including the allimportant time of conception. In 1834, Professor James Blundell admitted that “the most certain mode of knowing whether a woman be in a state of gestation ... is by waiting till the term of nine months is complete.” Medical textbooks estimated gestation to be anywhere from seven to nine-and-a-half months. Women’s folk wisdom supported a 40-week estimate (Sterk and Hay 2002, 11–12). As late as 1900, Dr. William Gardner, Professor of Gynaecology at McGill University, noted that the state of pregnancy diagnosis remained imperfect, with attending pitfalls for practitioners: “Failure in the recognition of existing pregnancy is rarely pardoned by a woman.” Accurate diagnosis was, however, still dependent upon the input of the patient: “A diagnosis [can] be made by a careful investigation of history, symptoms and physical signs [but] we are not always freely admitted to possession of each of these sources of evidence. Many women are proverbially inaccurate as to dates and in the description of symptoms.” Gardner also mentioned a bête noire of the medical profession — women who deliberately misinformed their physicians about symptoms in the hope of procuring an abortion.10 Traditional folk beliefs were replaced by medical theories in some instances. In 1877, Dr. E.H. Trenholme attempted to solve the age-old mystery of maternal impressions by establishing a connection based upon a mother’s stomach: It is by the digestive apparatus alone that the pabulum becomes converted into living matter ready for tissue formation. Emotional disturbances exert a controlling influence over this important process. Depressing influences are able to arrest digestion, while cheerfulness and hope favour digestion.... [Moreover,] traits of character, as well as expression of face and form of body, are also under the same controlling influence of the mother.... The influence of scenery, etc., is well known in the production of many great men, the mothers of such heroes often passing through most exciting and soul-inspiring scenes while pregnant. The direction given to thought and sentiment

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are capable of working marvelous alterations in the physiological development of the young. (Trenholme 1877, 3–5)

Pregnant women consulted nineteenth-century physicians for less uplifting conditions such as severe nausea and vomiting. Dr. M.D. Brochu (1898) of Quebec’s University of Laval used electrotherapy in these cases. Like other aspects of pregnancy, the causes for nausea in pregnancy were unclear, but in the late nineteenth century, they included “exaltation of nervous tension,” “irritation of the medullary centers by toxic materials circulating in the maternal blood,” peripheral irritation of the uterus, gastric ulcer, and intoxication of gastric secretions caused by contractions of the uterus (Evans 1899). Another prenatal condition for which women sought medical attention was eclampsia, considered one of the “most terrifying and dangerous symptoms of parturition” in the nineteenth century. It was estimated that eclamptic convulsions or seizures, the most serious symptoms, occurred in one in 600 pregnancies, with a mortality rate of 20–25 per cent (Moss 2002, 514–15). The cause of eclampsia was unknown, and its origins remain mysterious. In 1843, the British physician John Charles Lever first made the connection between eclampsia and toxemia (poisoning) of the kidneys, resulting in dangerously high blood pressure, the measurement of which was not in common practice until the early twentieth century. Nineteenth-century treatments for eclampsia were heroic: “Bleed, 20, 30, 40 or 50 ounces, until you empty the blood vessels and relieve the plethora; then resort to the usual treatment for apoplexy — cold to the head — mercurial cathartics — active enemata — cups and leeches may sometimes be employed after one free bleeding” (Moss 2002, 516). Delivering Babies —The Emergence of Obstetricians For much, if not most of the nineteenth century, midwives and physicians both worked on maternity cases. Imperfectly trained physicians starting out in practice often “welcomed the knowledge” of midwives, nurses, and even experienced labouring mothers (Leavitt 1986, 59). In York, Upper Canada, midwives worked alongside and enjoyed the patronage of physicians. Sarah Tebutt, an English immigrant who opened her practice in 1829, boasted the patronage of Dr. Christopher Widmer, president of the Medical Board of Upper Canada, who supported the training of midwives in lying-in hospitals (for more on Widmer, see Baehre1995). One of York’s charities, The Female Society for Relief of Poor Women in Childbirth, employed a midwife (Young 2004, 281). By the time York grew into the City of Toronto in 1834, independent midwives were considered respected, skilled health care workers.

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Their numbers were small, and they ranged from immigrants trained in European lying-in hospitals to helpful, trusted neighbours. Edinburgh, the native home of many Canadian immigrants, housed a three-month training program at its Maternity Hospital, and a similar one was offered in Montreal at the charitable Lying-in Hospital. As the numbers of physicians in Toronto increased by 1850, the less successful complained, however, that they had to compete with “quacks” and midwives.11 Certainly midwives were cheaper; in the 1850s they charged $2.00 per delivery while physicians charged $5.00, and, as elsewhere, midwives remained in the home and helped with chores following the delivery. While they may have been successful, urban midwives, like their rural sisters, they were not necessarily prosperous. They lived in working-class, sometimes dangerous areas of the city and were often widows trying to make ends meet. Nevertheless, they were frequently women of standing in their communities (Young 2004, 284–85). Dr. Widmer’s support for the training of midwives was shared by some American practitioners, and several American schools for midwifery were established in the 1840s, including Samuel Gregory’s eclectically based New England Female Medical College, one of the first institutions to train female physicians. The opposition of some aspiring female physicians, such as Elizabeth Blackwell, to the establishment of professionally trained midwives added another layer of obstruction. Female physicians viewed midwifery training as a threat to their own full participation in the medical profession (Sablosky 1976, 11). Despite, or perhaps because of their imperfect knowledge of childbirth, by the 1840s American (male) physicians were arguing that midwives should be trained in all aspects of medicine (that is, be qualified physicians) before they could practice midwifery. This argument served the needs of aspiring female physicians, who used the argument of their “special calling” as women to promote themselves as valuable potential doctors. It did not, however, serve the needs of practicing midwives, who worked outside of the home due to financial necessity and for whom professional education was out of reach, nor did it save patients. Consequently, their lack of professional training and modern instruments, as well as their gender, rendered the midwives relatively powerless and vulnerable to charges of incompetence and ignorance (Donegan 1978, 5, 115). In 1800, Dr. Valentine Seaman published the first American handbook for midwives, The Midwives Monitor and Mother’s Mirror, in which he established male midwives as superior to the traditional female practitioners, whom he characterized as suitable for only “normal” births. As more male physicians began to practice midwifery in the larger cities, they siphoned off the upper- and middle-class patients from the midwives, which further downgraded the latter to association with the poor, the

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immigrant, and the disreputable. To accomplish this, doctors presented themselves as having superior knowledge and techniques to ensure their patients could avoid many of the complications and dangers associated with childbirth (Donegan 1978, 126, 134, 142). Prior to the availability of Chamberlain’s forceps in the late eighteenth century, the presence of male surgeons at childbirth had been a symbol of death — a last-ditch effort to save either the mother or child through horrific practices such as embryotomies, craniotomies, or caesarean sections on dead or dying mothers. With the use of forceps to hasten deliveries, physicians were seen in a more positive light. However, the more frequent appearance of men in the birthing chamber met with considerable popular resistance due to the intimate nature of the female experience and the general belief that midwifery was not knowledge limited to the medical profession (Donegan 1978, 165–67). As Dr. Archibald Hall, Professor of Midwifery at McGill University, argued, “it is a commonly perceived opinion that the practice of Midwifery is an exceedingly easy one, one fully capable of being accomplished by any female or old woman who has herself previously borne a child. There can be no greater mistake ... It is but right and proper that a medical man should be always prepared for any emergency that may arise” (Hall 1860, 17).Yet the public was slow to convince. Only when they could offer new technologies and painkillers did male physicians become an acceptable part of the birthing process. Indeed, patients often demanded new technologies before their physicians were convinced of their utility and safety. Some medical attendants in nineteenth-century Ontario, for instance, avoided too rapid a recourse to forceps, fearing the onset of septicemia and possible malpractice suits. Others only administered chloroform during labour to women who “begged ... most piteously” for anaesthesia (Connor 1994, 124–25). This conservatism did not always have a positive outcome, however; ordinary Canadian physicians as well as leading American specialists were slow to convince about the efficacy of antiseptic conditions in birthing rooms, with tragic results. Walter Channing (1786–1876), Harvard Medical School’s first professor of midwifery, was one of the earliest and most renowned obstetricians in the United States. Like other early nineteenth-century physicians, he delivered babies in his street clothes with no particular attendance to hygiene. Nevertheless, other physicians sought him out to deal with births complicated by lengthy duration, breech presentations, and maternal haemorrhaging or convulsions. Channing’s therapeutics included opium, bloodletting, and ergot to induce labour. His influence upon obstetrical practice had both positive and tragic consequences on his and subsequent generations of physicians. On the one hand, he was one of the first

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Americans to experiment with the use of ether as an anaesthetic during childbirth, and his success encouraged other physicians (and their women patients alike) to advocate its use. On the other hand, Channing remained unconvinced by the findings of his colleague, Oliver Wendell Holmes, that puerperal fever was a contagion spread by birth attendants, including physicians (Kass 1999,78, 83, 85–87). In 1897, Montreal physician F.A.L. Lockhart recounted nineteenthcentury medical knowledge about the dreaded puerperal fever. He noted the work — dismissed by contemporaries — of Vienna’s Ignaz Semmelweis, who discovered the infection of puerperal fever in 1847 and Semmelweis’s policies of producing an antiseptic environment with the liberal use of chlorine. While renowned Scottish physician Sir James Simpson accepted that puerperal fever was an infection, antisepsis was only a part of his recommendations. He advised “prophylactic” use of diet, quinine, arsenic, fresh air, and ventilation as well as a sterile environment, mother, and attendants. For “curative” measures, Simpson fell back upon the traditional armament of the Victorian physician: venesection (bloodletting), leeches, blistering, enemas or purgatives, opium, ipecacuanha, internal turpentine administration, digitalis, stimulants, and washing of the uterus. Lockhart noted that in those cases where physicians were scrupulous in attacking infection, such as doctors Bischoff and Stadfeldt who used carbolic acid in midwifery at the New York Maternity Hospital from 1875–83, the results were remarkably positive. At that institution, the maternal mortality rate from sepsis dropped from 41.66 per 1,000 deliveries to 1.84 per 1,000 (Lockhart 1897, 1–2, 4). Certainly maternal mortality from sepsis was endemic. In 1894, the Ontario death rate from sepsis arising from childbirth was .45 per 1,000. In Toronto alone, the death rate was .71 per 1,000, and Hamilton suffered .97 per 1,000. In Quebec, the death rate was 1.62 per 1,000, excluding the three largest cities of Montreal, Quebec City, and Trois-Rivières. Montreal’s rate was 4.62 per 1,000, and Quebec City was .631 per 1,000. Lockhart speculated that the higher urban death rate was due to more complete civil birth registration among non-Roman Catholics, and the transporting of puerperal cases to the city for treatment in its hospitals (Lockhart 1897, 4). Despite the movement of most parturient women to the hospitals, a 1933 Ontario survey concluded that “there has been no significant reduction in mortality from puerperal causes during the last twenty-five years” (Oppenheimer 1990, 66).12 Clearly, the hospital remained a dangerous place to give birth. The hospitalization of childbirth was a gradual process over the first half of the twentieth century. The poor, recent immigrants, unwed mothers, and others without alternatives were the first to enter charity hospitals, reflecting their bad reputations. As late as the 1950s, some American medi-

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cal schools still focused obstetrics on the provision of home delivery services. This was due partly to the relatively low prestige obstetrics enjoyed within the medical profession. Such specialists were, after all, entering a traditionally female area of expertise. The fledgling specialty blamed midwives and inadequately trained general practitioners for the persistence of high infant and maternal mortality rates, yet they themselves had little to offer beyond a (hopefully) cleaner environment in the hospital — and in many institutions, as we have seen, they could not offer even that (Borst 1998, 221, 223). Obstetrical and Public Health Nursing —Women Bring Women to the Hospitals At the turn of the twentieth century, trained nurses who worked with maternity cases were an essential component in the movement of childbirth from the home to the hospital. As the life-threatening puerperal sepsis became better understood and managed, the hospital’s image improved. Private duty nurses hired by families, as well as attending physicians, highlighted the deficiencies of home births. The nurses who were trained in the maintenance of aseptic conditions and efficiency attempted to reproduce those conditions in households that often had rudimentary plumbing, heating, and other facilities. The maternity room — whether kitchen or bedroom — had to be scrubbed down thoroughly, and so did the labouring mother, who was given a warm bath, soap enema, and a brisk antiseptic douche on most of her body, including the perineum (Rinker 2000, 120– 21). Many of the medical interventions developed by the early twentieth century, and later criticized by childbirth reformers as dehumanizing, were responses to the increased cases of puerperal fevers that followed the hospitalization of parturient cases. Bathing, use of hospital gowns, shaving of the pubis, vaginal douches, and enemas were all techniques to promote an aseptic environment (Sterk and Hay 2002, 28–29). Although private duty nurses had considerable responsibility for quickly changing events, they operated under the model of strict submission to the authority of the physician.Yet, because the doctor did not want to be called before the third stage of labour, many nurses found themselves delivering infants, even though they were not thoroughly trained in midwifery. Faced with the additional challenges of saving both mother and child after the birth, with limited power, knowledge, or resources, nurses encouraged mothers to seek the relative security of the hospital for future deliveries (Rinker 2000, 123). Like private duty nurses, public health nurses, who were the primary providers of prenatal care in the 1920s and 1930s, situated themselves as handmaidens of the medical profession and encouraged their clients to

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have physician-attended births. The advice that pregnant women should make frequent visits to their physicians did not always go over well with the patients or their spouses in an age before government hospital insurance plans. Medical visits were expensive, and physicians were accused of gouging patients for unnecessary care. By the end of the 1940s, a generally prosperous period, prenatal visits were more commonly accepted, at least for the more affluent and European in origin (Arnup 1994, 70–73). The movement of labouring mothers from their homes to the hospital was not necessarily smooth. At the beginning of the twentieth century, American women were accustomed to having both the comforts of a home birth, surrounded by friends, and the expertise of medical professionals and private duty nurses (Leavitt 1998, 3–4). Once germ theory became not only well understood by the medical profession but accepted by the general public, home births, particularly those involving instruments and surgical procedures, became less desired.13 The possibility of being cared for away from domestic duties was also appealing to birthing mothers.Yet the reality of the hospital birth, including isolation from loved ones and submission to the orders and intrusive activities of strangers, was far from ideal. Many of the first generation of hospital patients (roughly in the 1930s-50s) complained about alienation and the lack of empathy from their attendants, particularly the nursing staff. As one woman remembered, “So many women, especially first mothers, who are frightened to start out with, receive such brutal inconsiderate treatment that the whole thing is a horrible nightmare. They give you drugs whether you want them or not, and strap you down like an animal.” This generation of mothers was encountering the generation of hospital-based nurses who were operating under the strictures of efficiency experts and compartmentalization of care. In the process, personal contact with individual patients was lost, and practices such as holding a woman’s legs together until the doctor arrived were experienced and remembered with outrage by parturient women (Leavitt 1998, 4–5, 7, 10, 13). Decline of Midwifery in the Twentieth Century The practice of midwifery was a profession that, like other professions, demanded forbearance and contributions from members of the practitioner’s family. Midwives could expect a relatively lucrative income comparable to that of contemporary female clerical workers, teachers, and social workers. Unlike the former, however, they were expected to be married women supplementing their husband’s income. Since they were often responsible for supporting their families, their husbands, children, and even extended family helped out with household duties. If they could not read or speak English, their adult, more formally educated children

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completed birth registrations and acted as interpreters with government agencies. Anna Carastro, a Philadelphia midwife who practiced in the 1920s and 1930s, was trained to university standards and was as respected in her immigrant community as a teacher or physician. She used her fees to purchase real estate, send her children to college, and open a licensed day nursery (Walsh 1994, 51–53, 56). Midwives tended to practice, although not necessarily exclusively, within their own ethnic group. In Galveston, Texas in 1910, for instance, Louise Ahi and Louise Cambeilh attended 83 and 50 births respectively, primarily of white families, while Sophie Best attended 69 primarily African-American births. Mrs. A. Saklavsky attended upwards of 20 primarily Jewish births each year (Vaiani 1997, 40). Some midwives had considerably larger practices. Canadian midwife Susan Eveleigh, who raised her own family of nine children, delivered 1,534 babies in a career of more than 50 years (Mitchinson 2002, 77). The midwives’ skills and hygienic practices were recognized within their communities, and their patients acknowledged their right to proper payment, whether by cash installments, fruits and vegetables, meats or wine. When infants were stillborn or facing immediate death, the midwives performed Catholic baptisms and were authorized to determine paternity (Walsh 1994, 58, 60). Significantly, it was not the perception of better medical care that led immigrant women to deliver in hospitals rather than by midwives, but the availability of free care in some general hospitals during the Depression. Free or nominally charged hospital care was one positive measure that led to the virtual elimination of midwives in the twentieth century. Others included governmental dissemination of public health information and improved hospital facilities and techniques for urban patients. The most significant negative measure was the unrelenting and powerful opposition of the organized medical profession, which used legislatures to severely constrict and then eliminate midwifery. This opposition, which commenced in the late nineteenth century, discouraged replenishing the midwives’ ranks as the career lost its respectability. As the remaining midwives aged, their eyesight weakened and their techniques became increasingly outdated, further diminishing their appeal as a birthing option.14 In the 1880s to 1920s, urban social reform groups emerged to focus on the worst aspects of tenement life: unsanitary living conditions including contaminated water and milk supplies and inadequate sewage facilities, overcrowding, and the high mortality rate among young children. The latter instance, which captured the greatest attention because of the death of innocents, was blamed in part upon the inadequate training of immigrant and working-class midwives, and the reformers pushed for the training and regulation of these women. Coming as they did contemporaneously with the professionalizing strategies of obstetricians and general practi-

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tioners practicing obstetrics, the drive to train midwives met with fierce opposition (Devitt 1979, 83). A female physician, Eliza H. Root of Chicago, raised the issue of regulating midwives at the 1893 Pan-American Medical Congress. While women had justified their admission to the medical profession — and to obstetrics, gynaecology, and paediatrics in particular — on the basis of their “special calling” as women, they attempted to differentiate themselves from other, less formally educated women who also could cite a “special calling” as well as ethnic and class identification with patients. New York’s Dr. Elizabeth Jarrett derided midwives as “ignorant, unskillful [and] dirty” and stressed that “the woman doctor and the midwife have nothing in common” (Reagan 1995, 575–77). In 1896, the Illinois State Board of Health succumbed to the pressure of Chicago’s obstetricians and established 12 rules for midwives, including direct supervision by obstetricians, registration, case-bookkeeping, and attendance only at uncomplicated births. Most ominously for the hens (the midwives), the rules were to be enforced by a volunteer panel of foxes —“eminent” obstetricians who invariably would benefit from the identification and decertification of offenders. Despite the reformers’ avowed goal of eliminating abortion, the medical boards were reluctant to investigate fellow physician-abortionists (Reagan 1995, 577–78). In her survey of New York midwives in 1907, Nurse F. Elisabeth Crowell found that 40 per cent held European midwifery diplomas, but she considered only 10 per cent to be adequate. She found “midwives carrying rusty scissors, old rags for dressing, and stiffened catheters to induce abortion” (Devitt 1979, 85).Yet in Chicago in the following year she found that over 70 per cent kept their equipment and persons clean. Other reporters emphasized that when taught proper procedures and hygiene, the midwives showed great improvement. The ethnocentric presumptions of the observers blinded them to the fact that foreign midwives, trained in Europe, often received an education far superior to North American medical schools. Furthermore, the programs offered in New York, New Jersey, and the southern United States, including refresher courses, also provided adequate training. Far from revelling in their ignorance, midwives sought out certification and training programs when they were available, often at considerable financial cost (Devitt 1979, 86–87). Dr. Josephine Baker, director of New York City’s Bureau of Child Hygiene, noted that 90 per cent of the city’s midwives, who attended 40 per cent of the births, were immigrants and 93 per cent were literate. Similar results were reported for Chicago, Minnesota, Baltimore, and Texas; in the latter two geographical locations, consistent with their ethnic composition, a significant proportion were African American and Mexican

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respectively. The women also tended to be at least middle-aged, still more fitting the damning image of the crone-witch (Devitt 1979, 84). Midwives, whose clientele were working class and/or immigrants like themselves, practiced in extremely challenging conditions. In 1915, the Children’s Bureau found that in Johnstown, Pennsylvania, the infant mortality rate was double in homes without indoor plumbing compared to those with it. Infant mortality also increased in families where the mother was forced to work outside of the home due to the father’s low wages. Despite the poverty that surrounded them, these midwives did not necessarily have a higher record of maternal and infant mortality than physicians who practiced in wealthier environments (Devitt 1979, 88). In 1911, obstetrics was not considered a prestigious part of the medical profession, and many who held professorships at medical schools “had no special training or liking for it.” In his survey of American and Canadian medical schools, J. Whitridge Williams found that 13 professors “had seen less than 500 cases of labor, five had seen less than 100, and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a cesarean section” (Devitt 1979, 84–85). Even if midwives were inadequately trained, many in the medical profession at this time shared that inadequacy. Despite the statistics, physicians persisted in their attacks upon the midwife, terming her “the typical, old, gin-fingering, guzzling midwife with her pockets full of forcing drops, her mouth full of snuff, her fingers full of dirt and her brains full of arrogance and superstition.” Such invectives replaced real evidence; according to law in 1919, the New York midwife’s bag contained “nail brush, nail cleaner, green soap ... clinical thermometer ... blunt scissors, Lysol, boric acid powder, silver nitrate solution outfit ... medicine dropper ... sterile gauze [and] sterile absorbent cotton.” (Devitt 1979, 89–90). The “vitriolic campaign” by influential American physicians to eliminate midwives as financial competition in the first 30 years of the twentieth century resulted in the decline of midwife-attended births from a national average of 50 per cent in 1900 to 12.5 per cent in 1935 (Devitt 1979, 81–82). One of the methods used by the medical profession and health reformers to put the practice of midwifery into disrepute was to link its practitioners with abortion, thereby placing the traditional practice under legal and governmental scrutiny. According to Leslie Reagan, this was an effective tactic because it spoke to generalized fears about the changing morals of immigrant and single urban women. By the early twentieth century, the overwhelming majority of midwives in urban areas were immigrant women — who by the nature of their class, ethnicity, and gender were de facto disreputable and easy targets for a white and male aspiring obstetrical profession that sought prestige. Although both

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midwives and doctors performed abortions, midwives bore the brunt of investigation and calumny. The ethnic and working-class composition of midwives also propelled middle-class female health reformers to associate themselves publicly with the physicians rather than other women (Reagan 1995, 569–73). Despite the dramatic portrayals of incompetent, superstitious abortionist-midwives, the most effective methods for physicians to replace them was to displace them — i.e., to make structural changes through education and legislation. In Quebec’s medical faculties at McGill University, Université Laval, Université de Montréal, and Université de Sherbrooke, for instance, midwifery courses were replaced by obstetrics and gynaecology, which were subspecialties of surgery, so that generations of medical students were taught to view childbirth as a medical event requiring interventionist techniques. Resident midwives were replaced by physicians in lying-in and maternity hospitals, such as the Anglophone McGill Maternity Hospital and the French Catholic Ste-Pélagie (Montreal) Maternity Hospital. In 1915, Ste-Pélagie’s mother superior was denied a request by the licensing body, the Corporation of Doctors, to upgrade midwifery courses to meet provincial regulations. Hospitals that offered midwifery courses were to replace them with nursing courses. The nursing profession, as it expanded and sought its own legitimacy, joined the fight against the midwives. By 1930, a group of Quebec nurses sought the abolition of midwifery courses at l’Institut Technique de Québec, confirming their own anti-midwife position (Laforce 1990, 44–46). In newer jurisdictions such as British Columbia, the medical societies never allowed midwives to have a legitimate toehold on childbirth, at least for non-Native cases. Obstetrical knowledge was jealously guarded even from nurses, and the Victorian Order of Nurses (VON) failed in attempts to import European midwives to assist women in rural areas where little medical care existed. As a former VON superintendent noted, “The medical profession is responsible for this condition. They do not fear competition of the nurse in any other department of medicine.”15 Winnipeg’s midwives also rapidly disappeared, despite the western city’s substantial ethnic population. In 1917, midwives attended 18 per cent of births, but this fell to 5 per cent in 1925 and .1 per cent in 1945 (Mitchinson 2002, 72). Midwifery remained a significant part of childbirth in the twentieth century only in geographically isolated and impoverished Newfoundland and Labrador, which did not become part of Canada until 1949 (see Benoit 1991). In the early twentieth century, with the establishment of a national birth and death registry in the United States and provincial provisions for registration in most Canadian jurisdictions, extremely high infant and maternal mortality rates soon became evident. American women’s groups

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used these statistics to advocate the passage of a federally funded public health initiative, termed the Sheppard-Towner Maternity and Infant Protections Act of 1921, which provided services such as prenatal centres, well-baby clinics and public health visitors, hygiene classes, and midwifery training. While organized opposition from the medical profession about this perceived encroachment upon their turf led to the repeal of the Act in 1929, this federal initiative had long-term benefits for the medical profession. It accustomed the public to the use and benefits of prenatal care and accelerated the movement from midwife to physician (and obstetrician) through underwriting the costs of obstetrical and hospital care for much of the population (Borst 1998, 224). Equally significantly, it removed childbirth from the female-centred home birthing chamber to the male-dominant hospital, thereby helping to remove the feminine “taint” of obstetrics from the emerging surgical specialty.16 In terms of public health information, the American Children’s Bureau first published the pamphlet Prenatal Care in 1913 and over the next 20 years distributed it to over 22 million women. It is ironic that while the American Medical Association was opposed to the Children’s Bureau, Prenatal Care was a document that promoted the medical model and encouraged women to consult with physicians prior to delivery. Before 1920, only about 5 per cent of American women contacted a doctor before labour commenced. By the 1940s, most pregnant women still did not have prenatal care. Yet by the 1990s, 96 per cent of all pregnant women had regular prenatal consultations. Prenatal Care conceptualized childbirth as “potentially disease-like,” thereby requiring medical intervention. This was despite the fact that for most of the twentieth century, it was not prenatal care that reduced infant and maternal mortality but improved sanitation and aseptic and antiseptic procedures that reduced postpartum infections (Barker 1998, 1068, 1069). The Canadian government took similar measures at virtually the same time to combat the high rates of infant mortality, particularly in the larger cities. Federal expenditures in maternal and child health were justified by the unsettling evidence during recruitment for the Boer War (1899– 1902) that Canadian young men were unfit.17 As Dr. Helen MacMurchy, the founding director of the Federal Department of Health’s Division of Child Welfare (established 1920) argued in 1910, “We are only now discovering that Empires and States are built up of babies ... Armies are recruited only if and when we have cared for our babies” (MacMurchy 1910, 6). Although MacMurchy and other social welfare workers noted that poverty, poor living conditions, and malnutrition were factors in the high infant mortality rate, they focused upon mother’s ignorance and poor rearing habits as most significant. The Division of Child Welfare, like the American Children’s Bureau, therefore produced a series of pamphlets on

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child care, called the Canadian Mother’s Book, which they freely distributed to Canadian homes. First published in 1921, the Canadian Mother’s Book, popularly known as The Little Blue Book because of its cover, was distributed to about 800,000 Canadian mothers by 1933, when the Division was closed. Its chief recommendation was that “doctors knew best” and that Canadian mothers should commence prenatal visits early, follow medical advice, and ignore “traditional sources of information and support” (including midwives) to ensure healthy outcomes to their pregnancies (Arnup 1990, 193). The average mother likely did not jettison popular advice at a pamphlet’s recommendation; folklore, by definition, has great longevity. With respect to the perennial belief in infant marking, Canadian journalist Kate Aitken was assuring her audience as late as 1955 that “the appearance of your baby or his features or his body cannot be influenced by your encountering something ugly or horrible” (cited in Arnup 1994, 69). The general mobilization of the domestic population in North America with the outbreak of World War II further expanded the roles of the federal governments and had the unforeseen consequence of accelerating the movement of maternity cases from the home to the hospital. Recognizing the medical needs of soldiers’ families and the absence of physicians on the home front, the American federal government passed the Lanham Act of 1941, which paid for the construction of 847 hospitals in defence areas by 1946. With the consequent availability of maternity wards, and with the financial benefits of the Emergency Maternity and Infant Care Program (EMIC) of 1943, which underwrote obstetric care for the wives of servicemen, the admission of thousands of American women into hospitals was facilitated (Borst 1998, 236). There were improved services in Canada as well, although not to the extent as those enjoyed by American military wives. In 1946, the Province of Ontario legislated one complete prenatal medical examination for all resident mothers-to-be, reflecting the movement to physician care, as well as to hospital care, which had been growing since the 1920s. In 1947, almost 40 per cent of Ontario women received prenatal examinations, increasing to 54 per cent by 1949 and 66.5 per cent by 1953 (Oppenheimer 1990, 67). Increased medical care was not an option for all Canadian or American women, however, and the real tragedy of the elimination of midwifery was that it often was not replaced for many years, if not decades.

Rural Childbirth In the transitional period when midwives were being displaced but doctor care was not available to all, many groups of parturient women were

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without proper obstetrical support, often with deadly results. 18 These groups included women pioneers in new territories far from organized (or any) medical care, white women in isolated, indigent areas such as the American Appalachian region, and African-American women in the rural South who were isolated by their race and poverty. Prairie Childbirth In the classic Hollywood Westerns of the mid-twentieth century, the greatest threats to frontier women and children were marauding Johnny Rebs or Mexicans or Indians or whoever the villain of the day happened to be. Those threats could be and were successfully vanquished by a male hero with noble profile and glistening rifle. The reality, however, was that the greatest danger for the pioneer woman and her children was a solitary childbirth in primitive conditions. This threat was greatest in the colonial period through the early nineteenth century, but it extended well into the twentieth century, even as the medical profession slowly established its sovereignty over childbirth and its reputation as the saviour of mothers and babies. In Canada, the last European frontier was the Northwest Territories, which included the prairie region of Saskatchewan and Alberta (proclaimed provinces in 1905), the British Columbian interior, and the far North. Hundreds of thousands of pioneers were enticed by the Canadian government with the promise of free land, particularly in the prairies. The land may have been free, but the costs were high. From the opening up of western immigration in the 1880s until the 1930s, the experience of homesteading for women was defined by childbirth: Conditions and circumstances converged to make an expectant homestead woman vulnerable and powerless: the isolation, the poor trails and slow means of transportation, the uncomfortably cold (or hot) shack, the unpredictable weather, the lack of medical facilities and personnel, the lack of friends and relatives, the lack of compassion and understanding from her partner, her lack of knowledge about childbirth, her own weakened condition from overwork and an inadequate diet, and her inability to abandon even temporarily her responsibilities on the homestead. At the same time, the ways in which prairie women approached the challenge of childbirth, sometimes many times over, demonstrated remarkable resourcefulness and fortitude. (Langford 1995, 279)

The checkerboard of land grants in the prairies meant that each homestead was isolated from the next, so that many women gave birth

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alone. Doctors were far away, if available at all, and many were farmers who only practiced medicine part-time. Medical fees, such as $25.00 plus $1.00 per mile for maternity cases, were expensive. Although some rural doctors waived or carried the fees for indigent patients, others did not or could not in a region where so many homesteaders were rich in land but poor in other material resources. Rural doctors also varied in their competence and sanitary methods (Langford 1995, 283). Despite the shortage of physicians, the provincial medical societies, located in the cities, refused to license midwives. Much of the literature on the poor health care and food provided to Native peoples on prairie reserves, which led to epidemics and the devastation of communities, has blamed the federal government, far away in Ottawa, for criminal neglect, in fact if not in intent.Yet the dearth of medical care for prairie homesteaders also calls in question the competence of local as well as federal politicians. The women who survived, indeed thrived, under these conditions were those who successfully took care of their own home births, at times by themselves; who sought outside assistance, often from neighbours; or who left the homestead to give birth elsewhere. Husbands, hired men, and older children regularly assisted in the birth. Despite their lack of training or experience, homestead women also sought each other out for mutual aid in these times (Langford 1995, 279). Because of these conditions, pregnant women had to face the possibility of death for either themselves or their newborns, particularly if any complications followed the birth. In her memoirs, pioneer woman Peggy Holmes wrote, “There were so many bereavements in the district. Two widowers were left with seven children each. That made fourteen more motherless children to be cared for. Most of the deaths were caused by neglect at childbirth and still the government would not allow midwives to be licensed in Canada. Why not I wonder?” (Holmes 1980, 164). As politicians and medical societies debated the broader issues of professional qualifications and licensing, the mothers and babies without support died or suffered long-term disabilities. The same politicians who had encouraged settlement of isolated rural areas, without providing the infrastructure or medical support for the safety and health of these homesteaders, had to share part of the blame (Langford 1995, 283). The medical societies who decried the competition of “ignorant” midwives left women vulnerable to truly ignorant care. By virtue of their womanhood, neighbours were forced to be midwives by default. Homesteader Clara Middleton recalled her own experience: His wife was in labour and would I come? I protested that I wouldn’t be any good, that I knew nothing and urged him to go at once for Mrs. Lane. No, his wife wanted me.... In a rebellious mood I dressed,

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and while still sure that I must refuse got into the wagon. My own child had been born with a doctor and a nurse in attendance. I had been a passive figure in their hands. What I knew or didn’t know was of no consequence. Now it was of terrible consequence. So I arrived at the house distinctly “in a state.”... I waited until the doctor [who arrived after the birth] said the mother would be all right, and then went home to stumble into bed and gave my ragged nerves a rest by a fit of wild crying.... I went there every day for two weeks, and the Barnes family, quite foolishly, regarded me as a sort of benefactor, when in reality I was only an ignorant woman standing around helpless in the face of a crisis. (Middleton, 1947, 48–50)

Lena Kernen Bacon was a homesteader with nursing training, and she held parties to teach her neighbours about childbirth and care. However, according to the laws of the territory, she could have been prosecuted for performing midwifery services. Some physicians, recognizing the exigencies of rural life, provided on-the-spot training to women present at births (Langford 1995, 288). Nonetheless, it is not surprising that prairie women would be at the forefront of women’s suffrage and women’s welfare institutions in Canada during this period. Women in eastern and central Canada, sharing their concerns for the dearth of maternity services in rural areas, joined them in this work. From the 1890s until the 1920s, some women’s groups, spearheaded by the National Council of Women, attempted to deal with the high rates of infant and maternal mortality in Canada by recommending that trained midwives be placed in communities without medical care (Langford 1995, 289). The VON was established in 1897, shepherded by Lady Ishbel Aberdeen, wife of the Governor General and leading feminist. Its reach was limited, however, by opposition from medical and nursing societies, and it did not have the resources to access the widely scattered rural areas where midwifery support was urgently needed. The full extent of this need was not realized before 1924, when the Canadian Medical Association commissioned Helen MacMurchy to prepare a survey of maternal mortality. MacMurchy discovered that far from being the “Healthful White North,” Canada suffered from a rate of 6.4 maternal deaths per 1,000 live births, which was 45 per cent higher than in Britain. Furthermore, many feminists correctly made the association between maternal and infant mortality rates; MacMurchy found that infants who lost their mothers at childbirth were far less likely to survive themselves (Arnup 1994, 58–59). The VON set up small cottage hospitals by 1904, but the communities could not financially sustain them. Furthermore, they did not meet the needs of isolated prairie women who could not leave their homesteads

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and other children to travel to the hospitals. In 1910, Saskatchewan offered a “maternity package,” which included a few basic supplies for newborns, as well as “maternity grants” to pay for doctors’ fees. The grant was not considered a right, however, but a charity administered by local magistrates. Alberta established a municipal hospital system in 1917, but it did not serve three-quarters of the rural women. The province also provided public health nurses who were not permitted by law to attend childbirths. Alberta’s most successful, but tiny, endeavour was to place in 1930 four female physicians, who travelled by horseback in remote areas. Wherever physicians were introduced into an area, the prospects for mothers and their babies immediately improved (Langford 1995, 291, 293). The imperfect care offered by rural nurses, who could not be given full midwifery training by the mandate of the organized medical profession, is evident in the reminiscences of Helen Wedel, a Mennonite living in the Canadian prairies in the early twentieth century. Her first delivery took place in her farmhouse, where her husband, who was holding the kerosene lamp, passed out from the chloroform. She was delivered by both a doctor, who stayed for the afterbirth, and a midwife, who came every morning for a week, bathing the baby and looking after the mother. After the sixth or seventh child, it was more convenient to give birth in the hospital and have the older children supervise the younger ones at home during labour and recovery. But rural hospital birth was problematic. In one delivery, the nurses “were a bit flustered, they were just changing shifts.” Helen felt the baby coming before the doctor arrived, and the head nurse instructed her assistant, “Push it back!” which she did with cotton wool, stopping the contractions momentarily. When Helen’s husband heard this, he ran to find an older nurse, Sister Johanna, who prevented the women from pushing the baby back in a second time. Both younger nurses were later fired, but what midwifery training would they have had, given the nursing textbooks of the day (Martens and Harms 1997, 11, 14, 23–24)? Isolated rural areas in the United States had similar experiences during this time period. In rural Arizona, for instance, there were registered and impromptu midwives, who helped to save mothers, though not always infants. This had much to do with poverty and poor living conditions, particularly among Native American and African-American communities. The Arizona State Board of Health regulated midwives by statute in 1920. Professional (paid) midwives had to register with the county and follow the state “Midwifery Safety Rules,” which included proper hygiene, the administration of silver nitrate eye drops to the babies, and the reporting of births within five days. The regulations also set out the limits of the midwives’ authority; they could not introduce any instruments or fingers into the birth canal or administer drugs, and they had to refer any difficult or protracted births immediately to a physician. The realities of an isolated

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rural population meant that many midwives were unaware of the rules, and many births went unreported (Melcher 1999, 184, 188). Where both midwives and doctors were available in rural communities, women often preferred midwives because they were cheaper. The Arizona Mormon community also preferred midwives since their leaders disapproved of male attendance in the birthing room. To get the best modern care for their womenfolk, the Mormons sponsored the education of a number of women in eastern medical schools (Melcher 1999, 185). They also sponsored classes in hygiene and midwifery, such as those organized by Eliza R. Snow in 1873 in the capital of Salt Lake City, and invited women from each ward to participate (McPherson and Mueller 1997, 341). The Mormons were fortunate to get qualified foreign converts to practice and teach midwifery. Hannah Sorensen, a Danish citizen who had practiced obstetrics in Denmark for 22 years, left her home, marriage, and 10 children to immigrate to Utah, where at least one of her sons later joined her. Once in the United States, she was commissioned by the church authorities to teach midwifery and general health information to women in the smaller Mormon settlements (McPherson and Mueller 1997, 336). In her 1892 book, Notes Written for the Benefit of Members of the Woman’s Hygienic Physiological Reform, which was based upon European homeopathic principles,19 Sorensen interestingly held men as well as women accountable for the future health of their offspring, stating that a virtuous man must be free from bad and contaminating habits such as drinking, gambling, smoking, swearing, blaspheming and ... promise to live a strict continent life [because] the wife is poisoned by having a husband that uses tobacco, by intercourse with him, for nicotine is all through his body and there is a large portion of this in semen, and the delicate organs are so susceptible that they become diseased. (McPherson and Mueller 1997, 342–44)

Sorensen also promoted proper aseptic procedures, such as boiling bedcovers and using clean white cloths in which to wrap the newborn. In practice, the Mormon childbed scene was similar to the Native experience. When labour was protracted, elders were called in to pray by the bedside. The midwife remained with the family, or visited daily, to help out during the 10-day confinement (McPherson and Mueller 1997, 348, 341). In rural West Virginia and Maryland, other isolated, impoverished areas, midwives delivered babies well into the second half of the twentieth century. Amy Mildred Sharpless, for instance, delivered 784 babies over a 31-year career. She undertook midwife training at a nursing school but

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was still unlicensed when she delivered her third baby. She provided more extensive care than doctors offered: You seen the doctors didn’t want to do deliveries. There were times when I would be out a day and a night more, and after the baby was born, there was a cleanup procedure plus all the care required to make sure that the mother and child were both doing well before I left.... In those days [she was licensed in 1938] we kept the mother in bed ten full days after the delivery. So I always went back to the home on the third and the seventh days to check the mother and baby and to bathe them. (Beckman, 1993, 55–57)

Sharpless saw herself as an associate rather than as a replacement of the doctors, although some patients may have thought otherwise: “If I knew ahead of time that the mother was pregnant and was expecting me to do the delivery, I insisted that she have an examination by a doctor. Most of the ladies did, but some would wait until they were in labor and send for me.” Sharpless’s supplies reflected the poverty of the midwife and her clientele. She used bleached feed sacks, sterilized in her oven, to make birthing pads (Beckman 1993, 60). Nurse-Midwifery and the Frontier Nursing Service The specialty of nurse-midwifery developed in the 1920s out of the urban public health movement’s concern for high rates of infant and maternal mortality and its focus upon immigrant and working-class midwives as one of the causes. Nurse-midwifery experienced rapid growth following the passage of the Sheppard-Towner Act of 1921, with the establishment of two centres: the Frontier Nursing Service (FNS) in eastern Kentucky in 1925 and the Maternity Center Association (MCA) in New York City in 1931. Practitioners first completed standard nursing training and then postgraduate training in obstetrics. Along with attending births, the nursemidwives functioned as public health nurses, holding classes for parents and traditional midwives. This experiment met with immediate success, with the maternal and infant mortality rates in both regions falling as a consequence. However, due to opposition from the medical profession, particularly the obstetricians/gynaecologists, and the declining status of female professionals during the middle decades of the twentieth century, the initial promise of nurse-midwifery did not materialize (Ettinger 1999, 47). The Frontier Nursing Service was founded by Mary Breckinridge (1881–1965), a British-trained midwife from an elite Kentucky family. Breckinridge distrusted government involvement and control of public

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health organizations, so she developed the FNS along the lines of a private charity, with committees of wealthy patrons engaged in fundraising. The FNS offered unique public relations opportunities such as founding a volunteer corps of “couriers,” debutantes from Kentucky’s “horsy set,” who looked after the nurse-midwives’ horses. Breckinridge also exploited the racism and nativism of the 1920s by emphasizing the necessity to protect the “pure” Anglo-Saxon stock of the quaintly “uncivilized” Appalachian “hillbillies.” Yet she emphasized, and this was reproduced in media reports of the FNS, that the service was only for the poorest and geographically isolated communities, therefore avoiding direct economic competition with the state’s physicians (Ettinger 1999, 48–50, 52, 54). The success of the FNS was attributed to the fact that “the midwives go out to the homes of their clients and are aware of the environmental conditions producing the inability of a patient to understand the instructions or follow them. [The nurse-midwife] will check on small children and also on other aspects of the pregnant woman’s health” (Devitt 1979, 82). The success of this badly needed service in an isolated rural area led to the opening of New York’s Maternity Center Association (MCA ) in 1932 to train American nurse-midwives to treat poor immigrant women in the densest tenement population of the country (Bergstrom et al. 1999, 29). The MCA also initiated a large public relations campaign to bring pregnancy and childbirth information out of the shadows, the highlight of which was an exhibit at the New York World’s Fair in 1939 that was viewed by over 700,000 people. In this exhibit and in its other literature, the MCA emphasized the value of a physician-assisted birth, despite the organization’s own training of nurse-midwives. By the 1940s, the MCA, now with prominent obstetricians on its board, noted the attendance of an obstetrician (rather than a general practitioner or midwife) as the optimal type of delivery and changed its focus to providing access for poor women to the specialists. As more hospital care was available to poorer women by the mid-1930s, and as the maternal mortality rate declined, the urban nurse-midwife became less relevant and harder to promote as a separate profession (Ettinger 1999, 55–57, 59). Elizabeth Berryhill, a Canadian nurse from London, Ontario, was one graduate of the MCA and founding member of the American College of Nurse-Midwives. Her background in public health and her avowed intention to return to the field in Canada were prerequisites for entry into the MCA; only public health nurses and foreign nurses returning to their countries were deemed to be acceptable non-competitors for physicians in obstetrics (Bergstrom et al. 1999, 33). This same severe stricture upon potential female rivals for lucrative private practice was put in place at the Hôpital St-Sacrement de Québec, the province’s sole school for midwifery, which exclusively trained missionary nuns for work abroad

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(Laforce 1990, 43). Because of the realities of rural life, however, midwives did exist, did practice, and did receive varying levels of education and financial remuneration. In two disparate regions, the American South and Newfoundland, granny midwives flourished for much of the twentieth century. Granny Midwives Granny midwives — a term of respect within their own communities but paternalistic derision among the white medical elite — comprised an essential component in the American southeastern states with their large, impoverished, isolated African-American populations. Through apprenticeships, granny midwives passed on their knowledge, some of which had African roots. These included the ritualistic disposal of the afterbirth and the “taking up” ceremonies, when the mother resumed her normal life. Other traditional beliefs found resonance with Native shamanistic practices, such as that of performing prayers and religious rituals during the labour and for the midwife to consider herself divinely called to the work. Many of the midwives’ practices, which had been abandoned with the rise of hospital deliveries, have been rediscovered, such as keeping the mother moving during labour and using massage to facilitate delivery (Holmes 1984, 389–90). Following the passage of the Sheppard-Towner Act, the American Children’s Health Bureau implemented measures to combat high levels of maternal and infant mortality in impoverished rural areas, particularly among African Americans. Arkansas, a state in which two-thirds of its residents were rural, was particularly lacking in proper health facilities for its African-American population, and racial barriers prevented the training of physicians and nurses within their own communities. In 1940, with only one physician for 1,382 people, three certified obstetricians, and 23 hospital beds for African-American women in the entire state, there was a desperate need for prenatal and obstetric care. The care that did exist was provided by the granny midwives, who were delivering one-quarter of Arkansas babies by 1941. Since 1925, the state health department tried to lower maternal and infant mortality through the regulation of the midwives, who were required to secure annual permits. By 1940, they had to have a physical examination, Wasserman test (to diagnose syphilis), and a clean bag. Nevertheless, fully one-third of active midwives were never registered. As the disparity between white and African-American maternal mortality rates persisted through the 1940s, the state medical society considered outlawing midwifery or replacing the granny midwives with nurse-midwives. Neither of these responses was feasible, however, since there were no practitioners or hospital beds with which to replace them.

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The only practical solution (save providing the necessary funds) was the education of the granny midwives (Bell 1993, 155–58). In 1942, the Arkansas State Board of Health hired Mamie Hale, an African-American graduate of the Tuskegee School of Nurse-Midwifery, to establish community-based midwife training courses. The benefits of even a single health care provider in isolated impoverished regions were immediate. “Nurse Hale” presented a series of seven lectures to local midwives, accompanied them to patients’ homes, and facilitated the accessing of hundreds of women for prenatal care. Because most of her students were illiterate, Nurse Hale used innovative techniques such as movies, demonstrations, songs, and posters to teach procedures such as the roasting of newspapers for use as hygienic pads under the mother. Contrary to the stereotype of the ignorant and negligent midwife, Nurse Hale’s pupils were well-respected women, between 60 and 80 years old, who considered their vocation to be a divine calling, an attitude encouraged by their teacher, who began every meeting with prayers and hymns (Bell 1993, 158–61). The granny midwives’ practices included folk beliefs, some of which could be harmful to the mother and child. A common practice was placing an axe under the bed to cut labour pains; “other superstitions included biting the baby’s fingernails so the baby ‘wouldn’t be a rogue,’ putting salt on the afterbirth as it was being burned so the mother ‘wouldn’t have no trouble,’ spitting in the baby’s eyes to ‘keep them from getting sore,’ and putting soot on the cord to make it ‘heal up well’” (Bell 1993, 162). Nurse Hale’s set of lectures included the completion of the birth certificate; selection of cases for delivery; prenatal visits and interpreting warning signs such as swelling, bleeding, and severe vomiting; prenatal care, including the importance of drinking milk; the necessity for medical supervision; and proper cleaning techniques for the delivery room, the nurse’s bag, and especially her person. Nurse Hale also made follow-up visits to households to ensure that the delivery had taken place properly and in hygienic conditions. Those midwives who completed the program were feted in community graduation ceremonies. As would be expected from such a thorough and innovative program, the number of maternal deaths in Arkansas fell from 128 in 1930 to 43 in 1950 (Bell 1993, 162–63, 166). Before the introduction of certification in Georgia in 1925, an estimated 9,000 practicing granny midwives learned their craft through apprenticeship and the handing-down of knowledge. In that year, the State Board of Health, at the behest of the Medical Association of Georgia, instituted formal instruction through a year-long program of monthly classes taught by public health nurses. The classes, held in the midwives’ homes, included instruction on handwashing; the hygienic maintenance of uniforms and equipment; and the outfitting of bags with caul dressing, eye

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drops, birth certificates, and other necessities. The midwives were required to have annual physicals. While the state certified midwives, the community’s women determined “a midwife’s fitness, to pass judgment on her skills and ‘the way she do.’” The law required that those women planning to deliver with a midwife see the public health nurse by the fifth month, so that high-risk cases could be screened. After the seventh month, physicians would write a certificate or “pink card” allowing a midwife delivery for those women expected to have normal deliveries. It was illegal for a midwife to deliver any cases without a pink card. On a practical level, many physicians were unwilling to travel long distances into the countryside to deliver cases when a midwife was already present, so that the regulations were relaxed to a promise that the midwife would bring the mother and child to the hospital for an examination soon after the birth. Furthermore, many women had no prenatal care prior to labour, so that there was no notice given to the midwife (Walters-Bugbee 1977, 5–7). One community leader was Gussie Jackson, an African-American granny midwife for 32 years in Sumter County, Georgia, who brought over 600 babies into the world, as well as 10 of her own. During that time, she never lost a mother, “though I did carry one or two to the hospital.” She began her career as a tenant farmer on a property owned by a doctor, and she accompanied him on maternity calls. A 1932 report by the White House Council on Child Health and Protection found that in Alabama, Maryland, and Virginia, African-American maternal mortality rates were significantly lower with midwife than physician-assisted births. The certification of midwives in Georgia ended in 1963, due to a state expansion of hospital and health services. Furthermore, the inception of Medicare and Medicaid in the 1960s rendered it financially advantageous for hospitals to admit indigent patients. By 1976, Georgia’s granny midwives numbered only 58, and they were responsible for only 250 deliveries (Walters-Bugbee 1977, 4, 9, 11–12). Alabama’s leader was Dr. Halle Tanner Dillon Johnson, who in 1891 became the first woman, and first African-American woman, to become licensed by the Alabama Medical Society. A graduate of the Woman’s Medical College of Philadelphia, Dr. Johnson raised funds to build a dispensary in Alabama to deal with some of the widespread dire poverty of sharecroppers and their children. There was little medical care for the African-American population, who relied upon granny midwives, many of whom used traditional remedies such as black pepper, may apple root, ginger root, spiderwebs, and tread sash tea to induce labour. The midwives also recognized, like Native peoples and contemporary advocates of the Alternative Birth movements, the efficacy of heat, placing hot towels on the stomach, or placing mothers in hot baths (Smith and Holmes 1996,

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20–21, 38–39). The granny midwives also retained traditional West African practices in their treatments, such as abdominal massage and palpitation during pregnancy ... maintaining a birth fire [in the mother’s room to promote healing and relaxation] into the postpartum period; burial of the placenta near a tree; placing a sharp knife under the birthing bed or baby’s bed (also practiced by white women in Appalachian regions); giving the baby an oil bath right after birth; naming the baby on the seventh or ninth day because its spirit is unsettled before then; and guarding against future use of the placenta by medicine men or others who wished to harm the mother. (Smith and Holmes 1996, 40)

In all of these regions, properly trained midwives substantially lowered maternal and infant mortality in even the poorest and most isolated households. Far to the north of Alabama in Newfoundland, throughout most of the twentieth century expectant mothers in rural communities enjoyed a unique blend of traditional granny and professional midwifery. Newfoundland’s rocky terrain and economy based upon fishing resulted in far-flung villages, or outports, strung along the coastline. Many outports were not connected by road until the 1980s, so that traditions such as the granny or “handy woman” outlived those in other Canadian regions. Because of its relatively recent history as a British colony, Newfoundland was influenced by such British practices as the retention of legalized midwifery. Newfoundland midwives comprised two groups. The first was an older cohort of “handy women” similar to American granny midwives, who had little training other than an informal apprenticeship and experience in attending births. They were highly esteemed in their communities, but many reported that they had become midwives from necessity (“falling into” the job) due to the lack of local birth attendants and found the work arduous for little material gain. Like the southern granny midwives, they were not only birth attendants but transmitters of cultural values and rituals, including disposing of the afterbirth (they wrapped it in an old sheet and threw it in the hot stove), consoling bereaved family members, offering prayers and baptism, and preparing the deceased for burial (Benoit 1991, 1, 77, 75). The grannies were joined (and succeeded) by a younger generation of trained midwives, who considered the work their calling and who had obtained formal qualifications, a government licence, and a salaried position. The prized birth attendant position was that of a qualified midwife in a cottage hospital, which was a small regional maternity hospital with several midwives, so that each could work at scheduled hours. The cottage

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hospital system was developed for Scotland’s far north and imported, along with many British-trained midwives, to Newfoundland (Benoit 1991, 3, 19). Once improved highway infrastructures permitted rapid transportation across the island, the cottage hospitals were replaced by the modern regional hospital and Newfoundland’s unique birthing structure was lost. In the rest of North America, contemporary alternative birth and other birth reformers advocate free-standing birthing clinics or a revival of the cottage hospital. Thwarted Attempts to Professionalize Midwifery At the beginning of the twentieth century, however, the revival of midwifery was not seriously explored as an option to combat high rates of maternal mortality. Parturient mothers died from puerperal septicaemia, haemorrhage, and toxaemia, but these medical conditions often were caused by poverty and inadequate health care. While preparing her study on maternal mortality, Helen MacMurchy surveyed Canadian doctors and reported, “In 68 cases [of maternal death] the doctor stated that the patient was very poor.... In the opinion of the physician, the mother’s life might have been saved if she had not been so poor, destitute and uncared-for.” Infection (septicaemia or sepsis), noted as the leading cause of maternal death, often was the result of hasty or improper use of forceps or inadequately hygienic caesarean sections by hurried physicians, as well as inadequately hygienic procedures by midwives. Yet MacMurchy retreated from laying blame upon her brethren, male physicians whose professional approval she courted and who were members of her own class. Instead she focused, as she would in The Canadian Mother and Child, upon the ignorance of mothers “for not obtaining adequate prenatal care” (Arnup 1994, 60–61). These government pamphlets, the American Prenatal Care, magazine and newspaper columns, and public health education accelerated the medicalization of pregnancy and childbirth in North America. Mothers were told that although pregnancy was a natural state, it was fraught with dangers that only physicians could recognize and deal with, even though the reality of the early twentieth century was that prenatal diagnostics was an imperfect and fledgling science (Arnup 1994, 67; Mitchinson 2002, ch. 4.) Nonetheless, pregnant women learned to use whatever means they had to access prenatal medical care, and this would provide the death knell for traditional midwifery. As the Canadian provincial medical colleges grew in stature and power, the midwives’ roles became increasingly limited. In the 1920s, the College of Physicians and Surgeons in British Columbia secured legislation granting only its members the ability to provide “medical or surgical

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assistance,” including anaesthetics, at births, so that a pain-reduced birth could be provided only by a physician. Physicians also limited obstetrical knowledge; nursing students did not receive obstetrical training, which would severely restrict their utility in postings in the far North or other isolated areas where medical care was hard to come by. Despite her identification with the goals of the medical profession, MacMurchy recognized the dire need for obstetrical assistance in outlying areas and created a supplement to The Canadian Mother’s Book in 1923 to provide details of medical procedures in the birthing room. This supplement was short-lived, however, due to medical opposition. By the 1940s, however, The Canadian Mother’s Book did include detailed birthing information, which reflected both the continued need (“some 16,000 mothers were without medical attendance for the birth of their babies”) and more likely the improved financial and professional security of the physicians (Arnup 1994, 75–77). In the 1950s, American nurse-midwifery training programs were established at Yale, Johns Hopkins, and Columbia universities with the support of some leading obstetricians. However, the conservative climate of the decade and restrictive legislation made it difficult for graduates to practice. The problem of limited obstetrical care in rural areas remained. From 1960 to 1963, a pilot nurse-midwifery program was undertaken in Madera County, California, to serve indigent agricultural workers. The prenatal services offered resulted in a decrease in premature birth and neonatal mortality, both of which rose substantially following the cancellation of the program by the California Medical Association (Devitt 1979, 82). Not until the feminist and health consumer movements of the 1960s and 1970s was nurse-midwifery revived as a profession. By the 1970s, the American College of Obstetrics and Gynaecology officially recognized the certified nurse-midwife, and hospitals competing for a shrinking patient population (due to a declining birthrate) advertised the nursemidwives on their staff as one of their attractions for consumers (Sablosky 1976, 12). Professional Triumphs/Incomplete Successes In 1951, the American Academy of Obstetrics and Gynaecology was formed, signalling the recognition of obstetrics as a hospital-based surgical specialty. With the advent of sulpha drugs (antibiotics) in domestic medical practice following World War II, the hospital death rates for mothers and babies fell precipitously. In short order the professional organization turned its attention away from the old battle of outlawing midwifery (which it had pretty well won) to discouraging general practitioners from delivering babies. By 1968, 68 per cent of American births were attended by an obstetrician, yet the persistent problem of lack of access to mater-

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nity services for impoverished or isolated women remained (Borst 1998, 243). The death rate during childbirth for white mothers fell from 56.4 per 1,000 live births in the first half of the 1930s to 39.7 per 1,000 by 1940. The rates for African-American women were 97.1 per 1,000, only dropping to 84.1 by 1940. The infant mortality rates were correspondingly disparate; white infants died at a rate of about 44 per 1,000 live births during the 1930s, while African-American babies died at a rate of 73 (Bell 1993, 157). Canadian statistics showed similar disparities. In British Columbia between 1955 and 1965, the Native maternal mortality rate was 1.09 deaths per 1,000 live births, while the non-Native rate was .346 deaths per 1,000 live births (W.D. Thomas 1971).

Conclusion The replacement of midwives with physicians as birthing attendants, and the movement of parturient women from home to hospital, was a lengthy and painful process with many casualties along the way. By the 1930s and 1940s, however, the majority of women in Canada and the United States could approach childbirth without the dread of a possible impending death for themselves or their infants. The next chapter focuses upon the succeeding half-century, when women, particularly those who were educated and urban, had the luxury to look for ways to improve the birthing process — to diminish or even eliminate labour pains; to reduce the period of recovery, even to choose the day and time of the birth. They sought to be the partner of the physician in the pregnancy experience from conception to birth. At the same time, however, physicians attempted to control births within the hospital setting to ensure the safest and best outcome for each delivery. They and the nursing and other hospital staff also had to process great numbers of births as efficiently and cost-effectively as possible. The family’s desires, the physician’s views, and the hospital’s needs often clashed, straining the partnership ideal.

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Notes 1

2 3 4

5 6 7 8 9

10 11 12 13 14 15 16 17 18

See, for instance (and this is a tiny selection from a vast literature), Rich 1976; Ashford 1983; Leifer 1980; Oakley 1990; Cosslett 1994; Apple 1997; Rubin 1984; Miller et al. 1991; and the numerous other sources used in the next two chapters. I walked around a high school track and sang to my belly in the last weeks of my pregnancy. I ascribe my daughter’s love of show tunes to this behaviour. For more on the therapeutic revolution, see Vogel and Rosenberg, 1980. For more on contraceptive practices in the nineteenth century, see Brodie 1994. See also the orthodox medical profession’s association of Thomsonian and other sectarian medical practitioners with the practice of abortion in McCulloch 1993. For more on birth control and abortion, see McLaren 1990; McLaren and McLaren 1986; McLaren 1984. Jenny Forster, “Are Midwives Part of Herstory?” Inkwel, July 2002, http://www. wel.org.au/inkwell/ink0207/midwives.htm, 2. With respect to psychology and physiology, consider, for instance, supposedly infertile women who become pregnant soon after they adopt a baby. For an excellent account of a midwife’s experiences in colonial America, see Ulrich 1991. Eclampsia is a serious condition of pregnancy with symptoms including hypertension (high blood pressure), seizure, and coma. Pre-eclampsia was a term once used to describe the hypertension and other symptoms such as protein in the urine, abdominal pain, and foetal distress leading to the seizures or coma. The causes of eclampsia are still unknown, but theories include abnormal blood or capillary production, or abnormal functioning of the mother’s immune system. See Craig Weber, “What Causes Eclampsia?” High Blood Pressure, 10 December 2007, http://highbloodpressure.about.com/od/eclampsia/f/ eclampsia-cause.htm?once=true&. Gardner 1900; for more on the American medical profession’s anti-abortion platform, see Mohr 1984. For more on the regulation and ultimate disappearance of midwifery in Ontario and Quebec, see Biggs 1990; Laforce 1990; Biggs 2004, 17–45. See also maternal mortality rates for British Columbia in Strong-Boag and McPherson 1990, 76–77. For more on the acceptance of germ theory in American culture, see Tomes 1998. For more on the decline of midwifery in Ontario, see Connor 1994. Charlotte Harrington, director of the VON, quoted in Strong-Boag and McPherson 1990, 83. Judith Leavitt made this observation and is quoted in Borst 1998, 227. For more on child-saving in the early twentieth century, see Warsh and StrongBoag 2005. Helen MacMurchy in her 1928 report, Maternal Mortality in Canada, noted that of 1,532 maternal deaths between 1925–26, 1,302 had no prenatal care at all; cited in Langford 1995, 299, n.7.

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19

Homeopathy was a medical regimen developed by a German doctor, Samuel Hahnemann (1755–1843), as a corrective to the excesses of heroic medicine, such as purging and bleeding. His theory was based on “similars,” that is, he believed that illnesses could be cured by natural substances that, when ingested, produced similar symptoms. His followers opened homeopathic medical schools in the United States in the early years of the nineteenth century, and many homeopathic physicians had flourishing practices since patients favoured the milder treatments offered.

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C H A P T E R

4

Modern Childbirth MOTHERS AND DOCTORS

By the 1940s, due to a number of factors, the prospects for the

survival of both mothers and babies brightened substantially. These factors included medical and biotechnical advances, such as blood-banking and intravenous fluid therapy; safer hospital deliveries; and improved contraception, which allowed women to space their pregnancies. A generation of public health improvements and social welfare measures, as well as increasing economic prosperity, produced better maternal health as well. Infants born in hospitals between 1940 and 1970 also fared better, with the percentage of living children increasing from 55.8 per cent to 99.4 per cent (Grimes and Cates 1977, 832). However, the steady decline of maternal mortality in North America in the twentieth century stalled after 1980. Between 1982 and 1997, the American rate remained from 7 to 8 per 100,000 live births, while the Canadian rate was 3 to 5 per 100,000 live births (Hoyert et al. 2000, 4–5). Yet the Canadian maternal death rate from 1997–2000 rose to 6.1 per 100,000 live births. The principal causes of death were pulmonary embolism, pre-eclampsia/pregnancy-induced hypertension, amniotic fluid embolism, ectopic pregnancies, and intracranial and other forms of post117

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partum haemorrhage. Many of the victims had a history of coronary artery disease and/or diabetes. However, some deaths were caused by medical negligence, including women who sought medical care but received no follow-up investigation (such as ultrasounds), which would have revealed ectopic pregnancies, as well as “surgical or anaesthetic misadventure.”1 The risks of dying from childbirth for American women varied according to age, ethnicity, geography, marital status, and level of education. African-American women were more at risk than white or Hispanic women, as were older women, those living in the South, the unmarried, and those with less education. Since the 1980s, there has been a significant increase in the number of older women giving birth; in 1997, 44 per cent of Canadian live births were to mothers 30 years and older.The persistently lower maternal mortality rate in Canada must reflect the universal access to health care enjoyed by Canadians under Medicare (Hoyert et al. 2000, 6–7). From 1900 to the 1980s, Canadians delayed beginning a family longer than Americans, spaced their children more closely together, completed their families (marrying off the last child) earlier, and survived as a couple longer (Rodgers and Witney 1981, 727). In those years, a Canadian woman on average married at 22.8, while men married on average at 26.1. Canadian mothers born in 1931 had on average 3.2 children. This dropped to 2.72 in 1941, rose to 3.29 in 1951, rose again to 3.59 in 1961, and then dropped precipitously to 1.97 in 1971 and 1.7 in 1986 (Rodgers and Witney 1981, 730; Milligan 2002, 2–3). White American married women in 1900 bore an average of 3.56 children, while African-American women bore more than five children (Leavitt 1986, 19, 267). The general fertility rate for the United States fell from 106.2 births per 1,000 women aged 15–44 in 1950 to 68.4 per 1,000 in 1980 to 60.7 per 1,000 in 2004. The Canadian general fertility rate fell from 109 births per 1,000 women aged 15–49 in 1951 to 91 per 1,000 in 1965 then rose to 1.54 per 1,000 in 2005 (still well below the 2.1 children per woman necessary to replace the population).2 There was a sharp decline in fertility rates in the French Catholic province of Quebec, which supposedly “out-birthed” English Canada.Yet as Angus and Arlene McLaren point out, Quebec’s demography was complex because up to 25 per cent of its women from the 1870s to the 1960s either did not marry or had no children. The province’s fertility rate fell from 117 births per 1,000 in 1951(above the national average and the highest rate of the provinces) to 109 per 1,000 in 1961 or below the national average as well as lower than Nova Scotia, Manitoba, and Saskatchewan (McLaren and McLaren 1997, 126–27). One consequence of a lowering birth rate, better survival prospects for mothers and infants, and a more educated and prosperous female population was that mothers-to-be demanded a better childbirth experience.This presented a number of challenges for obstetricians, maternity ward nurses,

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and hospital administrators since many of the technological and surgical improvements that led to the positive outcomes were now seen as intrusive, humiliating, and even dangerous. Furthermore, by the end of the twentieth century, the financial imperatives of government and private insurers were becoming more apparent, particularly with the rise in the rate of caesarean sections. Preferred by obstetricians for their relative safety and controllability, and by some mothers for their convenience and reduced pain, caesareans were criticized by other mothers as alienating and by insurers as expensive. By 2000 then, childbirth had become a formal waltz between doctors and parturient mothers, with other partners, such as alternative birth advocates, spouses, governments, and insurance companies, occasionally cutting in. The first section of this chapter will discuss the evolution of hospital births and women’s experiences with them. The various pharmaceutical approaches to pain, pregnancy, and (childbirth) labour management will be analyzed, as well as mechanical and surgical approaches such as forceps, episiotomies, and vacuums. Finally, the positive and negative consequences of the increasingly popular use of electronic foetal monitoring and caesarean sections will be discussed. The second section focuses on modern mothers and their obstetricians. The cultural diversity of mothers and their childbirth experiences and expectations is explored, as is the increasing intrusion of the state into the prenatal period and the condition of postpartum depression. The third section discusses obstetricians and groups who challenge their monopoly of childbirth, including family physicians, nurse-midwives, and the alternative birth movement. The final section looks at changes in the hospital environment as a response to the institution’s critics. These innovations include “natural” childbirth techniques and prenatal preparation, the involvement of fathers and significant others in the labour process, and the architectural reconfiguration of maternity wards to include birthing suites. By the end of the twentieth century, hospital administrators were attempting to combine the attentiveness and ambiance of the nineteenth-century midwifery experience with the safety and technological advancements of today. How successful they have been will be an issue for us to confront.

The Hospital Experience By the middle of the twentieth century, the hospital was where most North American women gave birth. In 1926, only 17.8 per cent of Canadian births took place in a hospital. By 1935, 32.2 per cent of Canadian babies were born in hospitals, and between 1940 and 1945, this number jumped from 45.3 to 63.2 per cent (Mitchinson 2002, 175). By 1960, this transformation was virtually complete, with 94.6 per cent of

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births taking place in hospitals (Arnup 1994, 74). In 1938, half of American babies were born in hospitals, while this number jumped to 95 per cent by 1955 (Leavitt 1986, 269). Women who chose to deliver in hospitals (and as the century progressed, that choice increasingly was circumscribed) desired minimum pain and maximum safety. Obstetricians and attending staff attempted to fulfill both desires, although at times they conflicted. Pain It is interesting how many analyses of childbirth, while critiquing its medicalization and hospitalization, fail to discuss pain, given that “pain is surely a major reason why many women desire medical assistance during birth” (Fox and Worts 1999, 336). A woman’s judgement of her delivery as joyful or negative had much to do with whether she experienced intense or little pain. When the Scottish physician James Young Simpson first used ether in obstetrics in 1847, he met with opposition from both clergymen and physicians. Clergymen considered pain in childbirth to be the curse of Eve and thus its circumvention an irreligious act. This opposition evaporated after Queen Victoria used chloroform for the delivery of her eighth child. Medical opposition centred on the importance of the pain sensation as a diagnostic tool for the attending physicians (Farr 1980, 896). The American obstetrician Charles D. Meigs considered pain to be an essential component of labour and was leery of the introduction of a drug with dangerous side effects into a natural process. His professional rival, Walter Channing, was an enthusiastic proponent of ether, writing A Treatise for Etherization in Childbirth as a defence of anaesthesia. Medical folklore traces ether’s first use in American obstetrics to Channing’s administration of the drug to Fanny Longfellow, wife of the great American poet Henry Wadsworth Longfellow in 1847 (Stampone 1990, 3–4). The potential effects of anaesthetic gasses upon the unborn child were of longer lasting concern. Channing considered the risk to be “negligible,” since he could not smell ether on the umbilical cord. As Donald Caton noted, the notion that ether could not cross into the placenta ran contrary to traditional — indeed ancient — knowledge that nutrients from the food the mother ingested were transferred to the foetus and more recent medical knowledge that the unborn could contract the mother’s smallpox or syphilis (Caton 1977, 132). Other physicians, such as Britain’s Sir John Snow, one of the innovators of anaesthesia, did detect ether on the breath of newborns, and German obstetrician C.C. Huter warned of the potentially lethal effects of chloroform upon the vascular and nervous systems of both newborns and their mothers. Despite both these warnings and increasing observations that infants born of addicted patients appeared

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“dull and sleepy in the first hours of life,” anaesthesia in labour grew in popularity — an indication of the great demand by mothers for a pain-free childbirth (Caton 1977, 133–34). In the early 1900s, half of all American women delivered by physicians were given either ether or chloroform. It soon became clear, however, that these inhalation anaesthetics could lead to postpartum haemorrhaging, infant asphyxia, and extended labour. Ether and chloroform were succeeded by nitrous oxide (first utilized by Russian Dr. Klikowitsh) and morphine, one of the components of “Twilight Sleep.” Twilight Sleep, a combination of morphine and scopolamine, was a birthing regimen popularized in 1908 by two German obstetricians, Carl Gauss and Bernhardt Kronin. The method did not eliminate labour pains but obliterated the memory of it after the birth. Twilight Sleep required intensive and careful oversight by the anaesthesiologist, with an initial combination injection of morphine and scopolamine followed by small injections of scopolamine during the labour. It had many side effects, including “excitement, restlessness, hallucinations and delirium” in labouring mothers, occasionally leading to self-injury. Consequently, hospital staff had to strap the mothers to the operating table or use a “birthing jacket,” which was akin to a straitjacket for the mentally disturbed. Due to the potentially harmful effects of both morphine and scopolamine, Gauss spelled out in detail the precise dosages for a woman in labour to receive. Nevertheless, many patients became disoriented and violent from the scopolamine, and Gauss combated this with the elimination of “extraneous sensory input”: he performed the deliveries in dark, quiet rooms; bandaged the women’s eyes and stuffed their ears with cotton; and tied them to a padded bed with an attendant nearby to restrain them, often with leather straps (Caton 1977, 133). Twilight Sleep was popularized in North America when a group of wealthy American women, aware of the dangers of ether and chloroform, travelled to Germany for their deliveries. Their subsequent account in McClure’s Magazine in 1914 “evoked more response from readers than any other that the magazine had ever published.” The women established the National Twilight Sleep Association (NTSA), an influential lobby group connecting women’s feminist goals with access to pain-free childbirth (Caton 1977, 137, 139). The NTSA ran a popular campaign in the national press that touched a chord with American women who described childbirth as “torture.” The organization and its supporters also castigated the medical profession for its reluctance to embrace the German method. While physicians argued that it was risky and could interfere with the newborn’s breathing abilities, the pro-Twilight Sleep lobby characterized them as ignorant and even demonstrating a “callous indifference” to women in labour. What the popular press did not reveal was that women under Twilight Sleep still suffered from pains and thrashed about in their

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sleep, often screaming, nor did it detail the restraints involved (Caton 1999, 140–41). Moreover, like ether and chloroform, it also led to respiratory problems in newborns. The craze for Twilight Sleep ended as abruptly as it began, due in large part to the death of one of its leading socialite promoters, Mrs. Francis X. Carmody, during her second labour. The Great War put an end to childbirth “tourism,” as it became nearly impossible for Americans to reach Gauss’s clinic in Freiburg. Twilight Sleep also could not match its hype, and some physicians attempting to meet the demands for the painless delivery began to be more reckless in their dosages of opium or combined opium and scopolamine with other anaesthetics (Caton 1999, 150–51; King 1997, 377). Canadian doctors and patients were less caught up in the craze, although Toronto obstetricians Gordon Gallie and W.A. Scott published a series of articles on the procedure in the Canadian Practitioner and Review in 1915. Their main caveat was that Twilight Sleep was difficult for attending physicians and nursing staff to oversee properly on busy hospital wards (Mitchinson 2002, 216–17). During its short reign in 1914 and 1915, thousands of American women attested to the efficacy of childbirth under Twilight Sleep. The craze produced two lasting and in many ways contradictory results. First, the fact that its proper administration required hospital care and a number of trained attendants rendered it inappropriate (according to the obstetricians who supported it) for either general practitioners or midwives. Therefore, its use facilitated the admission of middle-class patients into hospitals for childbirth and offered attending physicians complete control of the birthing process. On the other hand, the NTsA ’s lobbying tactics encouraged women to be advocates for their own birthing choices; women who demanded Twilight Sleep, often over the objections of their physicians, were asserting some personal control over pain in labour (Leavitt 1984a, 175, 179, 180). In the 1940s, other medications included the barbiturates sodium thiopental (Pentothal) and sodium secobarbital (Nembutal), which were also found to cause respiratory problems for both newborns and mothers (Stampone 1990, 6). During the 1950s, researchers introduced localized anaesthetics or blockers. When anaesthesiologist Virginia Apgar developed her test in 1957 to score the well-being of newborns, she noted that babies born under localized anaesthetics were less affected, livelier, and more alert at birth (King 1997, 377). There was controversy regarding the causeand-effect of epidurals given early in labour and the likelihood of a caesarean section. Anaesthesiologists argued that problems in labour resulted in the caesarean, rather than the anaesthetic itself. By 1997, epidurals were employed in 29 per cent of all deliveries in the United States. Some American third-party insurers attempted to deny the use of epidurals to their members, using the argument that it increased their costs (Cohen

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1997, 19). Their concern (for financial reasons) and many women’s concerns (for health reasons) was — and is — that the use of epidural anaesthesia has been linked to a greater likelihood that forceps or vacuum extractors will be used, that the second stage of labour will be extended, that caesarean sections will be resorted to, and that an additional drug — oxytocin — will be administered to promote labour (Eakes 1990, 329). Twilight Sleep was one of a series of controversial innovations in hospital births introduced or popular during the twentieth century. Others included the prescription of the drug stilbestrol; the routine use of episiotomies, forceps, vacuums, and electronic foetal monitoring, and the increasing incidence of caesarean sections. Stilbestrol In the 1940s and 1950s, obstetricians prescribed the synthetic hormone stilbestrol to pregnant women who were at high risk of miscarriage. By 1971, the drug was termed “a time bomb” for the child, as teenage and young adult women contracted carcinomas of the vagina. The stilbestrol scare was particularly tragic because the mothers had been trying to protect their unborn children rather than endangering them with reckless prenatal practices. In an article written in the Journal of the American Medical Association (JAMA) in 1971, Dr. Kathryn Huss considered that a public announcement by the medical profession about the potential longterm effects of stilbestrol was “of questionable advisability,” since the risk was “small” and many of the medical records may no longer have existed (Huss 1971, 1564–65; see also Greenwald et al. 1973, 568). This attitude of “protecting” the public from itself — i.e., generalizing panic — was also self-serving for a medical profession fearful of loss of reputation and most especially of class action lawsuits. Their foremost medical journal advised physicians to inform their patients about the drug’s side effects only in a “careful, responsible fashion.” Not surprisingly, this did little to counter distrust and helped to inspire the medical consumers’ movement. Forceps The use of forceps, which distinguished physicians from midwives in the nineteenth century, became standard procedure in hospital and physicianassisted home births in the twentieth century. In 1920, Joseph B. DeLee recommended the routine use of forceps and episiotomies as the proper management of labour (quoted in Vosler and Burst 1993, 296). Properly used, forceps (“hands of iron”) could bring a successful end to lengthy labours and save the lives of mothers and babies that would otherwise be lost. Improperly or hastily used, as was the case for many physicians

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whose medical training in obstetrics was imperfect, forceps use could lead to head injuries in babies and perineal lacerations in women, often leading to lifetime disabilities if not death through sepsis (Leavitt 1984a, 44–45). There also were many instances of physicians who were too impatient to allow nature to take its course over the long hours of labour and used forceps high up the birthing canal to hurry things along. A French-Canadian mother, for instance, described her first delivery in the 1930s. She was too drowsy “from the ether administered by the doctor to push, so he had to use the forceps, almost pulling the baby’s head off in the process. ‘He was a butcher,’ she said. ‘If we’d had a competent doctor, the baby might have been saved.’” Indeed, other women, rightly or wrongly, blamed Quebec’s high birth rate during the Depression years on poor medical care: “In those days, women would have 15 or 16 children because they would lose 5, 6 or even more. That’s how the babies died — the doctors didn’t know a thing” (Baillargeon 1999, 80–81). Such loss of confidence further galvanized the efforts of obstetricians to improve their skills and technologies and reduce the numbers of non-specialists performing deliveries, yet these skills and technologies did not immediately translate into more positive outcomes. Episiotomies The resort to forceps and other interventionist measures produced more interventions. As DeLee stated above, forceps use generally involved the minor operation of the episiotomy. American obstetricians began advocating for routine episiotomies, or episiotomies as a standard procedure for non-caesarean births, in the early years of the twentieth century, primarily for its utility in shortening the labour process in hospitals. By 1950, episiotomy, despite not being medically necessary in most cases, was the second most frequently utilized procedure, trailing only the cutting and tying of the umbilical cord: “Women’s perineums were sacrificed for efficiency.” Despite mounting evidence from Britain and elsewhere that episiotomies unnecessarily caused pain and long-term disability for women, they only slowly declined in the United States; by 1993 the rate was still 50 per cent, falling to 39.2 per cent in 1998 (Montini 2000, 137–139). The same prevalence and slow decline existed in Canadian hospitals, where the episiotomy rate was 55 per cent in 1989, falling sharply to 25.4 per cent in 1998 (Klein 2002, 74). By 2000, a return to old ways — the use of massage with mineral oil and the slow “catching” of the baby — was recommended as an alternative to episiotomies (Chase 2000, 64). Vacuums Vacuum extraction was a technology developed to replace the use of forceps in hospital deliveries. The vacuum extractor is composed of a soft

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plastic cup attached to a tube and suction pump. The cup is attached to the child’s head in the birth canal through suction, and further suction creates a vacuum, allowing the head to be pulled through the canal. Vacuum extraction was more gentle and less damaging to the mother’s soft tissues than forceps and was first believed to pose only minor risks, such as fluid collection and limited haemorrhaging of the child’s scalp. However in 1998, the FDA issued a warning to medical practitioners to limit the use of vacuum-assisted deliveries, citing 12 deaths and nine serious injuries in the previous four years. The serious complications included subgaleal haematoma (swelling between the skull and the brain), which could lead to fatal haemorrhaging and shock; and intracranial haemorrhage (bleeding beneath the skull), which could lead to convulsions, damage to the heart, and other injuries.3 Four months later, the American College of Obstetricians and Gynaecologists (ACOG ) countered with their own statement that the incidence of injury or death was extremely low and that if the vacuum were discontinued, it would be replaced by a greater recourse to caesarean section and forceps. A larger study of 600,000 cases of births to nulliparous women (first-time mothers) between 1992 and 1994 found that the rates of death and serious injury were far higher than indicated in previous reports. The death rate following spontaneous vaginal delivery was 1 per 5,000; delivery with vacuum extraction was 1 per 3,333 and with forceps delivery was “4 to 10 times as high as the FDA estimate.” Furthermore, the incidence of intracranial haemorrhage was 1 per 1,900 in unassisted vaginal deliveries, 1 per 860 in vacuum deliveries, and 1 per 664 in forceps deliveries — that is, 13–37 times greater than the ACOG estimate of 1 serious injury per 25,000 births. Thomas Benedetti concluded that “attempts at operative vaginal delivery after an uncomplicated pregnancy and labour can result in injury to the infant and possibly to the mother” (Benedetti 1999, 1758–59). Electronic Foetal Monitoring Electronic foetal monitoring and caesarean sections are two medical interventions that were used with much greater frequency over the last half of the twentieth century; their uses have often been connected; and both have faced considerable controversy. The electronic foetal monitor, with its scientifically sounding beeps and heart rate diagram, has been extremely popular with hospital staff despite its deficiencies and dangers. Obstetricians and labour nurses can instantly note changes in the infant’s heart rate and react to the evidence of possible infant distress. Controversy arose over whether the monitors were too indiscriminately used and whether staff was too quick to intervene in natural labour. Furthermore, the monitor’s readings were imprecise, not always accurate,

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and not always interpreted correctly by staff. The monitor was originally developed for high-risk cases, which likely would have been delivered by caesarean section. However, in some hospitals in the 1970s and 1980s, the monitor was attached in routine labour cases, leading to an increase in the rate of caesarean sections. By 1980, it was estimated that three times as many American women who were connected to foetal monitors underwent caesarean sections than those who had not been (Francome and Huntingford 1980, 359–60; see Katz 1976, 11). The monitors were controversial due to the unknown consequences of prolonged foetal exposure to ultrasounds and the possibility of trauma and infection resulting from the attaching of electrodes to the foetus’s scalp. The monitor is attached to the foetus’s scalp by a “clip,” which is a miniature corkscrew screwed into the scalp, possibly causing abscesses and a permanent bald spot (Dow 1984, 21). As Bonnie Donovan noted, “Iatrogenesis, the convenience of staff, inaccurate interpretations of foetal monitor readings, overuse of medications, artificial rupture of membranes, oxytocin drips to induce or augment labour ... have undoubtedly contributed to the increase [in caesarean sections]” (Donovan 1977, xix). Being attached to the foetal monitor was one significant factor in the dissatisfaction of many women with their hospital childbirth experience. As family practitioner Lucy Candib observed in the 1970s, “What are the effects of monitoring itself? If a woman is lying on her back with a catheter inside her uterus to measure contractions, an electrode on her baby’s scalp to record its heartbeat, and an IV in her arm to stimulate contractions, and if she has a catheter in her epidural space to relieve her of the pain of these contractions, who is asking what effect this has on the mother and the baby?” (Candib 1976, 394). There were many groups with vested interests in the maintenance of the electronic foetal monitor, as there are with any new medical technologies. In 2002, under a federal-provincial agreement, the Canadian government offered $1.5 billion in medical technologies to Canadian hospitals and held a conference to discuss the distribution of funds. David Banta, an American assessor of such products, argued that the foetal monitor was a risky and needless expense, since foetal heart rates were easily monitored by stethoscope. Jill Sanders, president of the Canadian Coordinating Office for Health Technology Assessment, a federal-provincial agency sponsoring the conference, admitted that “inevitably some technologies are creeping into usage that won’t be effective,” but argued that the Health Department’s mandate was not to determine whether a new product was an improvement over a previous one, but if it was harmful. She further stated, “The foetal heart monitor is not harmful even if it leads to a high rate of caesarean sections because a caesarean section is not harmful.”4 How much further apart could federal government bureaucrats — dazzled by bil-

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lion dollar budgets funded by anonymous taxpayers and hobnobbing with prestigious hospital administrators and obstetricians, not to mention multinational biotech corporations — be from the reality of the individual labouring mother and her tiny infant? There are many levels of harm, and we will now consider whether the caesarean section was indeed not harmful. Caesarean Sections The caesarean operation has had a long (indeed classical) history, yet for many centuries was extremely dangerous and usually performed on dead mothers or those likely not to survive childbirth. The first recorded caesarean operation on a living mother was performed in 1500 by a Swiss hog gelder, Jacob Nufer, who cut open his wife during an obstructed labour. She survived (Flamm 1990, 15). During the Franciscan Mission period in California, there were 14 recorded caesarean operations between 1769 and 1833. They were not strictly therapeutic caesareans but the removal of the foetus after the mother’s death, as per the Catholic Church’s directive to secure the foetus for baptism, if not a viable life (Valle 1974, 265–68). The earliest recorded caesarean section in the United States was a horrific operation performed by Dr. John Lambert Richmond in 1827. Dr. Richmond was called on a stormy April morning in Ohio by two midwives to attend an unmarried girl dying in labour, living in a newly built log cabin without a floor and with only one candle supplying light. The girl had been in labour for 30 hours and had suffered convulsions. Richmond administered laudanum and sulphuric ether, and applied flannel soaked with hot spirits at the feet, to prevent further convulsions. The caesarean section was performed with no anaesthetics or antiseptics and with pocket instruments. Determined to save the mother, he did a “destructive operation” on the child. The mother, “who never complained of pain during the whole course of the cure,” survived and later married, but she never again became pregnant (King 1971, 61). In his 1849 textbook on obstetrics, Dr. Charles Meigs noted that the risks from the operation were so great it should only be performed if the mother were sure to die without it. During this time, physicians did not understand the necessity of sewing up the uterus after the baby was delivered, resulting in almost certain death for the mother (Flamm 1990, 17). However, the surgical revolution in the last decades of the nineteenth century led to safer procedures and better outcomes for both mothers and babies. Although it would not be until after World War II that the procedure was common enough to be considered routine, caesarean sections did allow physicians to “reconfigure the definition of risk” (Mitchinson 2002, 230). Similar to their reception of anaesthesia in labour, Canadian physicians in the 1930s were cautious about the growing popularity of

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the operation. Ontario physicians C.B. Oliver and H.B.Van Wyck praised the procedure in medical journals, yet worried that it was too quickly resorted to when vaginal birth was still a viable option (Mitchinson 2002, 32). However, its use accelerated in both countries. At Montreal’s Royal Victoria Hospital, the 1927 rate of 1.8 per cent nearly doubled to 3.3 per cent by the late 1930s, while Vancouver General Hospital’s rate was also 3 per cent in the 1930s. Canada’s national rate was 2 per cent of hospital deliveries, which were still only a minority of maternity cases, but this rate jumped to 4 per cent a decade later. American caesarean rates were higher but fluctuated widely. Some hospitals in the 1930s recorded rates of 14 per cent, or even 32 per cent for one Kansas City hospital, while the national average was 3 per cent (Mitchinson 2002, 232–34). Physicians favoured caesareans to decrease the risks of the death of either or both the baby and the mother. They understandably feared the gruesome consequences of the craniotomy and embryotomy, that is, the dismemberment and killing of the foetus to save the life of the mother, yet the high maternal mortality rate of the caesarean persisted, estimated at 10 per cent in Canada in 1915, 8.2 per 1,000 in Ontario in 1933, and at 30 per cent at Winnipeg General Hospital in 1936. That maternal deaths from caesarean sections were ten times the rate of vaginal births was characterized as unfortunate, albeit acceptable risk by practitioners increasingly invested in the procedure, or, as Wendy Mitchinson describes it, “The surgery had become the subject whose rights needed to be protected.... By reifying the surgery, [its defenders] took it out of human hands, making it less able to be changed or stopped. C-section could be safe if there were no birth complications, but the point of C-section was to mitigate those complications.” Furthermore, as we will see in the next chapter, the increased recourse to surgical intervention positioned the survival rights of the foetus over that of the mother by the end of the 1940s; physicians argued they could save “both mother and child even though, in most cases, the mother was not at risk [unless she underwent the caesarean]. Mother and child became one, and the one was the child; the child’s risk became the mother’s” (Mitchinson 2002, 242–43). By the 1950s and 1960s, caesarean sections were becoming safer, and their popularity continued to grow, especially in specialized maternity hospitals. Toronto’s Women’s College Hospital (WCH) gave caesareans to 4.2 per cent of its maternity patients in 1949, 5.1 per cent in 1960 and 7.2 per cent in 1967. The WCH was an institution founded by women physicians, and its higher caesarean rate likely was due to its acceptance of difficult maternity cases by referral. Elective (and emergency) caesareans also provided women with the opportunity to obtain tubal ligations at a time when other effective means of birth control were not available (Feldberg 2003, 124, 131, 135).

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The numbers of caesareans continued to grow in the United States as well. A study of a large American urban hospital found that between 1968 and 1978, a 150 per cent increase occurred in the rate of caesarean section, with the increase highest among private rather than public ward patients for primary sections (elective caesareans for breech presentations). For the ward patients, caesarean sections also increased for breech presentations, prolonged rupture of membranes, and indications of foetal distress (Coady 1980, 9). In 1970, 5.5 per 100 deliveries in the United States were by caesarean section. By 1978, this had increased to 15.2 deliveries per 100 (Placek and Taffel 1980, 543). What was the reason for such a dramatic increase? Along with the increased use of electronic monitoring of the foetal heartbeat, which indicated distress or potential distress to which the obstetrician would respond with surgery, there also was the reluctance of physicians to allow extended periods of labour or to attempt vaginal deliveries of breech babies, which increased risks to the infant. Caesarean deliveries of breech babies increased from 6.1 per cent in 1970 to 12.4 per cent in 1978. Caesarean sections also replaced forceps deliveries as the latter were demonstrated to pose high risks to the infant and the mother. For many physicians, mothers infected with genital herpes necessitated a caesarean section, although it was unpredictable which mothers would pass on the infection (Flamm 1990, 22). As more women delayed childbearing, the older primiparous (firsttime) mothers were seen to have more risks of complications, to the extent that elderly primiparity itself became a case for caesarean sections. There also were fears of malpractice suits, as well as the belief that “once a c-section always a c-section.” By 1978, mothers 30 years and older had a 1 in 5 chance of having a caesarean section delivery.Yet the rate also increased for the youngest mothers, with women under the age of 20 having a 1 in 10 chance. This also accounts for the continued increase, since many of these women would be delivering more babies in the future (Placek and Taffel 1980, 540, 545). The decline in maternal mortality associated with the operation was another reason that became clear by 1980. The reported rate was 20–70 cases per every 100,000 operations, comparable to the 1950s rate for vaginal deliveries. Perinatal mortality rates also fell by more than one-third during the same 30-year period. Despite the fact that one of the “central tenets” of obstetrics is that caesarean sections are riskier for both the mother and the infant than vaginal births, obstetricians, when asked their preference for a normal birth, opt for caesarean sections for a variety of reasons. One of the protective aspects of caesarean section is less incidence of anal incontinence due to damage to the pelvic muscle and anal sphincter, which can occur with the use of forceps and episiotomy (Farrell 2002, 337–39). Caesarean sections are safer for babies in the cases of “breech presentation, dystocia, diabetes,

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placenta previa, abruption placentae and prolapsed umbilical cord,” than vaginal deliveries, and there are increased risks of respiratory distress syndrome and “neurologic deficits” associated with “traumatic vaginal delivery” and birth asphyxia (Bottoms 1980, 559–60). Dystocia or abnormal labour is a label that includes “cephalopelvic disproportion” and “failure to progress in labour,” as well as any form of prolonged labour. There is no uniformity about what medically constitutes prolonged labour, so that some physicians will perform a caesarean section after only a couple of hours. In all of the cases noted above, fear of lawsuits is one of the underlying causes of not letting labour go on too long, particularly in the litigious world of American private medicine (Flamm 1990, 22–23). It has been argued that “social distance between patient and physician has often been used to explain the social class differences in medical care.... Women who most resembled the wives of the male doctors in their social status got the best treatment and the most humanized care.... The greater the status differences, the worse the treatment” (Hurst and Summey 1984, 626).Yet the evidence in terms of ethnicity (which interacts with class) is contradictory. In the state of New York in 1977, the caesarean section rate for African Americans and Puerto Ricans was 27 per cent higher than for whites. The rate rose sharply for women over 35, and those over 40 had twice as many as those aged 15 to 35. Both white and non-white women with higher education had higher caesarean section rates, but this appeared to be associated with age and delayed childbearing. Women having their first child were three times more likely to have a caesarean section than women who already had one to three children. As Francome and Huntingford cogently observed, “If the increase in the use of Caesarean section, and indeed any obstetric operation, is soundly based, [then] hospitals with high rates should show improved maternal and perinatal mortality, and fewer babies with breathing difficulties at birth, compared with those hospitals having lower Caesarean section rates for a similar population.... There is no such evidence available.” While caesarean sections were safer in 1980, they remained more dangerous than vaginal deliveries; the average mortality rate for vaginal deliveries was 2.7 per 1,000 births, compared with 69.95 per 1,000 caesarean sections, which was extremely high even factoring in those cases in which serious complications had warranted the operation (Francome and Huntingford 1980, 355, 358–59). The growth in the number of caesarean sections is worldwide. The WHO reported that between 1983 and 1988, caesarean sections rose to a “staggering” rate of one-third of all births in the United States, Canada, Greece, and Australia. There also was an increasing tendency to “hurry labour along” through the administration of oxytocin, which in some countries occurred in 20 per cent of deliveries, and in others was as high as 80 per cent.5 By 1987, almost one million women underwent caesarean

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sections in the United States, five times the rate in 1970, despite a constant rate of 3.7 million births in both years. Therefore, by 1987, one-quarter of all parturient women had caesarean section deliveries. One-third of these were routine repeat caesarean sections, which, after years of consideration, the ACOG announced were for the most part unnecessary. A study at McMaster University Health Sciences Centre in Hamilton, Ontario, in 1982, for instance, found great success with vaginal births after caesarean sections. To put the American rate in context, between 1965 and 1986, while the number of mastectomies decreased 102 per cent, tonsillectomies decreased 332 per cent and hernia repairs decreased 57 per cent, the number of caesarean sections skyrocketed 436 per cent (Flamm 1990, xix, xx, 169, 2). The increase in caesarean sections is also due to patient demand. In 1996–97, the Canadian caesarean section rate was 18.4 per cent of all deliveries, an increase from previous years and a shift from the 1980s, when the caesarean section rate was decreasing. By 2004, 29.7 per cent of live births in British Columbia were by caesarean section, or a rate of 297 per 1,000 live births.6 Part of this trend was due to the desires of the women, particularly older mothers, who requested them at first instance, as well as when there were problems in labour. As Dr. Alice Benjamin, Director of Obstetrics at Montreal’s Mount Royal Hospital commented, “More and more these days we are doing them for the mother’s satisfaction.... It’s mainly urban, professional women who are having their first child in their thirties and they are quite prepared to bypass the whole natural processes of labour” (Nichols 1999, 34–35). With “falling birth rates, increased control over family planning, later timing of births and a wider range of pregnancy diagnostic tools,” the private patient — that is, the woman of higher social class — demands a “perfect baby.” Indeed, it has been found that “more caesareans are being performed in the socio-economic group of women with the lowest medical risk.” These women were older at first childbirth, had high levels of education, had more prenatal and private obstetrical care, and gave birth (in the American cases) at a non-public hospital. As in Canada, regional differences exist in the United States. The Northeast, with its highest concentration of university teaching and private hospitals, has the highest caesarean section rate, followed by the South, the West, and the North-Central areas (Hurst and Summey 1984, 627, 621, 623). Other women considered the increasingly frequent use of the caesarean section to be a major disincentive to a hospital birth and began to seek out alternative birthing options such as the attendance of a midwife and/or a home birth. Psychologists have noted a number of negative emotional responses associated with a caesarean section, including:

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Concern about their inability to deliver vaginally, especially if childbirth preparation classes were taken; loss of the ability to witness or participate in the birth; loss of being allowed to have a significant person attend and participate as desired; loss of control, of feeling a sense of powerlessness over the events ... loss of, or interference with, the opportunity to immediately interact with the newborn baby ... feelings of inadequacy or loss of “womanliness” because of the inability to produce a baby in the “natural way”; feeling that part of the birth process has been taken away; longer loss from undertaking roles viewed as essential to the mother’s self-concept, such as mothering the new baby, taking control of the household, and interacting with other children. (Flamm 1990, 40–41)

What is striking about the last comment is that one of the complaints of many women following childbirth is that, unlike decades earlier, there is too abbreviated a recovery time. Many women have less of a support network than earlier generations and are expected and required to resume their domestic duties soon after the birth. Some of the complaints, such as the absence of the spouse and the mother’s inability to witness the birth under general anaesthetic, have been addressed by hospitals that have relaxed their regulations as they have perfected the procedure. During the late 1980s and early 1990s, the caesarean section rate declined in many areas of the United States. In Ohio, this coincided with an increased use of electronic foetal monitoring and inductions of labour. There was a 30 per cent decline in the number of repeat caesarean sections, which represented a concerted effort by obstetricians to reduce caesarean section levels, and electronic monitoring might have been more carefully interpreted to reduce mistaken conclusions of foetuses in distress. However, the decrease also coincided with the increased use both of drugs to induce and stimulate labour and of vacuum extraction, all with health risks of their own (Koroukian and Rimm 2000, 12, 15, 16). Hospital Childbirth Options at the End of the Twentieth Century By the 1990s, there was substantial progress in terms of family involvement in hospital deliveries in Canada. A survey of 523 hospitals revealed that virtually all encouraged the spouse or partner to participate in the labour and vaginal births, 84 per cent encouraged another labour support person, and 75 per cent encouraged the partner’s presence for caesarean sections with epidural anaesthesia. Two-thirds of the hospitals no longer gave a perineal shave upon admission, and only 11 per cent required women to have an enema or suppository. However, all of the hospitals in New Brunswick and half in British Columbia administered a 20-minute

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routine electronic foetal monitoring upon admission. For pain control, these hospitals offered narcotics, nitrous oxide, epidural anaesthesia, and one-third also offered transcutaneous electrical nerve stimulation (TENS). Two-thirds of the hospitals allowed the women to choose their position for giving birth, and two-thirds gave first-time mothers an episiotomy.7 In another Canadian survey in 1998, hospitals were assessed to determine whether maternity ward practices reflected the most recent evidence or customs that had been found to be unnecessary and/or potentially dangerous. The procedures examined included perineal shaves, enemas and suppositories, intravenous infusions, electronic foetal heart monitoring, and episiotomies. Practice varied tremendously. Hospitals in the Atlantic and prairie provinces and in Quebec were more likely to routinely administer perineal shaves and enemas upon admission. Small hospitals and nonuniversity teaching hospitals were less likely to administer intravenous infusions, initiate foetal heart monitoring, and perform episiotomies. These procedures continued to be routine in a large number of hospitals, despite the evidence that shaves and enemas were unnecessary and perceived as “degrading” by women in labour, that intravenous infusions of glucose and other fluids could be harmful to the baby and could be replaced by feeding the mother during labour, and that continuous electronic foetal monitoring resulted in higher rates of caesarean birth and use of forceps and vacuums (Kaczorowski et al. 1998, 11–12). Class and ethnicity remain significant factors in the outcomes of pregnancies. In 2000, the American Centers for Disease Control reported that African-American women were still four times more likely to die during childbirth or postpartum than white women. While poor women in the United States have access to care through Medicaid, the reimbursement for caesarean sections is lower than from private insurance, which reduced the probability of its use (Grant 2000, 40). In Canada, universal health care has not translated into universal access to all procedures. From 1991 to 1998, British Columbia’s Status Indians had a caesarean section rate of 162.7 per 1,000, which was 20 per cent lower than the rate for all other provincial residents. This was not the result of the availability of superior alternatives. The premature live birth rate was 1.5 times higher that of other residents, while perinatal complications such as problems with the placenta, cord, and membranes resulted in a stillbirth rate slightly higher than the provincial average.8 By the end of the twentieth century, the caesarean section was a common childbirth option for North American women. In the nineteenth century it had been a dreaded operation of last resort, only becoming a viable option after the incorporation of antiseptic techniques in operating rooms. Nevertheless, it remained, for most physicians and their patients, an option to be practiced only after a fruitlessly long and difficult labour.

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Because of its association with failure, women who delivered by caesarean section were perceived, for much of the twentieth century, as having not fully come up to bat. Bonnie Donovan picturesquely described the “classic image” of the caesarean mother: “short, small-boned, perhaps frail, nervous creature. Tiny feet are supposed to be another way to spot a woman who will have to deliver by caesarean. Some people say that a pointed jaw, or thin lips betray the woman ... Just as women who have irregular, painful periods are blamed for bringing them on themselves, so too, it is whispered, women who are uncomfortable in their roles as child-bearers are to blame for imposing caesarean deliveries upon themselves” (Donovan 1977, 19). Such assessments drew upon the Freudian thinking that gynaecological disorders ranging from dysmenorrhea to infertility to hot flashes can be traced to psychological conflicts. By the beginning of the twenty-first century, caesarean sections had become so common that the women who underwent them, particularly after an unsuccessful, lengthy labour, were no longer viewed in a negative light. Less sympathy was directed towards the growing cohort of women who chose to have planned caesarean sections or what were derisively referred to as “designer” births. Like the women over a century earlier who avoided Eve’s curse by inhaling chloroform, these mothers-to-be were somehow subverting nature by avoiding labour altogether. They were stereotyped as career women, too busy to fit in an unplanned due date in their Daytimers. Canada’s most famous “designer” mother was Mila Mulroney, wife of Prime Minister Brian Mulroney, who planned the birth of her fourth child to coincide with the anniversary of her husband’s election. While it is true that the caesarean section rate in North America is substantial (although how high is too high is an arbitrary designation, particularly when determined by government health departments and insurance companies), the alternative to the caesarean in the hospital is not usually “natural” but a combination of drugs and other interventionist technologies like forceps and vacuums. An interesting parallel can be made here between the critique of women choosing to have planned caesarean sections and women choosing to have elective abortions. Women’s right to choose an abortion was not part of the public discourse as long as abortions were difficult to access, humiliating to undergo, and potentially lethal. A woman’s right to choose a pain-free childbirth similarly overturns centuries of external controls over her reproductive organs. It is only when Eve is no longer divinely cursed that man fills the breech by castigating her for embracing beneficial modern technologies.Yet other men, and some women, who provide that technology wish to maintain control over their patients in very traditional ways. The next section will focus upon a diversity of mothers and how they confronted their pregnancies and their caregivers in the later twentieth century.

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Mothers and Their Obstetricians The Mothers Some of the difficulties faced by pregnant women and their physicians were due to the nature of maternity care itself. As Barbara and Irwin Kaiser observed, “Obstetrician-gynecologists are the only specialists a woman routinely goes to as a patient for care at times when she is not merely well but in abounding good health: that is, for prenatal care and delivery.” Some of the difficulties arose because of the attitudes of the medical attendants. Hopefully, there has been some improvement in the century since Oliver Wendell Holmes characterized a woman as “a constipated biped with a backache.” (Kaiser and Kaiser 1974, 652, 658). However, only the utmost sensitivity on the doctor’s part could counter the unequal nature of his encounter with the patient, and such sensitivity was more likely an ideal than an everyday occurrence, given a hectic and stressful practice.9 The initial encounter was the gynaecological examination, which is, “from the point of view of the patient ... the paradigm of the ordinary humiliation of a woman at the hands of a man. But it has not generally occurred to [the male gynaecologist] that the patient is literally helpless in his hands and feels that way; naked, supine, being manipulated with fingers and tools in her bodily orifices by someone hidden behind a sheet” (Kaiser and Kaiser 1974, 658). Attitudes taught in medical schools were barriers of another sort. A study of textbooks used by medical and nursing students in the 1960s found that women’s functional conditions, such as dysmenorrhea and nausea in pregnancy, were described as psychogenic in origin. Even labour pains, it was asserted, were caused by neuroses (as if an eightpound human with a hard skull shoving through a cervix wasn’t reason enough for the pain). By the 1970s, however, nursing texts, written by and for women whose personal experiences would belie these lingering Victorian attitudes, were somewhat more even-handed in their approach, for instance, emphasizing that nausea had an organic cause. Yet they too often presumed a white, middle-class, two-parent household model and asserted that mothers who returned to work before the child was six years old were failing in their maternal responsibilities (Benton 1977, 270, 272, 277, 280). Diversity in Mothers Despite these assumptions, diversity remained the birthing experience of North American women throughout the twentieth century. Race and ethnicity, age, marital status, and ability all contributed to varying childbirth attitudes and outcomes. In a 1981 study for instance, women of the Navajo,

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who comprised one-quarter of Native American and Alaskan populations, were found to have insufficient prenatal care. Part of the problem, beyond inadequate resources, was the clash of beliefs of the Navajo people and Western health care providers. Many Navajo wished to retain particular rituals for disposing of body parts such as the umbilical cord, the mother’s pubic hair, and the placenta. Also, the prescription for mothers to rest, particularly in cases of pre-eclampsia, ran counter to the Navajo belief that childbirth was a natural and harmonious event not requiring restricted movement. On the other hand, the Navajo maintained restrictions upon thought, speech, and behaviour that could adversely affect the foetus (persistence of the traditional idea of maternal impressions upon the foetus). The notion of delivering a baby in a hospital, where people were sick and died, was considered an untoward risk to the foetus and mother (Milligan 1984, 85–86, 89). In Canada, traditional Cree births, as in other cultures, were attended by women recognized in their communities as particularly skilled as well as having an excellent “way with words.” A midwife with a soothing and empathetic manner was seen to be “the best guarantee of an easy short labour” and helped to “calm laboring women” (Dufour 1994, 4–5). When Cree women were moved into maternity hospitals and faced brusquely efficient nurses and male doctors, they often found the experience disturbing. The myth that Native women did not suffer from labour pains in childbirth was employed by colonizing observers from the Jesuits onwards to distinguish them in general from Europeans. Nor have Native birth experiences lost their association with colonization; government statistics that focus upon the lowering of infant mortality rates in the far North as “proof ” of benevolent Canadian imperialism “has transferred the impact of resettlement, poverty and disease to the body of the Inuit woman” (Jasen 1997, 384, 397). Until the 1950s, two-thirds of the babies born in the Northwest Territories were home births attended by midwives, families, and friends, using traditional techniques and knowledge. Due to poor living conditions and malnutrition, the infant mortality rate was high, but it was reduced in the 1960s and 1970s with the federal government’s institution of nursing stations staffed by mostly European-trained nurses. After the 1970s, the federal government attempted to centralize and standardize births by requiring that all deliveries take place in larger centres such as Edmonton, Yellowknife, Montreal, or Churchill. This usually meant that the women would be travelling alone in the last stages of pregnancy and delivering in an alien environment, away from husband, children, and friends, amid strangers who spoke a foreign language. Many of the pregnant women subsequently rebelled against this requirement by avoiding prenatal visits (so that the requirement worked against proper

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prenatal care), hiding from transport planes, or deliberately misstating their due dates, necessitating “emergency” deliveries at nursing stations nearer to home. By the 1980s, many of these stations were under- or unstaffed, due to inadequate wages to compensate for the isolated conditions. In response, a number of Inuit women, who were trained in southern Canadian nursing schools, set up their own birthing clinics, which integrated Western medicine with traditional practices. They also developed apprenticeship programs to bring future midwives into the system, as well as to offer pre- and postnatal education for mothers (Lowell 1989, 23–24). They aimed to combine “best” practices. In the high Arctic, the placenta was carefully wrapped and buried in the rocks. In protracted labours, women would “get up, go outside and return inside very quickly to make the baby come. Newborns were greeted by everyone, even the children, with a handshake.” At the end of the twentieth century, maternity clinics built in the Arctic included architecture with cultural sensitivity: to emphasize that birthing was not a sickness, the maternity ward was separated from the hospital by heavy doors and its own entrance (Gallagher and Lowi 1997, 3). Diversity is not always associated with poverty or lack of education. Pregnant Japanese-American women traditionally wear cotton sashes called chakutai and amulets sent by their families in Japan. They are also expected to have a medication-free pregnancy and delivery, so that they avoid medicines, including vitamin supplements (preferring to rely upon careful diets), and attempt to work through their labour with Lamaze and other natural methods as much as possible. As in other cultures, the umbilical cord has special significance; traditional Japanese mothers save the cord in a wooden box as a keepsake, possibly to be given to the child’s spouse at marriage (Ito and Sharts-Hopko 2002, 669–70). Ancient traditions of keeping the cord are all the more interesting given current stemcell research into the use of foetal blood in possibly curing Parkinson’s disease and other serious ailments. In another combination of the traditional with the modern, the sonogram has become an integral part of the Japanese birthing experience. Japanese couples expect to be given a foetal sonogram at every prenatal visit and collect the pictures as the child’s earliest baby photos (Yeo et al. 2000, 194). The middle-class, educated Japanese woman represents one of the optimal types of maternity cases encountered by physicians. Other types, such as the disabled and teenage girls, offer more challenges. Women with disabilities are discouraged from having children by being characterized as incapable mothers. Those who become pregnant may find that prenatal instructors and maternity nurses are ill-prepared to assist them with their particular challenges (Blackford 2000, 898). Maternity wards, washrooms, and even bassinettes might be inaccessible to paraplegics and others. One

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disabled and creative woman,Val Richardson, designed an accessible crib and special tray for her wheelchair. In a moving description of videotaped interactions between disabled mothers and their babies, Megan Kirschbaum noted that there was a “dance between disabled mother and infant — the mutuality, reciprocity as it occurs in caretaking and play.” The tapes showed the co-operation between a mother with paraplegia and her baby. The mother’s problems with balance meant that she had to lift him with one hand; at one month of age, he would adapt by curling up like a kitten and remaining very still during the lift. As time progressed, the co-operation intensified. [The] infants were more patient with their disabled parents than with other caregivers. (Ridington 1989, 9–14)

Another group who did not fit the idealized image of parturient womanhood was teenage mothers, usually unwed, and often of minority origin, which further distanced them from the ideal. In the postwar era, psychoanalysts speculated on the causes of white unwed motherhood and blamed emotional maladjustments. As in much of the psychoanalysis of the day, the theories were profoundly sexist and conservative, and they served many social functions. They absolved the male partner of any responsibility for the pregnancy, labelled all women who strayed from traditional domesticity ill and requiring intensive psychological treatment, and removed any element of degeneration or “hereditary taint” from the newborn (Solinger 1990, 45). This last point was very significant during the 1950s and early 1960s; white unwed mothers were considered “socially productive breeders whose babies, unfortunately conceived out of wedlock, could offer infertile couples their only chance to construct proper families” (Lesko 1994, 125). African-American single mothers were less likely to be ostracized by their families, who incorporated the children into the household. At the same time, African-American babies were considered less valuable in the adoption market.10 By the 1960s, young white women were more experienced with early contraceptive use and recourse to abortion than non-white women and therefore had fewer teenage and unwanted pregnancies. This would have life-long ramifications, since The girl who has an illegitimate child at the age of 16 suddenly has 90 per cent of her life’s script written for her. She will probably drop out of school; even if someone else in her family helps to take care of the baby, she will probably not be able to find a steady job that pays enough to provide for herself and her child; she may feel

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impelled to marry someone she might not otherwise have chosen. Her life choices are few, and most of them are bad. (Presser 1971, 332, 338)

Given these potentially high costs, at least some teens must have perceived that there could be possible benefits. The desire for motherhood “grows out of and is intimately connected to the adolescent’s sense of herself and where she fits into the world.” The poor minority girl “no longer need wonder who she is: she knows — she is a mother. This new identity at the developmental crossroads of adolescence, when everything in her life seems up in the air, in an environment that offers no chance to explore other options ... motherhood promises a path to personhood” (Presser 1971, 332, 338). It was the perceived absence of life choices, rather than minority status per se, which led many teenage girls to have babies. It was found that when young American women of Puerto Rican descent, another minority group, completed high school, they had 25 to 30 per cent fewer children (Jaffe and Cullen 1975, 197). By the 1970s, while the number of large families was declining, the rate of teenage pregnancies in the United States was increasing, with a growing number of mothers under the age of 16 (Held and Prystowsky 1971, 35). Between 1975 and 1978, over 60 per cent of first births to white teenagers, and 90 per cent to African-American teenagers, were conceived before marriage. These numbers rose 100 per cent for white teenagers and 50 per cent for black teenagers since the 1950s (O’Connell and Moore 1980, 16). In Canadian First Nations communities, single motherhood was also prevalent. By 1996, Native women between 15–24 years old were three times more likely to be single mothers than other young Canadian women, and this held true both for urban and rural areas. Furthermore, consistent with the “life script” discussed above, Native single mothers had a 30 per cent unemployment rate, compared to 18 per cent for other Canadian single mothers.11 The prevalence of teenage pregnancy was also due to diminished availability of safe abortions for teenagers, as opposed to women in their twenties or older. Abortions were difficult and often expensive to obtain, even after the liberalization of abortion laws in Canada in 1969 and the United States in 1973. In both countries, decriminalization did not translate into equal or easy access, as many states and provinces had few or no abortion clinics and each jurisdiction maintained varying regulations regarding the right of minors to receive abortions without parental consent. In the familiar refrain concerning availability of health care, class, race, and geography were factors in access to abortion. Wealthier white women found the funds to travel to locations, even overseas, to obtain

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safe abortions. Teenagers, especially of colour, had fewer material assets and therefore fewer options (Sethna 2010). The rising teenage birth rate also was a reflection both of the diminished stigma of single parenthood and a recognition that marriages are not always “happily ever after.” Indeed, many single teenagers with babies receive personal and financial support from family members, which would not have been available should they have married the father to “legitimize” the child, only to have the marriage end in divorce (O’Connell and Moore 1980, 17, 22). By the early 1990s, the birth rates for American teenagers aged 15–17 were still high but began to level off, an indication of the more regular use of contraception (Worthington-Roberts and Williams 1997, 2–3). The correlation between teenage pregnancy and preterm birth and low birth weight, often leading to neonatal mortality, was not related to age but to the ongoing poor health of mothers who were socio-economically disadvantaged. Residents in ghettos had higher rates of sexually transmitted diseases and smoking and were likely to be malnourished and underweight — all of which are risk factors for neonatal mortality. Severe malnutrition among pregnant women can produce low birth weights, as well as perinatal handicaps and injuries, which in the first trimester interfere with the normal growth and development of infants (Jassa 1978, 27). In some American states, minors have been denied access to Medicaid, so that they cannot obtain proper prenatal care or abortions (Geronimus 1987, 252–53). Further complicating the situation for disadvantaged pregnant minority women, chronic psychological stress, such as experiencing racism or spousal violence, may release hormones that detach the placenta, causing preterm delivery. There is also a correlation between past physical and/or sexual abuse and increased incidences of substance abuse, hypertension, depression, and sexually transmitted diseases, all of which also threaten infants and complicate deliveries (Rich-Edwards et al. 2001, 124, 127). At the other end of the spectrum were the older mothers who became a significant group of parturient women by the close of the twentieth century. Women who delay motherhood have been found to offer “a healthier emotional environment”; they encourage independence and verbalization in their children as well as the active participation of fathers. On the other hand, they are less likely to have parents available to help out with child care. Contrary to the anti-feminist prognostications of the 1970s and 1980s, mothers and children bond equally well, whether or not the children are in daycare or raised at home (Gerson et al. 1990, 25–26, 28). Although late childbearing is linked to prematurity and chromosomal abnormalities, there is no clear cut-off date for optimal fertility. Rather, the risks rise gradually over time and can be mitigated: “A 35-year-

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old educated middle-class woman, well nourished and in good health, who has access to first-rate medical care, has more reason to expect an uncomplicated pregnancy and delivery than a 20-year-old working-class woman who is overweight, prone to hypertension and without prenatal care because she cannot leave her job during maternity clinic hours at a remote hospital” (Daniels 1979, 8). While older and younger mothers have been criticized at various times for not meeting the ideal motherhood standard, whatever that might be, many other mothers were condemned, and condemned themselves, for not responding to new motherhood as a joyful event. Sad Mothers Between 10 to 15 per cent of mothers in Western countries suffer from postnatal, or postpartum, depression (Tammentie et al. 2004, 141). While sleep loss and extreme fatigue is an expected aspect of having an infant at home, there has not been much research on the effects of extreme and prolonged tiredness. Women most severely affected tend to be first-time mothers, single mothers, women breast-feeding their infants, and those suffering the effects of a difficult delivery. Prolonged sleep deprivation can produce greater susceptibility to infection and stress, decreased cognitive abilities, mood changes, and other illnesses, including postpartum psychoses, all of which can occur while the mothers must cope with the added responsibilities and changes associated with having babies (McQueen and Mander 2003, 466; Sharma and Mazmanian 2003, 99). The experience of postpartum depression varies widely from mild to severe. The mildest, commonly known as “maternity blues” or “baby blues,” includes crying spells and mood swings; it is experienced by onehalf of all new mothers. Baby blues are likely related to the extreme hormonal imbalances caused by the baby’s departure from the womb and usually do not last longer than a couple of weeks. However, the tendency of hospitals in recent years to discharge new mothers within two days, rather than two weeks as in earlier decades, exacerbates the blues because the women are deposited back home without the added support and rest supplied by the nursing staff. Thus, the proper diagnosis and treatment for postnatal depression are hampered by hospital policies of early discharge. These cases, which may not manifest themselves until later, require proper supervision and support by trained community health care workers, who are not always available and who are the first to be laid off during financial crises (Morse et al. 2004, 465; Williamson 1993, 153). Postpartum depression has been recognized for many years, although not always labelled as such. Queen Victoria suffered from severe postpartum depression following the birth of her second child, Edward the

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Prince of Wales, in 1841. Although experienced by women of all classes, 80 years later there was still little medical recognition for it; in 1926, psychiatrist E.A. Strecker stated that postpartum depression did not exist and that those women so labelled actually were suffering from other mental disorders (Williamson 1993, 152, 154). Recent research appears to support Strecker’s claim for the most extreme cases at least, since women with severe postpartum depression tend to have had prior bouts of depression (Buesching et al. 1986, 61, 76). The most serious form of postpartum depression is “puerperal psychosis,” which affects about one in 500 women, and whose symptoms include hallucinations, delusions, suicidal thoughts, and even threats to harm the baby. Under British Common Law, puerperal psychosis has been a defence in infanticide (Williamson 1993, 154, 157). As in all aspects of the childbirth experience, socio-economic status influences the prevalence of and recovery from postpartum depression. Poor women are more likely to be alone with their children and have little emotional support or financial resources to access proper housing or childcare (Séguin et al. 1999, 69). Over the course of the twentieth century, there was great diversity, then, among North American parturient mothers, based upon age, socio-economic status, ability, or ethnicity in the degree of postpartum depression they experienced. Yet increasingly they shared the experience of delivering their babies either with an obstetrician or with attendants and procedures under the specialists’ direction. The Obstetricians

Competing with Family Physicians By the middle of the twentieth century, obstetricians had established themselves as the dominant force in the delivery of babies in North America. However, they faced competitors. Many general or family practitioners, who had superseded midwives in the nineteenth and early twentieth centuries, resisted being elbowed out by their professional colleagues. In the 1970s, obstetricians defended their predominance, asserting that it was a “fact that this discipline of medicine has accounted for a significant reduction in disease and death in women, through concentrated efforts in the areas of preventive medicine and public health” (Pearson 1975, 815). While this writer was preaching to the converted in the JAMA, it should be noted, as demonstrated elsewhere in this book, that this was not, in fact, a fact. Public health measures were initiated by bacteriologists, public health nurses, and boards of health, and many of the professionalizing strategies of the obstetrician/gynaecologist (ob/gyn) were counter to achieving a swift reduction in female disease and death. Nevertheless, the availability of prenatal care, and routine physical examinations either by an ob/gyn or family physician for cardiovascular disease, breast tumours,

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rectal carcinomas, and other conditions did help to lower the female death rate (Pearson 1975, 815). Such prenatal and routine examinations had customarily been the purview of family physicians, however, who argued that consulting women through pregnancy should be an integral part of their practice, and the points they raised resonated with those made generations earlier. Dr. Lucy Candib, for instance, contended that the inclusion of obstetrics guaranteed “the growth and development” of family practice as a specialty and accustomed the family to “longitudinal care during health, with an emphasis on nutrition, patient preparation and education, and changing family dynamics” (Candib 1976, 391). That is, a positive obstetrical experience opened the door for a family’s long-term loyalty and patronage of a particular physician. Despite the arguments raised by Candib and others, from the 1980s to the early 2000s, there was a substantial decline in the amount of prenatal care offered by family physicians in the United States, possibly due to the irregular hours of obstetrics, the availability of insurance coverage for obstetricians’ services, and higher malpractice insurance for those practicing obstetrics.12

Competing with Nurse-Midwives Nurse-midwifery, which was structured to be modelled after professional nursing rather than traditional midwifery, placed its practitioners in positions of dependence upon physicians. In communities where the medical profession perceived nurse-midwives to be economic competition, the doctors severely curtailed the latter’s ability to practice by denying hospital privileges, third-party reimbursements, licensing, and malpractice insurance. All of this was justified under the rubric of “safety.” During labour and delivery, the physicians retained the authority to provide interventionist measures as they saw fit, further undermining the autonomy of the nurse-midwife and the mother (Vosler and Burst 1993, 297). For a variety of reasons, however, many women continued to seek out the nurse-midwifery option. They might have been referred by a friend who had had a positive birthing experience, they might have been undergoing a stressful life event or an unplanned pregnancy and desired empathetic care, or they might have been looking for increased support for breastfeeding, all advantages most readily associated with other women (Murtland et al. 1994, 415, 423). Whatever the reasons, statistics have consistently borne out that those births with midwives as attendants are not more dangerous than hospital, physician-attended births. In 1991, the American National Center for Health Statistics compared the outcome of vaginal births attended by physicians or certified nurse-midwives and found the risk of infant mortality to be 19 per cent lower for those cases delivered by nurse-midwives. Furthermore, the risk of neonatal mortality (death within the first month of life) was 33 per cent lower and the

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delivery of a low birth weight infant was 31 per cent lower in nursemidwife deliveries.13 In 1999, the United States ranked 22 in terms of infant mortality, behind Japan, Finland, and Sweden, all of which provided midwifery care. Midwives were more likely to use “low technology care measures: oral fluids, ambulation and position change, baths or showers, fewer episiotomies [and offer] bedside emotional support” which were “appreciated” by their clients whose outcomes could well be superior (Albers et al. 1999, 53).

Competing with the Alternative Birth Movement During the 1970s, as part of the counter-culture movement, a number of women registered their protests against the technologically based hospital birth by “dropping out” and establishing alternative birth communities, which revived many of the practices of traditional midwifery. One of the earliest and most famous of these was The Farm of Tennessee, established by a group of women from San Francisco, and popularized by Ina May Gaskin in her book Spiritual Midwifery published in 1975. Similar communities and collectives were established throughout the United States at this time (Beckett and Hoffman 2005, 131–32). The lobbying strategies of the alternative birth movement were unique in that they combined feminism and consumer health activism with traditional motherhood arguments that appealed to paternalistic legislators. For instance, when faced with opposition from state medical associations, the lobbyists mobilized grassroots support and then attended legislative hearings in full force, complete with their infants. At the hearings, “reference was frequently made to the presence of these ‘ladies’— and, often, their audible babies: ‘Is there anybody in the audience who would like to testify ... I hear some babies crying, does anybody want to come up and state the success of the [home birth] program?’” While depending upon “the kindness of strangers” may seem a questionable feminist tactic, it met with success, since “some lawmakers clearly relished the chance to defend ‘these ladies’ from the machinations of the medical establishment.” Doctors had many critics. By 2005, midwifery was legal in 30 American states (Beckett and Bruce Hoffman 2005, 149, 160, 161, 139). Similar lobbying took place in Canada. In 1979, Ontario parents and health professionals petitioned for a birth centre in Toronto. They were taken seriously by the provincial minister of health because a physician was a member of the group. Despite the centre’s establishment of safety protocols, such as screening for low-risk mothers and agreements with local hospitals for emergency transfers, the province’s medical establishment, however, was vocally opposed to the centre, citing the common refrain: “It won’t be safe, its babies will die” (Walker 1984, 10).

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In both countries, organized medicine kept up swift and persistent opposition to any members who strayed from the hospital norm and other practitioners (especially midwives) who were offering similar alternatives. In 1978, the ACOG, which had earlier characterized home births as “child abuse,” fired their broadside with the publication of a policy statement that “out of hospital” births were two to five times riskier to a baby than hospital births. This statistic did not differentiate, however, between planned home births, attended by a health professional, and those that were unplanned or occurred in emergency conditions, such as in the back seat of a car. The following year, an American resident obstetrician, Dr. Howison, was censured by his county Board of Obstetrics and Gynaecology and denied hospital privileges because he offered prenatal care to women known to be planning home births (Randal 1980, 16). By 1983, Ontario’s College of Physicians and Surgeons was pressuring its membership to stop accepting home births, but home births slowly increased (Starr 1991, 16). Facing the same punishment as the American doctor, one Canadian physician who attended home births had his hospital privileges withdrawn from Vancouver’s Saint Paul’s Hospital. There was little consistency in terms of hospital policies relating to childbirth. Toronto’s Mount Sinai Hospital, for instance, was very liberal in terms of offering alternative forms of childbirth and yet was also one of the most frequent users of electronic foetal monitoring (Boscoe and McDonnell 1979, 9–10). The provinces of Ontario and Quebec permitted licensed midwives to attend home births in 1994; they were followed by British Columbia in 1998.14 A subsequent study found that women who gave birth at home in that province had fewer epidurals, inductions, administration of oxytocin or prostaglandins, or episiotomies than hospital births. Furthermore, the newborns had similar rates of mortality, Apgar scores, meconium aspiration, or neonatal complications. However, it was noted that serious perinatal complications such as haemorrhaging or meconium in the amniotic fluid were less easy to deal with in home births (Janssen et al. 2002, 315–16, 324). The medical societies’ most powerful weapon, however, was the use of the court system. Midwives found themselves vulnerable when deliveries ended tragically. Between 1977 and 1980, three California midwives were charged for the “unlawful taking of life.” The timing was significant, in that in one instance the prosecution occurred in Madera County, a poor region populated by Mexican-American fruit-pickers. Pregnant indigent women there traditionally had been attended by nurse-midwives because there was no government support for medical services. Once the California government established its Medicaid program (Medi-Cal) in 1963, making it profitable for physicians to attend indigent patients,

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the midwives were targeted and characterized as ignorant and dangerous (Randal 1980, 18). In 1983, three Nova Scotia midwives were charged with criminal negligence causing bodily harm following a Halifax home birth, when a 10-pound baby suffered cardiac arrest after birth. The infant was rushed to the local hospital and placed on life support, and the hospital’s head of neonatal care pressed charges against the midwives. The Nova Scotia Medical Society immediately initiated a campaign against midwifery and said its members would not attend home births.15 Significantly, the response of the profession was to take the path most advantageous for themselves — moving to squeeze out any form of midwife or non-hospital birth — rather than explore other options such as better training and diagnostic tools for midwives and more medical support for home births. The standard argument that hospital births by their definition were safer than home births did not address neonatal mortality rates in hospitals, which could be subsumed under the category of “high-risk births” and protected by malpractice insurers and their lawyers. In 1990, the Alberta government, prompted by the province’s medical establishment, charged experienced midwife Noreen Walker with practicing medicine without a licence after a home birth, even though the delivery was successful (Starr 1991, 16). In 1992, the province of Manitoba held a two-year inquest into the death of Robin Cameron, a twin who died after his twin was successfully delivered in a home birth by two midwives, Darlene Birch and Marla Gross. The midwives had rushed the mother to hospital fearing that Robin was tangled in his umbilical cord; what happened thereafter was contradictory. The midwives testified that the baby was still alive, while the hospital nurses testified that they did not hear a foetal heartbeat, subsequently delaying a critical caesarean section. Judge Connor based his findings upon the testimony of the hospital and one of its obstetricians, Dr. Allardyce, who had spoken out previously against home births, but who had not been present for the Cameron delivery. Consequently, the inquest report, and the news accounts following, emphasized the dangers of home births (Grant 1993, 21, 25).

Nurses versus Midwives By the end of the twentieth century, the checkered development of the professionalization and autonomy of nursing had rendered many nurses, on an institutional and personal basis, suspicious of the legitimization of midwifery as a threat to themselves. In the early 1990s, the Ontario Nurses’ Association would not permit midwives to train in their facilities, citing the midwives’ critique of the medical model upon which registered nursing is based. Exacerbating relations was the fact that midwives would be permitted to perform medical tasks, such as episiotomies, administra-

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tion of drugs, and use of “invasive instrumentation,” which were not available to nurses (Burfoot 1991, 123). In a 2000 review of midwifery practice in British Columbia, researchers found that many points of hostility still remained, particularly among perinatal nurses who had trained as midwives in other countries, yet who did not have the “prestige, recognition and scope of practice granted to midwives” (Kornelsen et al. 2000, 5). Nurse-midwives who worked to improve their status within the hospital structure often moved at cross-purposes with lay midwives who based their practice upon a de-institutional ideology (Kornelsen et al. 2000, 7). Despite the various layers of opposition to midwifery, however, some of the criticisms of hospital births have resulted in changes.

Hospital Innovations Many nurse-midwives, physicians, and hospital administrators working within and outside of the hospital environment absorbed the legitimate critiques of the over-medicated, overly interventionist, and alienating traditional hospital birth and made improvements — some substantial and some superficial — to the hospital experience. One of these innovations was the development of alternatives to excessive and possibly dangerous medication. These included the use of hypnosis to decrease anxiety and reduce labour pains. A 1993 study of self-hypnosis taught to pregnant women found that there was significantly less use of epidurals, forceps, intravenous, and episiotomies during deliveries (Letts et al. 1993, 335). Hypnosis was very time-consuming, however, and mothers would have to be trained thoroughly prior to the delivery, so it was not considered practical for high-volume hospital cases. One of the first innovators in “natural” childbirth was Britain’s Grantly Dick-Read, who published Natural Childbirth in 1933. DickRead argued that much, if not all, of the pain of childbirth is due to tension created by fear, so that by removing the fear through preparation in stress-reducing techniques, the pain would diminish. Dick-Read’s method introduced women to the idea of preparing for childbirth with deepbreathing, exercise and visualization strategies. A parallel innovator was the Polish-French Fernand Lamaze, who learned the methods of conditioned response from innovators in Russia. In Painless Childbirth, published posthumously in 1958, Lamaze introduced what has become known as the Lamaze method, which purports that if negative perceptions of pain are replaced by a positive trained reflex (such as short deep breaths and relaxation exercises), the pain will be eliminated. A third male birthing specialist, Fredrick Leboyer, in Birth without Violence (1975), popularized his method of delivery as a metaphor for the improvement of humankind

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by removing violence from birth. Leboyer’s method highlighted the birth experience of the child, virtually reducing the mother to the vessel that holds the infant (Burfoot 1991, 121). Dick-Read’s and particularly Lamaze’s methods had a cult-like following, so that when women who faithfully followed the methods experienced intense labour pains and required anaesthetics or caesarean sections, they sometimes felt like personal failures (Stampone 1990, 10–11). Like other aspects of women’s health, a one-size-fits-all method does not work. Labour will be experienced differently by all women, and indeed by the same women in subsequent deliveries. However, the natural childbirth movement has offered many valuable alternatives and forced reconsideration of the progressively technocratic hospital birth of the twentieth century. Prenatal Preparation Sociologist Elizabeth Armstrong made the intriguing argument that prenatal classes address the needs of the hospital staff rather than those of the parents. The classes “teach women to be compliant with the institutionally determined regimen for labour and delivery.” During the 1960s and 1970s, birth preparation classes were first instituted by alternative birth movements, such as Lamaze, as a reaction to the over-medicalization of childbirth. Deep-breathing and other relaxation techniques, and the assistance of a birthing couch, enabled women to take back some control of the birthing experience. By the 1980s, prenatal education as well as care became de rigueur in North American childbirth; yet its goal was subverted from a successful “natural” childbirth to a “prepared” childbirth — the preparation to include persuading women to “adopt the values, expectations and orientations of the hospital” (Armstrong 2000, 583, 585, 586). Teaching women to count their contractions, for instance, serves to enhance a hospital’s efficiency by avoiding cluttering up the wards with women not ready to deliver. The classes also severely limit the choices: elective caesarean sections, or the use of midwives, are often not discussed, precluding the possibility such options might be available in the hospital. Patient behaviour is also taught, with emphasis upon “staying calm”— i.e., not screaming or expressing anger or any other disruptive emotion during labour, which may be disturbing for other patients and require additional services from the staff. Preparation classes also avoided much discussion about the intense pain of childbirth, focusing upon the tools and procedures — such as forceps and episiotomies — rather than on what it would be like to undergo them. This emphasized a mechanistic rather than natural or emotional view of childbirth and led to many women’s further

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alienation from and disappointment about the delivery they actually experienced (Armstrong 2000, 591, 592, 594). Father’s Role A 1975 study determined that women whose husbands or significant others had attended prenatal classes with them (as required by the Dick-Read and Lamaze methods) and then had acted as labour coaches, experienced reduced pain, required less medication, and considered the labour and delivery to be a positive experience (Henneborn and Cogan 1975, 215, 218–19). Did this produce additional anxieties for expectant fathers who yearned for the good old days of pacing floors and handing out cigars? As Morton Walker et al. quaintly described in their manual, The Complete Book of Birth, the husband who agrees to act as labour coach will “have to deal with the least attractive part of his mate as she goes through the effort of labour.” The authors asserted that husbands worry that “the techniques of unmediated childbirth will in a way turn their wives more towards the women’s liberation movement. Many husbands want no fires under their wives that will cause them to feel superior.... Consequently, a few men will feel suspicious of prepared childbirth classes and wonder if their women will be turned into those kinds of militant feminists” (Walker et al. 1979, 90). Did childbirth classes lead to a more politically aware sisterhood? Or were the claims of female moral superiority based upon the travails of labour as ephemeral as they were in the nineteenth century? In either case of course, newborn cries at three in the morning (and five ... and seven ...) do diminish one’s capacity for militancy, at least for a year or two. Greater choice in birthing positions was another innovation. Dr. Robert Caldeyro-Barcia, one-time president of the International Federation of Gynaecologists and Obstetricians, made the picturesque comment that “except for being hanged by the feet, the supine (on the back) position is the worst conceivable position for labour and delivery.” French obstetrician Dr. Michel Odent determined that when women were free to choose their position during labour, the most popular was a supported squat. He found that in this position women successfully were delivered of breech births and rarely required forceps or vacuum extractions (Dow 1984, 20). By the 1960s, medical and nursing textbooks were beginning to note what Native and other cultures had known for centuries: that the “lateral” rather than “supine” positions of delivery facilitated contractions, were more relaxing to the women, and were even better for their blood pressure. One author admitted that “as strange and uncomfortable as it appears to observers, some patients instinctively assume either a hands-and-knees or a squatting position at this time” (Roberts 1979,

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26–27). Note that the observers’ discomfort — that of attending physicians and nurses — was the focus, rather than the overwhelming discomfort of the labouring woman. By 1980, the success of the alternative birth movement was evidenced in its co-optation by hospitals, which built, with much publicity, “homestyle birth rooms” or “family birth centres.” Families were usually permitted to remain in these rooms, in which the mother would labour and deliver, with the infant remaining with her there until discharge. The room was designed to be “home-like” (or at least hotel-like), with “a queensized bed, carpeting, hanging plants, pictures, stereo, overstuffed chairs and a dining table” (De Vries 1980, 47, 50). Often medical equipment such as foetal monitors and IV units were hidden behind wood-panelled walls or in armoires (Mathews and Zadak 1991, 54). In the late 1970s, hospitals in Hamilton, Calgary, and Vancouver erected “birth suites.” Other initiatives were the out-of-hospital birth centres (although these were apparent in the abstract rather than in reality). Hospitals tended to regard birthing rooms as “loss leaders”: features that would entice pregnant women to use their facilities rather than another hospital’s. By 1995, popular demand for hospital birthing rooms that would replicate aspects of the home birth experience while retaining the safety aspects of hospital births was showing results. Seventy per cent of Canadian hospitals responding to a survey reported that they had built combined birthing rooms (for both labour and birth), while 34 per cent had rooms that were used for recovery as well. Nevertheless, over one-half of births in those hospitals still took place in traditional delivery rooms, demonstrating a lag between the trumpeted innovation and the institution’s actual practices (Levitt et al. 1995, 4). Once in the hospital, the traditional hierarchy and lack of decisionmaking on the part of the mother remained; one study found that 46 per cent of the women in the birthing rooms were transferred to traditional delivery facilities during labour (De Vries 1980, 55). By 2002, however, women were found to express greater satisfaction with their labouring experience in birthing rooms, used less pain medication, were more likely to walk and move about during labour, and had fewer caesarean section deliveries than low-risk women in regular hospital settings (Nikodem 2002, 29). Hospitals likely were encouraged to adapt to the demands for alternative birth options over the last decade of the twentieth century to attract their middle-class clientele, while many of the women sought the best features of hospital and alternative birth options: For many [well-educated, self-determining women], childbearing is a planned occurrence which will happen only once or twice in a lifetime. For many women and their partners, a perfect pregnancy outcome is imperative. This expectation is reflected by the

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sharp increase in maternity-related malpractice suits in recent years. Therefore, many well-educated, middle-class women demand ultrasonography during pregnancy, accede to electronic foetal monitoring for early recognition of foetal distress, want analgesia during labor, and readily accept caesarean section. In other words, many middle-class women trust technology yet desire the family-centered, home environment provided by alternative birth services. (Mathews and Zadak 1991, 53)

The caveat is that this is a middle-class solution to a middle-class pregnancy. The glorification (or rather, revival of the nineteenth-century glorification) of the home is not necessarily an appropriate model: “Home does not signify autonomy and bodily control for all women, nor is domestic space always the safest place for women. Statistics on the higher rates of domestic violence against pregnant women point to the very real dangers of reifying the domestic as a site of women’s empowerment.” Furthermore, the home birth experiences of rural women without access to hospital care, of single young women avoiding the stigma of an unexpected birth, or of religious or socially conservative women whose birthing choices are directed by a dominant patriarchal figure are not those of the middle-class ideal (Fannin 2003, 521). Regardless of the variety of birthing options, birthing attendants, and characteristics of the mothers, childbirth in the twentieth century was one technological refinement of woman’s natural biological function. The next chapter will discuss some of the emerging trends in reproductive technologies that have the potential of irrevocably altering that function. Most of the story has not yet emerged; nevertheless, what is developing is the diminution of the mother’s role in childbirth and the growing relationship between the physician/scientist and the foetus.

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Notes 1

2

3

4 5 6 7 8

9

10 11 12 13 14 15

Public Health Agency of Canada, “Key Findings: Current Provincial/Territorial Maternal Death Review Activities,” http://www.phac-aspc.gc.ca/rhs-ssg/ srmm-rsmm/page2-eng.php; Public Health Agency of Canada, “Special Report on Maternal Mortality and Severe Morbidity in Canada Enhanced Surveillance: The Path to Prevention,” http://www.phac-aspc.gc.ca/rhs-ssg/srmm-rsmm/ page3-eng.php. United States, National Center for Health Statistics, “Vital Statistics of the United States, 2000.Volume 1, Natality,” as cited in Wisconsin, Department of Health and Family Services, “Other Measures of Fertility,” http:// dhfs.wisconsin.gov/wish/main/fertility/MEASURES.HTM; Statistics Canada, Canadian Vital Statistics, Birth Database Table 2: Live Births, by Geography — Crude Birth Rate, Age-Specific, and Total Fertility Rates, http:// www.statcan.ca/english/freepub/84F0210XIE/2005001/t005_en.htm. Diane Dwyex and Sonia Swayze, 1998, “Device Safety: Problems after Vacuum-Assisted Childbirth,” FDA Health Advisory, www.fda.gov/cdrh/ medicaldevicesafety/tipsarticles/nj/0102.pdf. Canadian Press, 12 October 2000, “Electronic Monitoring of Foetal Heart Offers No Benefit, Says Researcher,” NewsWire, Toronto. “Meddlesome Obstetrics,” Lancet 339, 8808 (20 June 1992): 1533. British Columbia,Vital Statistics Agency, “Summary,” http://www.vs.gov.bc.ca/ stats/annual/2004/xl/fig10.xls. “Snapshot of Maternity Care in Canadian Hospitals,” Women’s Health Matters 2, 6 (1996): 2–3. British Columbia,Vital Statistics Agency, “Analysis of Health Statistics for Status Indians in British Columbia, 1991–1998: Overview of Birth Statistics,” http:// www.vs.gov.bc.ca/stats/features/indian/birth.html. The use of the male pronoun for the obstetrician is deliberate and reflects the reality of the profession for most of the twentieth century, as discussed in Chapter 6 below. Lesko 1994, 126. For more on the relative desirability of non-white or mixedraced children as potential adoptees in Canada see Strong-Boag 2006. More positively, Native single mothers are willing to upgrade their education by entering post-secondary institutions as mature students; see Hull 2001, x, xi, xiii. “Family Physicians’ Declining Contribution to Prenatal Care in the United States,” Editorial, American Family Physician 66, 12 (December 15, 2002): 292. “Study Reveals Excellent Results of Births Attended by Midwives,” Nation’s Health 28, 6 (July 1998): 12. For more on the persistence and re-emergence of midwifery in twentiethcentury Canada see Benoit 1991; Bourgeault 2006; and Bourgeault et al. 2004. “Midwives,” Herizons 1, 2 (April 1983): 8.

C H A P T E R

5

Future Childbirth DOCTORS AND BABIES

As we saw in the previous chapter, the “natural” childbirth

movement modelled after the techniques of Dick-Read, Leboyer, or Lamaze was co-opted by hospital administrators to “prepare” women to be tractable, obedient, and hopefully non-litigious (Armstrong 2000, 584). It was not a return to the woman-centred birthing experience of traditional midwifery; rather, the use of birthing coaches (expected to be male partners in stable heterosexual relationships) tended to highlight fathers and place them as additional male authority figures in the delivery room. Women were sometimes portrayed in this literature as vessels and environments from which the main participant, the infant, would emerge. By the beginning of the twenty-first century, biotechnologies such as prenatal diagnoses and genetic engineering were publicized as the potentially alarming, potentially fascinating creators of human life in a Petri dish — a new version of Dr. Frankenstein. Even the vast majority of women who created and delivered their babies the “natural” way increasingly were characterized and treated not as sacred vessels but as human beakers. Furthermore, the increased ability of medical science to peer into the womb from the earliest stages of conception helped to establish a direct 153

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relationship between physician and foetus. This devalued the profound physical and emotional relationship shared by the mother and the infant growing inside her. It also supposed an adversarial relationship, as the traditional advice and practices that women followed to ensure an easy delivery and healthy child became medical, social, and judicial directives which, if mothers chose not to follow, left them open to charges of maltreatment and neglect of their foetuses. The focus upon rendering individual mothers solely responsible for the health of their babies is an effective technique to avoid the much more expensive tradition of rendering the state responsible for the provision of public health and social welfare initiatives that would provide mothers with the optimal conditions for raising babies (Armstrong 2000, 587). In the same way, the focus upon “correcting” infertility through newly developing and potentially dangerous genetic procedures rather than focusing upon its causes — which may include radiation, pollutants, and food additives — supports a research-based university and corporate elite rather than facing the daunting task of environmental clean-up. This chapter provides a review of some of the technologies and diagnostic procedures developed to assist physicians in improving the prospects for healthy babies and mothers, but which have wider socio-cultural and ethical ramifications. These include the venerable stethoscope as well as the currently popular ultrasound and amniocentesis. Examples of the increasing incidents of mothers being placed in adversarial positions vis-àvis their foetuses, with the physician, legal system, or other authority in a policing role, will be presented. Finally, some of the new reproductive and genetic technologies will be outlined.

The Stethoscope While this chapter is entitled “Future Childbirth,” the interposition of physicians in the mother-foetus relationship can be traced to the mid-nineteenth century with the adoption of the stethoscope in medical practice. Until that time, a physician would know that a woman was pregnant only when she informed him, usually after she had informed her husband, family circle, and close friends. She remained the first judge of her actions and her decisions. Under British Common Law, abortion was not a criminal act until a woman was “quick with child,” so there was considerable leeway for women to end a pregnancy in its early stages (Duden 1993, 82). In 1821, Lejumeau de Kergaradac, student of René-ThéophileHyacinthe Laennec, who invented the stethoscope, used the device to identify the foetal heartbeat. This development, published in English by Evory Kennedy in 1843, had revolutionary ramifications. For the first

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time, physicians were able to hear the foetus directly, unmediated by the mother’s actions or control. In his monograph, Kennedy distinguished this new manifestation of pregnancy as “rational and true,” as opposed to the mother’s personal signs, now characterized as “suspicious” or un-objective. In obstetrical textbooks published later, the roles of mothers and midwives were diminished. William Potts Dewees, in his Treatise on the Diseases of Females, published in 1853, stated that “uncertainty of pregnancy [was now] removed by the discovery of the heart’s motion ... by means of the stethoscope.” Women’s traditional methods of determining their pregnancies, including the lack of menses and the experience of quickening, were considered of lesser importance (Sparrow 2000). Doctors’ use of the stethoscope, or foetal auscultation, had tremendous benefits not only for diagnosing potential problems but for the professionalization of the medical profession. In their literature and through their organizations, physicians situated themselves as morally superior to selfish women who desired to end pregnancies, and they degraded the midwives who assisted them. Physicians were now the champions of unborn innocents, taking the first steps at artificially allying themselves with foetuses and placing themselves as adversaries of mothers. But the picture was still more complicated. When in the mid-nineteenth century the American Medical Association chastised women who underwent abortions and the medical practitioners and midwives who provided them, they were not simply attempting to claim moral ground upon the backs (or wombs) of women or seizing moral ground from clergy in an increasingly secular society. Rather, and in one of many paradoxes of patriarchal relationships, they were attempting to appeal to the middle-class Protestant female population who had adopted the moralistic ideology known as True Womanhood, or maternal feminism, and who comprised the prosperous, respectable clientele they so desired. Maternal feminism had its roots in the feminization of the Protestant churches, which occurred at the end of the eighteenth and the first half of the nineteenth centuries (see the classic studies by Douglas 1977; and Welter 1976a, 1976b). It was one important engine of the abolitionist and temperance movements, imperialistic missionary adventures, and public health reforms in both Canada and the United States. Such energy should not be underestimated; this was the population that the medical profession wanted to draw out of the churches and into their consulting rooms and hospitals, and the moral ground of an anti-abortion stance was ideal. How could respectable churchgoing women have come out publicly in favour of abortion in the mid-nineteenth century? The practice assumed promiscuity and the deviant behaviour of “foreign” and urban strangers and prostitutes. And, like all such “vices,” should a respectable woman or her daughter require an abortion, they could rely on the discretion, agree-

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ment, and ultimate power of her medical practitioner. While the introduction of the stethoscope in the nineteenth century increased the physician’s role in pregnancy, other twentieth-century medical innovations positioned mothers against their infants.

Mother versus Foetus By the 1920s, medical literature differentiated between the mother and the foetus. In Prenatal Care, widely distributed to American women by the federal government’s Children’s Bureau, the mother-foetus relationship was characterized as a host-parasite one: “The substances needed to build teeth are mineral salts ... and certain vitamins. The baby will take them from his mother’s body if he does not get them through her food” (quoted in Barker 1998, 1069). The assumption was that medical intervention was required to ensure the proper control of the “parasite.” Further, the new technologies advocated in Prenatal Care, such as the use of the stethoscope, urinalysis, and blood pressure monitoring, provided information to doctors that was “unobtainable, unseeable and unintelligible” to the patient/mother, and privileged this technical knowledge over her traditional (therefore backward) knowledge of her own body signs (Barker 1998, 1071). As the twentieth century progressed, other technologies intruded upon women’s awareness of and control over their own bodies. Both their knowledge of pregnancy and first introduction to the role of future motherhood were now based upon science rather than kicks: “Women are informed by mail, when the test results come from the lab, or they buy the latest ‘do it yourself ’ test kit and discover the circular precipitate at the bottom of the urine jar in their own bathroom” (Duden 1993, 80). Quickening is now characterized in medical literature as an “emotional” event for the “woman patient,” rather than one with legal status. Late twentieth-century pregnancy manuals, such as the bestselling What to Expect When You’re Expecting and Nine Months for Life, use artistic renditions of foetal imaging to depict fully developed persons, even in the earliest stages (Eisenberg et al. 1991; Quebec Medical Association 1990). The baby is rarely referred to as a foetus or embryo; it is described as having emotions and able to perform intentional acts such as yawning, frowning, and blinking, so that “word choice and visual practice simultaneously construct a powerful message for pregnant women: what lies inside their wombs is not a mass of undifferentiated tissue or a foetus of incipient personhood but an appealing, sentient, and vulnerable baby.” Images of pregnant mothers, on the other hand, were either non-existent (in Nine Months for Life, the foetus was drawn against an opaque background) or as

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disembodied “foetal containers” (in What to Expect, women were headless, armless torsos “containing only vagina, rectum, bladder, uterus and foetus” [Georges and Mitchell 2000, 189]). Just as in earlier generations, pregnant women purchase guidebooks to empower and educate themselves, yet the received message is that pregnancy is a time of great risk and uncertainty requiring compliance with medical regulations. Additionally, “by individualizing risk and responsibility, these guidebooks divert women’s attention from the social causes of discomfort, suffering, and risk during pregnancy (poor working conditions, the double shift at work and home, environmental toxins, poverty, and for many low-income women, lack of quality health care)” (Georges and Mitchell 2000, 200). Individualizing maternal risk to the foetus further alienates modern mothers from reliance upon their biological capabilities. The development of abortion laws solidified in legislative terms the doctor/child/mother triad. In the landmark judgements Roe v. Wade and Doe v. Bolton, the American Supreme Court confirmed a woman’s constitutional right to what was termed a “therapeutic” abortion in the first and second trimesters but with the caveat that the decision had to be made in consultation with her physician, thereby granting members of the medical profession the power of veto (Kaiser and Kaiser 1974, 653). This has been an issue particularly for poorer patients who need to access Medicaid payments to pay for abortions, and, depending upon individual states’ requirements for Medicaid programs, the standard for the definition of “therapeutic” or “medically indicated” can vary substantially. Furthermore, the medical standard served the purpose of limiting women’s complete discretion over the decision to have an abortion (based upon the patriarchal assumptions that women ultimately do not know what’s best for them and that women would run amok, having abortions left and right); however, leaving this decision to the doctors shifted responsibility from the judiciary without addressing the realities of the situation. A pregnant woman’s decision to have an abortion has many reasons, usually to do with her socio-economic situation, and only very rarely is it entirely or even partly a medical one. If that is the case, then “a doctor is no more qualified — simply by being a doctor, that is — to make that decision for the pregnant woman than is her mother, her best friend, or the corner druggist” (Kaiser and Kaiser 1974, 654). Following the Trudeau government’s Criminal Code reform in 1969, abortions in Canada similarly were legal if performed in a hospital following the consent of a therapeutic abortion committee. However, if performed elsewhere (and without medical consent), they were illegal under Section 251 of the Criminal Code. In the 1970s Dr. Henry Morgentaler challenged this law by operating a free-standing abortion clinic in Montreal; three trials led to three acquittals by French-Canadian

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juries who agreed that the existing law did not give women equal access to health care services. Backed by a national campaign by feminist groups to reform Canada’s abortion law, Morgentaler then began opening freestanding clinics in other provinces, which led to a constitutional challenge in the Supreme Court of Canada. In 1988, the Court struck down Section 251 as an infringement of a woman’s “security of the person.” Pro-life lobbies continue to fight for the recriminalization of abortion, occasionally resorting to intimidation and violence, and to fight alternatives to surgical abortions, such as RU 486 or mifepristone — an “abortion pill.” The arguments they use characterize pregnant women as threats to autonomous foetuses.1 The politicization of this aspect of health care maintained unequal access to abortion in Canada — the province of Prince Edward Island, for instance, has no abortion clinic, nor is there access in smaller and more isolated communities — and physicians, hospitals, and even pharmacists may deny abortion and birth control services if they so choose (McLaren and McLaren 1997, 142–47). In British Columbia, the introduction of the emergency contraception Plan B (levonorgestrel) as an over-the-counter medication was resisted by pharmacists on the basis of their personal religious beliefs, despite the fact that Plan B prevents fertilization if taken within 72 hours of intercourse; therefore, it is not a Right-to-Life issue. Although the College of Pharmacy’s Code of Ethics required that pharmacists refusing medication because of their own beliefs must refer customers to other pharmacies, this was not a practical solution for women, particularly young women, living in isolated communities.2 The religious pharmacists were following the lead of the American FDA Commissioner, Mark McClellan, a Republican government employee who blocked approval of Plan B in the United States, arguing that it would “increase teenage promiscuity” (Wadman 2005, 401).3 These actions highlight the continued policing of women’s sexual behaviour through limiting access to health services.

“Bad” Mothers By the turn of the twenty-first century, the pregnant alcoholic or addict bears the calumnious label of a “bad mother,” who recklessly endangers her foetus, the innocent inhabitant of her tainted womb (see Blank and Merrick 1995, Chapter 7). If she is of a minority and/or impoverished background, she is likely to come before the court or the social welfare system and may lose her freedom, if not her child. Fathers who use drugs, which can damage sperm, or who are arrested for impaired driving do not similarly suffer the loss of their children to state authorities. Even men

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who physically abuse pregnant women, if charged, do not suffer extraordinary penalties due to the potential damage they might have caused to the foetus. Middle-class addicts, on the other hand, are more likely to use alcohol and prescription drugs, rather than street drugs, and can seek help from physicians who keep their addictions private or who fail to notice them (Schmall 1993, 285, 299). In the nineteenth century, temperance literature associated mental retardation, infant mortality, and epilepsy to the drunkenness of fathers. Women were assumed to be helpless victims of the intemperance of the men in their lives. However, in 1889, William Sullivan noted a correlation between alcohol use among women in a Liverpool prison and birth defects in their children (Sullivan 1984, 3–4). Foetal Alcohol Syndrome (FAS ) was first cited in the American medical literature in 1973 by Kenneth Jones and David Smith; they identified it as a cluster of birth defects including small infant size and weight, mental retardation and problems of the central nervous system, distinctive facial features, and personality maladjustments (Robe 1982, 6). While the worst cases have been associated with heavy maternal drinking (six or more drinks) early in pregnancy, there is no known “safe” level of alcohol consumption, since even one or two drinks during a critical period of infant development, particularly of the brain, can have deleterious effects on the foetus. Here, then, is the terrible successor to Victorian temperance literature, which declared that the first drink can lead down the road to perdition. Current research has associated the father’s heavy drinking with miscarriages, stillbirths, and complications of pregnancy, but the connection is not as easy to make as with the mother (McTimoney 1989, 42).4 By the 1970s and 1980s, the mass media, particularly television news programming, repackaged the public health warnings concerning FAS as an issue of foetal protection; FAS became “what happened to innocent babies when their mothers performed criminal acts” (Golden 2005, 96–97). Addicted mothers, especially poor minority women, became targets of criminal prosecution for neglect. In 1987, Pamela Rae Stewart was the first American woman to be charged with exposing the foetus to drugs, on the basis of a California statute. By 2000, more than 200 women in the United States had been charged (Zivi 2000, 237). There were fewer, but no less sensational cases, in Canada. In 1996, Brenda Drummond of Ontario attempted to kill her foetus at nine months by firing a pellet gun through her vagina. Since the Canadian Criminal Code does not define “human beings” as existing prior to birth (in support of abortion rights), she was sentenced to 30 months probation for failing to report the injury immediately following the child’s birth. An even more tragic case was that of a young Native woman addicted to inhalants. The Winnipeg Child and Family Services received a court order to forcibly confine her to a drug

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rehabilitation facility for the duration of her fourth pregnancy. This decision was overturned on appeal; evidence was given that she had repeatedly sought treatment for her addiction; that she was a member of an impoverished, minority community with high rates of alcoholism, addiction, and suicide; and that there were few social services available to help her. Thus, her case demonstrates the injustice of “bad” women being incarcerated to “protect” their innocent foetuses.5 These actions have met with considerable opposition from feminist lawyers and activists, who argue that they violate the women’s constitutional rights to liberty, privacy, and equality, and that far from protecting infants, these prosecutions serve to frighten addicted pregnant women away from prenatal clinics. “Bad mothers” producing “crack babies” is an image used in the media to create a moral panic, even though foetuses are more often harmed by alcohol, tobacco, poverty, domestic violence, and poor maternal health. Furthermore, many addicts use their pregnancies as opportunities to seek help for their addictions so that they can properly nurture and keep their babies (Zivi 2000, 238, 244). This can be extremely challenging. Pregnant cocaine addicts suffer from more complications than does the general population, and their babies are born more often with “an increased rate of intrauterine growth retardation, prematurity, microcephaly, and perinatal morbidity” (Chasnoff 1989, 23).6 The infants also can be extremely sensitive to external stimuli and use sudden sleep and inconsolable crying states to protect themselves from over-stimulation. They may be unable to react normally to their environment or reach an alert state for at least a month, after which they still require swaddling and pacifiers to handle stimulation for more than short periods of time. The tragedy is compounded by the fact that addicted mothers do not live in environments conducive to the intensive care these babies require, and they may lack good parenting skills. The babies subsequently are likely to develop serious emotional and cognitive problems (Chasnoff 1989, 32–34). Increased sexual expression in the 1960s and 1970s had many unexpected casualties. Fertility, maternal health, and infant health have been severely impacted by sexually transmitted diseases. In 1983, it was estimated that up to 50,000 American women became involuntarily sterile every year due to gonococcal pelvic inflammatory disease, and in 1977 over 20,000 ectopic pregnancies were caused by salpingitis,7 a complication of many sexually transmitted diseases. More than 10,000 babies every year are born deaf, blind, epileptic, mentally retarded, or with cerebral palsy as a consequence of mothers with venereal infections, including genital herpes (Adams 1983, 21). The outcomes are worse in situations where the mothers are poor and without access to proper prenatal care and support, as is the case for many addicted mothers. At the other end

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of the spectrum, wealthier women who access prenatal care are offered increasingly sophisticated medical technology, which has provided physicians and others ever more opportunities to intrude into the womb.

Gene Culture By the turn of the twenty-first century, medical intrusion was facilitated by the ascendance of the genetic paradigm in health research and popular culture. Just as electricity had provided interpretations for nervous diseases in the nineteenth century, and germs were the paradigm in the early twentieth century, genes, according to late twentieth-century films, television, and magazines, were the overarching answers for the future (see, for instance, Gosling 1987; Tomes 1998). As Dorothy Nelkin and Susan Lindee concluded, “DNA in popular culture functions, in many respects, as a secular equivalent of the Christian soul. Independent of the body, DNA appears to be immortal. Fundamental to identity, DNA seems to explain individual differences, moral order and human fate” (1995, 2). From this perspective, the geneticist, through his or her interpretation of the genetic composition of the foetus, or — earlier — ova and sperm, further diminishes the importance of the mother and father (or any environmental factors) in the child’s development and upbringing (Silva 2005, 106). The popular, violent, and occasionally gruesome television franchise, Crime Scene Investigation (CSI ) is an example of this genetic thinking. The forensic police investigators not only identify individuals from tiny samples of hair or body fluid, they re-enact events down to emotions and conversations; the DNA sample is not simply a fragment of evidence but the complete, true, and unassailable explanation of all that had occurred. It is the homunculus of the owner’s life experiences. Just as the multi-billion dollar, multi-national space program is supported by a generation raised on Star Trek and Star Wars to expect planetary exploration in its future, this generation assumes that genetics has the ability to eradicate disease, crime, and malnutrition. Genetic testing, therefore, is presented as holding great promise for medical miracles. However, the state of genetic therapeutics at the turn of the twenty-first century is less than the expectations generated by the paradigm; many conditions and disorders are identified and predicted, but they cannot be treated. Women can be tested, for instance, for the BRCA1 and BRCA2 genes, which are linked to increased risks of breast and ovarian cancers. However, while it would be useful for a woman so identified to take measures to protect herself from cancer, there is no guarantee that she can prevent it or that she even will contract it. Furthermore, these gene mutations account for less than 10 per cent of all cancers.

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Most importantly, there is no treatment available, so many women might conclude that the knowledge is not worth the lifetime of worry (Silva 2005, 115). Genetic testing is a more powerful tool in terms of its use in prenatal screening and selective abortion (which will be discussed below); this resurrection of eugenics holds the same ethical dangers as earlier policies that culminated in the Nazi Final Solution, although now it is individually rather than nationally oriented. Or to continue my outer space analogy, mothers who undergo genetic pre-screening may be faced with a new directive: “Mission failure! Abort! Abort!” Fetoscopy An early example of this space age technology was fetoscopy, or diagnostic or operative embryofetoscopy, which were procedures developed to look into the womb, possibly sample part of the embryo-foetus or its environment, and then to perform in utero surgery. During the late 1960s and 1970s, medical researchers used a “transabdominal approach” to view an in utero foetus during the second and third trimesters. By taking photographs, physicians opened the womb to public view. Fetoscopy fell into disfavour, however, because the trocar (the large needle-shaped instrument required to house the endoscope, or probe) could rupture the uterus; an estimated 5–7 per cent of women who underwent the procedure suffered miscarriages. Furthermore, as ultrasound technology improved, the more detailed images it produced precluded the necessity for the endoscope, although some physicians continued to use it (Blizzard 2000, 413–14). By the 1990s, a new generation of smaller endoscopes allowed researchers to enter the womb earlier to perform gene therapies. As one proponent stated, “Embryofetoscopy will make it possible to perform stem-cell transplantation or gene therapy during the first trimester of pregnancy, at a time when the foetus is immunologically naïve and when the chances for engraftment are greatest. The new technology provides an opportunity for us to treat a variety of genetic disorders before their disabling effects are realized” (E. Albert Reece, quoted in Blizzard 2000, 415). However exciting the potential, the procedures are extremely risky for the loss of the foetus or amniotic fluid leakage. The researchers compare the risks favourably to open foetal surgery, but both of these invasive procedures are very dangerous relative to not intervening or waiting until the child is born and then performing surgery (Blizzard 2000, 418–19). Women with high-risk pregnancies who undergo these procedures describe their experiences as being on a “roller-coaster,” bouncing from one negative assessment to a second risk-filled decision to a third possible “miracle.” Yet the high-tech equipment is not infallible; the pictures on

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the screen are often ambiguous, and the physicians themselves, let alone the parents, can be unsure how to proceed (Blizzard 2000, 420). Some parents expecting twins have to make the heart-wrenching decision to tie off the umbilical cord to one dying foetus so that another can live, in effect mourning the loss of one baby while they await the birth of the other. As Rayna Rapp asked with respect to amniocentesis, does the technology offer “women a ‘window of control,’ or an anxiety-producing responsibility, or both?” (quoted in Blizzard 2000, 424). A cultural ramification of the fetoscopy and foetal imaging in general is to create the “public foetus,” whose existence is autonomous from a mother. This entity, or more correctly, this representation of the potential entity (since in the early stages, the ambiguous images must be interpreted by and communicated through a physician or technician) can “challenge a woman’s ability to define her own pregnancy experience and decide whether or not to continue the pregnancy.” Furthermore, through the use of diagnostic and operative fetoscopy, as well as ultrasound and amniocentesis, a woman may bond with a “potentially ill foetal patient.” To refer to the previous example, parents may have pictures of an ill foetus that they must decide to kill in order to save its twin (Blizzard 2000, 425–26). And these are parents who, by submitting to these costly and dangerous procedures, have proven their intense desire for children. As Eve was cursed because of her thirst for knowledge, mothers continue to want to know about the health of their unborn children, even if such knowledge does not guarantee a positive outcome. Ultrasound Ultrasound or sonography has become an extremely popular method for peering into the womb and observing the foetus. The use of prenatal sound wave imaging grew rapidly in the 1980s and 1990s in British Columbia as in other jurisdictions, despite the lack of evidence for the benefits of routine or mass screening. By 1994, an average of 1.7 ultrasounds per birth was performed in the province at a cost of $8 million — at a time when other services for women and children were underfunded. Routine ultrasound imaging was not found to reduce maternal or infant mortality or morbidity, although it did reveal multiple foetuses, as well as some major abnormalities and uterine growths (albeit not always accurately). More importantly, being able to detect these conditions for the most part did not change the outcomes of the pregnancies. One of ultrasound’s significant limits is that most foetal abnormalities cannot be detected before 24 weeks, after which abortion is risky and often illegal, if abortion is desired. Even worse, there is a high incidence of false-positive and false-negative readings of foetal malformations, which

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produces profound stress for the pregnant woman and her family (Green et al. 1996, 1–2). Therefore, if routine ultrasounds are simply chances to take “an early peek” at the baby, they may be an undue expense for a publicly funded health care system. However, it is questionable whether any government would take the very unpopular step of removing the early picture show from the prenatal experience. Amniocentesis Amniocentesis was first developed in 1964 as a diagnostic tool to allow neonatal specialists to perform therapeutic procedures in utero.Yet, within a year, Brooklyn’s Dr. Carlo Valenti and others were acknowledging that such procedures for genetic disorders were “unrealistic” and that amniocentesis’s true value was as a precursor for aborting severely “defective” foetuses (Powledge and Sollitto 1974, 11–12). There are several ethical ramifications to this biomedical technology. Firstly, the field of genetic engineering and new reproductive technologies, while trumpeting the cause of creating life, are based on recommending and providing abortions. Amniocentesis has two parts: administering the procedure and, based upon the results of that procedure, making a decision to abort or carry the foetus to term. Secondly, because this technology was developed for medical use, medical practitioners are increasingly at the forefront of determining how to proceed with the pregnancy. Are they trained to make such a decision? If not the physicians, should such a decision be made by an ethics board, a religious leader, a family court judge, a legislator, the father of the foetus, the father of the pregnant woman, if she is a minor — or should it, in every instance, ultimately be the mother’s choice? Who is to decide which foetus is “defective” enough to be aborted? Should abortion result from the detection of any defect, such as adrenogenital syndrome, a condition that will produce excessive male hormones, leading to the development of secondary (external) male sex characteristics in a genetically female infant? (Powledge and Sollitto 1974, 11). Should amniocentesis be recommended routinely to detect the existence of Down’s syndrome in the foetus for the increasing numbers of older women giving birth? Is there room in the twenty-first century for the child with Down’s syndrome? One study from the Boston area placed the selective abortion rate at 86 per cent for women whose foetuses were so identified (Silva 2005, 118). At the end of the twentieth century, the labelling of these individuals as mentally retarded was criticized, and blander labels such as “mentally impaired” or “special child” were used instead. Yet mentally retarded children were common enough to be familiar and at least conditionally accepted members of the community. However, once their defective gene was identified

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and identifiable in amniotic fluid, their very existence in Western society has become threatened, since parents can make the decision to abort and try again. Thirdly, at the same time as medical technologies have reduced the autonomy and experiences of the pregnant woman to that of the patient, they have left her (and her spouse, if one is present) with the tremendously difficult decision of whether to abort a defective foetus or carry and deliver a child with serious health and developmental problems. It is as if medical science has thrown the rock through the plate glass window of the jewellery store and then left it in the hands of the expectant mother as police sirens wail. Should she decide to carry the infant to term, she may face the calumny of a society increasingly unfamiliar with and intolerant of imperfect babies. In Western societies, where patient demand, equipment, and personnel costs for health care services are skyrocketing, such babies may be considered to take too big a share of a relatively shrinking pool of health care funds. Actually, they are taking too small a share. Support services, good institutions, teaching, and home care assistants — these expenses are slashed before high tech medical equipment. So, expectant parents of disabled children may have “the right” to choose, but the choice is far too circumscribed. Finally, as we have seen with the development of electronic foetal monitoring and routine ultrasound imaging, medical technologies have a life of their own. As the birth rate continues to fall in North America, the percentage of an ob/gyn’s practice centred on conventional obstetrics has fallen as well. Therefore, practitioners have begun to focus more upon treatments for infertility as well as to identify and deal with high-risk pregnancies, leading to increased reliance upon prenatal diagnostic techniques (Powledge and Sollitto 1974, 13). Also, just as they have for the past 150 years, hospitals base their reputations largely upon the facilities and equipment they have at their disposal and the specialists they hire to operate that equipment. If you have the ultrasound or the magnetic resonance imaging (MRI) machines, the patients (customers) will come.

Infertility Motherhood in North America, as in virtually all societies, is considered to be an essential part of womanhood. Therefore, women who do not wish to have children are condemned as unwomanly, while women who cannot have children are pitied as incomplete. Infertility is often considered to be a female problem; the lack of children in a marriage is blamed on some physical deficiency on the wife’s part, likely caused by painful or irregular menstrual cycles. Women are advised to treat these “obstructions”

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with mild therapeutics such as exercise, a vegetarian diet, cold baths, and tonics, as well as more invasive heroic treatments such as blood-letting or corrective surgery to fix a “defective” cervix (Marsh 1997, 216). Until well into the nineteenth century, male sterility and impotency were believed to be associated, so that a man who ejaculated was considered to be able to have children. Even as the physiology of semen production was beginning to be understood in the late 1890s, this was not deemed to be acceptable knowledge to the men in question, who responded to physicians’ “aspersions” upon their manhood with anger, denial, and occasional violence (Marsh 1997, 220, 231). Fertility specialists to the present day continue to meet such resistance. Infertility remains an “ambiguous condition whose etiology and progress still lack definition. Up to 20 per cent of cases remain unexplained”; like other “mysterious” disorders (those without cures), it has grown layers of explanations, such as “a syndrome of multiple origin, a consequence or manifestation of disease rather than a disease entity itself, a biological impairment, a psychosomatic disorder, a condition characterizing a couple rather than an individual, a failure to fulfill the personal desire to beget a child” (Sandelowski 1990, 37–38). Infertility is also a situational problem; a young single woman with no immediate interest or desire to have children would not be considered infertile, while the same woman approaching the end of childbearing years, or after an extended period after her wedding, may be considered infertile because her nowpresent desire for a child has not been fulfilled (Sandelowski 1990, 38; see also Shanner 2000, 142–60). In classic socio-medical fashion, that which cannot be explained and cured may at least be blamed on the victim, and just as the sexual health problems of Victorian women were considered to be the result of past indiscretions, infertility has been blamed upon a number of past risky behaviours, including delayed childbearing (choosing career, status, and financial well-being over domesticity); sexual activity (promiscuity), which is associated with contraceptives, abortion, and sexually transmitted diseases; and exposure to toxins and environmental hazards in certain occupations. Even though, as in the last instance, women may not have “chosen” this consequence, the higher incidence of miscarriages and sterility has not led to the expensive solution of wholesale cleaning of the environment. Similarly, the fact that long-term use of contraception may interfere with fertility has not led to the removal or improvement of the medication; rather, women who choose to continue to take contraception to remain sexually active are “choosing” the risk of infertility (Sandelowski 1990, 39).

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Fertility Treatments While infertility has not been fully explained, biomedical science has moved full steam ahead to discover new methods to confront it.8 The new procedures do not necessarily treat or cure infertility; rather, they “circumvent” whatever issue caused the fertility problem in the first place, and they can be accessed by fertile people (Sandelowski 1990, 37). Children, “once considered gifts from God, are now miraculous GIFT s (gamete intrafallopian tube transfer) from the fertility clinic” (Diepenbrock 2000, 109). As a consequence of the growth of fertility treatments, women in Western countries who have fertility problems are expected to consult medical experts and undergo lengthy and often extremely stressful and physically debilitating fertility procedures. These include not only hormone therapies and in vitro fertilization (IVF) but also employing a surrogate mother (Kitzinger 1995, 39). While childless women are considered to be acting with appropriate motherly instincts when they enter fertility programs, they must be approved by physicians, psychologists, and/or clinic social workers to ensure that they will be “fit” mothers. They must agree to submit to the lengthy course of treatments, be “emotionally well-balanced,” physically fit, and in some clinics not be over 35 or 40 years of age. In many clinics, they must also be in stable heterosexual relationships if not legal marriages (Kitzinger 1995, 40). Clearly what is occurring here is that physicians are using their access to vitally desired medical technologies to enforce their own often socially conservative values. While they are tinkering with ova and spermatozoa, the stuff of life itself, in ways far beyond what traditional societies would consider possible, they maintain the fiction that the life they are attempting to create will inhabit a “traditional” domestic world of Mom, Pop, and the Kids with a picket fence and no 60 per cent national divorce rate. At the same time, they exercise patriarchal authority unmediated by constitutional rights; desperate women and to a lesser degree their (male) partners will be judged worthy for the programs if they can provide evidence of a respectable sexual, physical, and emotional past (as well as a big bank account). Those couples deemed worthy then undergo a wrenching roller-coaster ride of hope and despair, as most procedures have extremely low success rates; the American Fertility Society found that of 165 clinics, the average success rate was 11 per cent, with the clinics ranging from 4 to 38 per cent success in producing babies. The drugs to produce super-ovulation, such as Pergonal, have extreme side effects, including headaches, exhaustion, tremors, and depression, and “every month that conception does not occur the woman grieves over a pregnancy that did not start” (Kitzinger 1995, 41–42). Furthermore, some procedures require multiple painful surgeries. Doris Del Zio, an

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American woman who was profiled in Good Housekeeping magazine in 1979, described her physical state after three operations to open her blocked fallopian tubes: “My abdomen now looked like a road map and my insides were a mass of adhesions. Sometimes they were so painful that I just couldn’t straighten up” (Diepenbrock 2000, 106). There are also serious consequences from artificially implanting several embryos in the hopes that at least one or two will be viable, as it is paired with the assumption, if not demand, by the reproductive expert that some of the embryos will be removed (killed) as wastage to allow those deemed the most viable to develop normally in the womb. This does not always work out as planned, as we have seen in the growing number of multiple births, of five, six, or even eight babies.9 They are born to considerable fanfare, trumpeting the skills of the neonatal unit staff to maintain the lives of infants born at extremely low birth weights but minimizing the early demise of those who do not survive. For those who do, parents may face a lifetime of dealing with severely handicapped children at extreme financial, physical, and emotional costs. One British couple conceived quadruplets, one of whom died after 20 minutes; another developed hydrocephalus and lived only five months. The remaining two babies were in intensive care until they were eight months old, and at the age of three still had to be tube-fed. The boy has cerebral palsy and hydrocephalus, cannot walk, and is both visually and aurally handicapped. The girl is hearing-disabled too. Their mother says, “We do not get any let-ups at all. I have completely given up my life for them. I have to cope no matter what it does to me or to my marriage.” Her husband states flatly, “It has ruined our lives.” (Kitzinger 1995, 43)

This new reality of biomedical scientific advances beyond and outside of ethical regulation has striking parallels to the centuries-old reality of women unable to control their reproduction and forced to endure multiple childbirths and the subsequent poverty, personal debilitation, and serious illness of their children. The argument that women and their partners “choose” to disregard medical advice (and likely the consent forms they signed) and refuse to abort one or more of their embryos is a specious one; those women who have submitted to these therapies have demonstrated by their actions, and by their acceptance into the programs, that they are intensely, desperately maternalistic. The idea that some of them are unable to submit to the anti-maternalistic act of aborting their sosought-after foetuses should be a given.

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Surrogate Motherhood The paradox of ideal mothers castigated for acting like ideal mothers has entered public consciousness with the debate over surrogate motherhood. Once a woman has accepted that she cannot personally carry her child, or her husband’s child, to term, she may be advised to turn to a surrogate. Surrogacy is an intensely patriarchal concept; indeed, it is rooted in the early days of patriarchy itself. In the Hebrew Bible, Sarah “gives” her handmaiden, Hagar, to her husband Abraham so that he can beget a son and continue his lineage. Significantly, the act doesn’t end well (which should have been a lesson for future Bible-reading generations). Hagar struts her swollen belly in front of a mortified Sarah, and when the Lord creates life in an aged Sarah, she exacts her revenge by tossing Hagar and her son Ishmael out of the tent and into the desert (an early example of blended family issues). In the twenty-first-century surrogate scenario, it is the (male) reproductive specialist who impregnates (via test tube) the surrogate mother and the (often male) fertility clinic agent and/or lawyer who makes the arrangements, which have been described as “an extension and reinforcement of men’s claim on women’s sexuality and reproductive powers” (Kitzinger 1995, 44). The terms of surrogacy contracts involve the surrender of the woman’s rights to the point where she can best be described as chattel, if only temporarily: A surrogate mother is paid for a service rendered to a man, rather than for the baby. It is similar to prostitution. If the surrogate mother has not conceived after six months she is removed from the program, and another surrogate is produced for the purchasing man. If she has a miscarriage, she usually gets nothing. Doctors dictate whether she should have amniocentesis or other investigations during pregnancy, and if the results show that the foetus is handicapped, she is required to have an abortion. If at the end of the pregnancy the obstetrician decides that the birth should be by caesarean section, the surrogate has to submit to that decision too. (Kitzinger 1995, 44)

Perhaps chattel is not an accurate analogy. The purchase of a new car would be a comparable commercial transaction, at least in terms of price. Yet, you cannot return a defective car to the dealership. The workings of an unregulated, often extra-legal surrogacy market is a chilling reminder of how easily and rapidly human relations can deteriorate into slavery, even if of short duration.

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Conclusion Beginning with the opening of the womb to public view in the twentieth century, advancements in reproductive technologies are rewriting the relationships between mother, child, and physician. The legal loophole followed by Roe v. Wade and R. v Morgentaler, that abortions approved by physicians are “therapeutic,” rather than criminal, sinful, or wanton acts by selfish women, places the power of decision-making upon the shoulders of the medical professionals, who are not automatically the best to make these decisions. This is one more instance where the doctor establishes a relationship directly with the unborn child through the “maternal vessel” and erases a woman’s autonomy of her person (Kaiser and Kaiser 1974, 653). Abortion has become a political and religious flashpoint in the last 30 years. By centering on the decisions and actions of individuals, the debate never strays too far from underlying anxieties about the rapidly changing roles of women. But this obscures its reality. Abortion is an essential component of reproductive and genetic technologies, those which celebrate the power of bioscience to produce life. Obstetricians who are engaged in the research and administration of the new reproductive technologies practice abortions on a regular basis. They fertilize extracted ova and sperm and destroy those that are “unworthy.” They implant multiple gametes back into women and then routinely abort some of the foetuses so that others have better chances for survival. They use the technology developed to perform safe abortions and effective birth control to perfect their procedures. Regardless of whether they are creating life or destroying life or potential life, these physicians and scientists are engaging in a relationship between themselves and the contents of the woman’s womb and ovaries, with the woman acting as (often inconvenient and noisy) vessel. Even though the relationship was likely initiated by the woman — whether due to her desire for an abortion or desire for a child — once the procedures are under way, her role is a submissive and dependent one, eerily reminiscent of the Victorian ideal.

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Notes 1

2

3 4 5

6 7 8 9

While the American George W. Bush Republican administration, acknowledging its significant Pro-Life support as well as the personal beliefs of the president, enacted Pro-Life legislation, the Canadian political situation is far less ideologically consistent. The avowedly Pro-Life Conservative government of Stephen Harper, while withdrawing public funding from feminist organizations, did not block the appointment of Dr. Henry Morgentaler to the Order of Canada and supported the appointment of several liberal-leaning Supreme Court Justices, including Rosalie Abella, a leading feminist. See “Most Back Order for Morgentaler,” Nanaimo Daily News, 9 July 2008: A3. B.C. Pharmacists, “Emergency Contraception Overview Update: Information for Pharmacists and Patients,” May 2007, http://www.bcpharmacists.org/ library/H-Resources/H-4_Pharmacy_Resources/5061-EC_Overview.pdf. The FDA’s assistant commissioner for women’s health, Dr. Susan Wood, resigned as a consequence of McClellan’s actions; see Wood 2005, 1650–51. For more on the father’s influence on foetal health, see Sheldon 1999, 129–49. Pro-Choice Action Network, Spring 1997, http://www.prochoiceactionnetworkcanada.org/prochoicepress/97spring.shtml#drummond. See also Rutman et al. 2000, iv-vii. Microcephaly is an abnormally small head due to incomplete brain growth. Salpingitis is an inflammation of the fallopian tube. For more on the ethical dimensions of the new reproductive technologies, see Blank and Merrick 1995, ch. 4; and Burgess 1993. See, for instance, Linda Carroll, “Too Many Babies: What Went Wrong? Birth of Octuplets is not a ‘Medical Triumph,’ Caution Fertility Experts,” http://www. msnbc.msn.com/id/28902137/.

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6

Networks of Support, Networks of Opposition THE MEDICAL EDUCATION OF WOMEN

In the 1890s, Sir William Osler, one of the greatest luminaries

of modern medicine, said to his female students at Johns Hopkins University, “Humankind might be divided into three groups — men, women, and women physicians” (Moldow 1987, 16). Despite this comment, Osler, unlike many of his colleagues, struggled to be scrupulously fair to these students. His statement does reveal, however, much about the ambiguous status of female physicians in the nineteenth century and the gender roles they appeared to challenge. Women physicians, although rare, always had been a part of Western medicine. Plato referred to female physicians in the fifth century BCE, while Galen consulted a woman named Iatrinai about instances of hysteria and gynaecological disorders. In medieval times, a Jewish woman named Virdimura was licensed to practice medicine on paupers in Catania in 1276, while the first woman known to receive a doctorate in medicine from a university was Costanza Calenda, who practiced in Naples in 1422 (Parker 1997, 131–36). Evidently, women’s illnesses had been the locus of women’s medical practice from the ancient world to the nineteenth and twentieth centuries.

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The popular perception that women were best suited to be healers, midwives, and physicians to other women was a significant factor in the opposition of the male medical profession to the entry of women in the nineteenth century. As regular physicians underwent a process of professionalization to distinguish themselves from homeopaths, eclectics, and other “irregulars,” they also began to reap the profits of eliminating their competitors in women’s health care — the midwives — and were reluctant to admit female practitioners who could reclaim this lucrative practice. These potential competitors and colleagues, although small in number, nonetheless proved a formidable and intrepid group in North America as elsewhere. This chapter will discuss both the strengths and successes, and the opposition and failures, of the campaign for women’s medical education. Emerging out of Victorian bourgeois and religious philanthropic ideologies, women’s “special calling” as healers to other women and children was an important raison d’être for medical education. Given its novelty and challenge to traditional gender roles, women’s medical training could not have been possible without the sustained encouragement of a network of support ranging from family to religion to other female practitioners, many of whom established separate women’s medical schools and hospitals to provide themselves and their sisters with the necessary education and clinical experience. Trained in the technological advancements in medicine by the end of the nineteenth century, many female graduates of co-educational programs left the feminist networks behind them and adopted wholeheartedly the male, objective, scientifically driven ideology of modern medicine. This “progress” was not without its costs, however. Many women, especially those in the twentieth century, discovered that the professional cloak of the male personae did not invest them with comparable power, authority, autonomy, or income. White male medical students did not have to face the sustained and often bitter opposition of a profession, its schools, its leadership, and its members. They did not, at the first instance, have to face the opposition of their own families’ and society’s expectations concerning their appropriate future roles. At a professional level, female medical school aspirants confronted theories, regulations, legislation, quotas, hostility, and harassment intended to discourage them. The successful were very extraordinary indeed, and this chapter is dedicated to their resolve and persistence.

Opportunities and Support Women’s Special Calling The advent of general co-education in nineteenth-century North America offered possibilities and ambitions to generations of intelligent women

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who found the homemaker role constricting and even the new profession of teaching insufficiently challenging. Imbued with the social reform theories of William Morris and T.H. Huxley, among others, they sought to make their marks and to secure their own independence through their religious and professional activities and, simultaneously, improve the lives of the less fortunate in their own communities and elsewhere in the world (Bacchi 1983, 21). The raison d’être for many was to improve the general poor state of health and ignorance of health issues among middle-class women. Catherine Beecher, a leading mid-Victorian American reformer, bemoaned that “ere long, there will be no healthy women in the country.” So acceptable was the precarious state of middle-class women’s health that it became fashionable to faint; as late as 1895, Mary Putnam Jacobi wrote, “It is considered natural and almost laudable to break down under all conceivable varieties of strain. Constantly considering their nerves, urged to consider them by well-intentioned, short-sighted advisers, [women] pretty soon became nothing but a bundle of nerves.” Although male specialists in women’s diseases, such as J. Marion Sims and S. Weir Mitchell, had built prestigious and lucrative careers devoted to female delicacy, many middle-class Victorian women were reticent about discussing their bodily functions, rendering it difficult for them to even consult male physicians. The results could be tragic. British reformer Josephine Butler crusaded for the right of “every woman ... to protect the secrets of her own person” (Vertinsky 1990, 112, 117). She was echoed by the American physician, Eliza Mosher, who in 1887 wrote, “A woman Doctor holds a position of greater responsibility than does a man. So many questions come to her which are never asked of men ... and her relations to families and family life is a very intimate and sacred one” (Morantz-Sanchez 1985a, 65). This “special calling” became one justification for the entry of women into the medical profession into the twentieth century as well. In her speech before the International Council of Women in Toronto in 1909, German medical pioneer Franziska Tiburtius observed that she had been employed by various insurance companies for 20 years, “as a great many women [workers] would rather resign than submit to the medical examination by men” (Tiburtius 1909, 496). Female health reformers, part of a critical consumer’s movement in the mid-nineteenth century, rebelled against traditional heroic practices such as venesection (bloodletting) with lancets and leeches and purges with harsh emetics and laxatives. Opposition mounted particularly when children were subjected to these measures. Ann Preston declared that the time had passed when “the licensed graduate whose lancet is sprung for every headache and heartache that he may meet can obtain public confidence” (Vertinsky 1990, 114). The reformers also took the very modern position that women should be pro-active concerning the health of them-

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selves and their families. They flourished in the wellness movement, which also sprang up at mid-century, and considered it essential for women to become knowledgeable about female physiology, even to the extent of undergoing medical training. The proliferation of homeopathic, eclectic, and other sectarian (unorthodox) medical schools in the mid-1800s provided a window of opportunity for talented women, as well as working-class, Native, and African-American students, to obtain a medical education. The Central Medical College of New York, in Syracuse, opened its doors to three women in 1849, while the National Eclectic Medical Association officially supported co-education three years later (Duffy 1979, 270, 273). By 1862, over one-half of the estimated 250 women who had graduated from American medical schools had been admitted to a sectarian program (More 1999, 20). Harriot Hunt (1805–75), for instance, has been called “the mother of the American woman physician” since she was the first to apply to Harvard Medical School. She supported women’s medical education throughout her 40-year career. Spurned by her first choice, Hunt apprenticed with two British-American health reformers, Elizabeth and Richard Dixon Mott, after they diagnosed and cured her sister Sarah’s tuberculosis. Sarah also became a physician, and the Hunt sisters popularized the Motts’ timeless self-help regimen of diet and exercise, sleep and cleanliness.1 For her efforts, the Woman’s Medical College of Pennsylvania awarded Harriot Hunt an honourary medical degree (Abram 1985b, 72). Some would-be female physicians were attracted by the self-help, non-invasive aspects of the unorthodox therapeutics, while others saw them simply as a means to an end. Marie Zakrzewska had been trained in the most advanced medical science in Europe, yet she became the director in 1859 of the New England Female Medical College, an irregular school despised by Boston’s medical establishment. As a woman of modern science, Zakrzewska did not, however, fit well with the anti-technology precepts of the New England College, severing her connections with it when she was refused thermometers, microscopes, or any other scientific devices (Abram 1985b, 89). The American sectarian schools proved the avenues of entry into the profession for aspiring Canadian female physicians as well. Medical pioneers Emily Howard Stowe and Jenny Kidd Trout of Ontario were graduates of American homeopathic colleges, and such schools’ popularity did not go unnoticed by male competitors. In 1874, Kingston, Ontario’s John Stewart “sarcastically suggested that homeopathy ought to be confined ‘to the crones of the Province’” (Strong-Boag 1979, 112; Backhouse 1991, 161). Ironically, even the homeopathic institutions were not immune from resistance to co-education. Cincinnati, Ohio’s Pulte Medical College, established in 1872, was “almost destroyed” over opposition to female students (Barlow and Powell 1984, 422).

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Female psychiatric wards and hospitals presented a special jurisdiction for women physicians. Male alienists (psychiatrists) in Victorian asylums frequently pointed to the uninhibited sexualized language and behaviour, including masturbation, of many patients. Women’s sexual delusions, which often involved male doctors, were also professionally dangerous and personally unsettling. Consequently, many superintendents and mental hospital boards called for the appointment of female physicians on the female wards. Once a few such appointments were in place, however, the male alienists, ironically enough, found the presence of female colleagues even more unsettling and professionally dangerous (McGovern 1984, 440). Asylum superintendents were not particularly respected in the medical community and derived their authority as patriarchal figures in the institutions. Medically trained women in charge of at least half of the patient population threatened that patriarchal model. Women’s medical contributions were greatest in the community, rather than in existing institutions. The emerging fields of public health and preventative medicine appealed to the pioneers’ conceptualization of women’s special calling. In 1852, Harriot Hunt declared that “we should give to man cheerfully the curative department, and women the preventative.” The female physician was, Elizabeth and Emily Blackwell asserted, “the connecting link” between medical science and domestic life, and this role was institutionalized with the establishment of women’s medical colleges, hospitals, and dispensaries. Individually and collectively, the early women physicians, like other female reformers, spent much time and energy in activities of social betterment as members and lecturers in mothers’ groups, temperance societies, and social hygiene organizations. They refined the traditional middle-class charitable function of visitor to the poor, becoming sanitary inspectors and providing essential services in urban slums. The New York Infirmary for Women and Children, for instance, engaged an intern as sanitary visitor. She ventured into the immigrant ghettoes “not only to treat emergency cases but also to teach cleanliness, proper ventilation, nutrition and personal hygiene” (MorantzSanchez 1985a, 62, 65–66). One of the best examples of the socially active physician was the American S. Josephine Baker, who founded the first Child Health Bureau in 1908 in New York, Little Mothers clubs to educate older sisters in child care, and milk stations nationwide to combat the serious levels of infant mortality caused by contaminated milk (More 1999, 74–76). Baker was following initiatives made by local reformers for a generation. By the 1880s in many American cities, female physicians had established dispensaries, or outpatient clinics, to serve the needs of the indigent and immigrant. The Baltimore Dispensary provided “lectures on hygiene; distributed clean milk to impoverished children; organized

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a social service department; and conducted studies of midwifery, birth registration and tuberculosis mortality” (More 1999, 58). Nor did charitable efforts go unnoticed and unrewarded. Reformers would be wellloved in their communities (More, 1987, 618). By the end of the Great War, however, governments were beginning to incorporate social services within their bureaucracies. The dispensaries, women’s hospitals, and other women-centred outlets for the professional and charitable energies of female physicians soon disappeared (More 1999, 5). One survivor, however, was Montreal’s first francophone paediatric hospital, l’Hôpital Ste-Justine, which was founded by Irma Le Vasseur, French Canada’s first regular female physician. She applied the modern therapeutics she had learned in the United States, France, and Germany to her new environment (Hacker 1974, 172). The relatively small Canadian reform community maintained its international connections. When Emily Stowe left Canada to enrol in the New York Medical College for Women, c0-founded by Elizabeth Blackwell, she met feminists Elizabeth Cady Stanton and Susan B. Anthony and received an education not just in medicine but in feminist thought and action. Upon her return to Toronto in 1868, she began both her medical practice and Canada’s suffrage movement (Bacchi 1983, 25). In 1883, frustrated by the intransigence of the Ontario medical association which refused to recognize her degree and allow her to be an officially licensed physician in the province (a situation that degenerated to absurdity after decades of a successful Toronto practice), Stowe enlisted her colleagues in the Toronto Women’s Suffrage Club to push for the development of the Toronto Woman’s Medical College, which opened in October in that year. Unfortunately for the future of separate women’s medical education in Ontario, the Toronto College’s establishment coincided with that of the Women’s Medical College in near-by Kingston. The second college was opened partly through the financial largesse of Stowe’s former protegé and present rival, Jenny Kidd Trout, who was the first woman physician to be licensed in Ontario in 1875 (Fryer 1990, 61–62; see also Dembski 1985, 182–206). The clash of the two personalities, the older Dr. Stowe and the wealthier Dr. Trout, resulted in the splitting and subsequent weakening of the women’s medical education initiative in Ontario (Fryer 1990, 88–92). Due to unrelenting opposition from the Ontario Medical Association and lack of organized popular support, the Kingston medical college closed in 1895 and was amalgamated with the Toronto institution, which was renamed the Ontario Women’s Medical College. In 1909, the college was absorbed by the University of Toronto medical school when the larger institution agreed to allow co-education. However, there was no agreement as to the number of women to be admitted each year, so that through the use of tight quotas, the University of Toronto severely limited

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the enrolment of female medical students, the very situation the separate women’s medical colleges had been established to combat (Gidney and Millar 1996, 37). The 1898 establishment of the Dispensary in Toronto was a positive and permanent legacy of the Ontario women’s medical college experiment. As in the United States, the female graduates found hospital postings barred to them, so they and their benefactors established a separate free clinic to provide essential public health services to their community as well as vital practical experience for recent graduates. In 1911, local prominent women established Women’s College Hospital, incorporating the Dispensary, which provided specialized care for women and children throughout the twentieth century and, until 1961, employed only female physicians.2 The close association of feminist and medical activism continued under the leadership of Emily Stowe’s daughter, Dr. Augusta StoweGullen, who founded the Canadian Suffrage Association. Margaret Blair Gordon and Elizabeth Smith Shortt (one of the first three graduates of the Kingston Women’s Medical College), among others, also played important roles in this organization. Physicians and other professionals in the Canadian suffrage movement reframed the conservative rhetoric of antifeminists by arguing that women’s suffrage would lead to “home protection.” Smith Shortt stated, “The greatest safeguard from incursions [of the home] from [crime, immorality, and disease was] to strengthen the forces within” (Bacchi 1983, 33). Physicians who were cognizant of the extensive physical, emotional, and familial damage caused by alcoholism, venereal diseases, child labour, and poor living conditions could marshal the statistics, case histories, and funds to promote their causes. Smith Shortt’s personal endeavours to combat tuberculosis in Ottawa and elsewhere in Canada reflected these public health initiatives (Strong-Boag 1980, xxxi-xxxii). Spinster3 physicians (and they formed a majority in the nineteenth century) shared and perhaps idealized the goal of domesticity and home protection (Morantz-Sanchez 1985a, 65). Dr. Helen MacMurchy, a member of Ontario’s social elite, was an important example. She toiled for 20 years as a teacher at Jarvis Collegiate, her father Archibald MacMurchy’s prestigious institution, before she was able to obtain a medical degree from the University of Toronto in 1901 at the age of 39. While she remained single, she lobbied for health reform measures for women and children; she was appointed “special investigator into infant mortality” for the province of Ontario from 1911 to 1913 and provincial inspector of the “feebleminded” from 1906 to 1919. During this period, she coined the pithy phrase, “Where the mother works, the baby dies” (Prentice et al. 1996, 163). The following year she joined the federal government’s Child Welfare Division, producing the Blue Books that disseminated advice on

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infant and maternal care to women throughout Canada (Dodd 1994, 137; see also Chapter 3, passim). MacMurchy’s essentially bourgeois perspective led her to support eugenics policies, and she failed to understand the difficulties of impoverished and immigrant families. Other Canadian female physicians shared many of her views. Augusta Stowe-Gullen, for instance, viewed child factory work as destructive to the individual and especially to the race through debilitated offspring. She noted that too often this was a tragically self-limiting group: “four or five years of this infamous drudgery kills” (Bacchi 1983, 90). Neither MacMurchy nor Stowe-Gullen, however, supported working-class labour or political movements, which worked to better the economic status of the poor, thereby rendering child labour unnecessary. Were female patients justified in their belief that female physicians provided more empathetic care? There is limited evidence that in some instances they were, although of course such generalization does disservice to many caring male doctors. Walsh’s study of male and female physicians in nineteenth-century Boston hospitals determined that the doctors in male-run maternity wards complained that “the maternity patients were too lazy to ‘work’ in delivering their babies or that their infections were their own fault.” By contrast, the medical staff at the female-operated New England Hospital for Women and Children uttered no such disparaging remarks (at least in patient records). They were also less interventionist in deliveries and performed practical charitable functions such as finding housing and employment for their indigent patients (Walsh 1984, 398). Women-centred medicine did not have to be a throwback to traditional separate spheres — quite the contrary. Elizabeth Bagshaw, a 1905 graduate of the Ontario Medical College for Women, took the very radical step in 1932 of becoming the medical director of Canada’s first birth control clinic in Hamilton, Ontario, a position she would hold until 1966, even though the distribution of birth control devices and information was illegal in Canada until 1969. In the depths of the Depression years, Bagshaw assisted desperate immigrant and other poor women to limit their family size and raise healthy children.4 A close association between female physicians and the “special calling” of women’s and children’s health still exists. Many contemporary feminists, far from distancing themselves from “feminine” issues, advise twenty-firstcentury practitioners to accept and draw strength from their distinctiveness. Dr. Mary Howell, a contributor to the feminist health manifesto Our Bodies, Ourselves, asserted, “there is a direct relationship between discrimination against women as medical students and as patients: the one supports the other.... If women physicians do not concern themselves about health care for women, then health care for women is not likely to improve in the near future” (quoted in More 1999, 233).

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Networks of Support In many instances, the emotional, financial, and intellectual support of a father or father figure was critical to a young woman’s medical aspirations. In 1847, 33-year-old Ann Preston began reading medicine under family friend and fellow Quaker Dr. Nathaniel Moseley. The Quaker community, which advocated gender equality, produced many female medical students (Abram 1985b, 77). In that same year, 18-year-old Sarah Adamson “gravely informed her parents that she wished to become a doctor.... [Her father] insisted, ‘Sarah, thee must not fail.’” Her parents could not have been more supportive, supplying her with a skeleton and books and even raising “the east wing of our house one story for my study” (More 1999, 17–18). Emily Stowe came from Quaker parents who “placed as great value on daughters as on sons” (Fryer 1990, 18). Other Quaker male mentors, led by Dr. Joseph Longshore, founded the Woman’s Medical College of Pennsylvania in 1850 as the world’s first orthodox medical school for women. Ann Preston became professor of physiology and hygiene there (Abram 1985b, 77, 81).5 As the nineteenth century progressed and women physicians did not disappear, colleges, medical societies, and individual male physicians were forced to confront female medical education. Its supporters emphasized the basic human right of equality, the small numbers that posed no threat to male financial and professional interests, many women’s preference for doctors of their own gender, and that barring women from regular colleges and societies simply swelled the ranks of the irregulars (Walsh 1977, 148). The debate over female admissions hit a picturesque low at the 1871 American Medical Association (AMA) convention in San Francisco, when arguments about female menstrual disability were raised by the anti-women forces: “When Dr. Gibbons of San Francisco retorted that a large majority of male practitioners fluctuated not once a month with the moon, but every day with the movement of the sun, because of the influence of alcohol, the convention dissolved into a shouting match” (Walsh 1977, 154). Dr. Marie Zakrzewska, mindful of the small yet important pro-women contingent of the medical community, mastered the arts of currying and maintaining male support for her cherished New England Hospital for Women. She well knew that the backing of elite physicians like Samuel Cabot and Henry Bowditch (even when they were less than helpful in gaining her admission to Boston’s medical society) was crucial to the survival of her institution (Walsh 1977, 395; Drachman 1984, 57). The sustained and active support of other female physicians, reformers, and family members steeled the backbones of the medical pioneers. This very small group worked together and lived together, providing financial backing and emotional support in the course of often life-long relationships (Morantz-Sanchez 1985b, 133). In 1851, when Elizabeth

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Blackwell opened her New York practice as a virtual social pariah, one ray of hope was an unexpected visit from Ann Preston (Abram 1985b, 80–81). Blackwell in turn “paid it forward” when she visited England in 1858 and encouraged the young Elizabeth Garrett (Manton 1965, 45). Blackwell offered even more assistance to the German-speaking immigrant, Marie Zakrzewska, allowing her to open an office in her crowded home, supplying her with textbooks, and helping her to get financial assistance from Harriot Hunt for her studies. Zakrzewska in turn had the business expertise to raise the funds first to open the New York Infirmary for Women and Children in 1857 and later the New England Hospital for Women and Children (Walsh 1984, 393, 396). The nineteenth-century feminist movements in North America and Europe also provided critical support. Victorian seminaries, colleges, charities, and reform societies produced intense sisterly bonds and shared social goals. In publications like The Englishwoman’s Journal (founded in 1858) and the Woman’s Journal (founded by American suffragist Lucy Stone in 1870), articles and letters promoted women physicians (Drachman 1984, 46; Manton 1965, 44; Rossi 1973, 340). Feminists also personally benefitted from the special talents of the women physicians.6 After many unsatisfactory consultations with male doctors for her depression, which she immortalized in her novella The Yellow Wallpaper (1899; 1913),7 American novelist Charlotte Perkins Gilman was helped by Mary Putnam Jacobi.8 Women’s Hospitals and Schools The American women physicians’ network was facilitated by the founding of three important institutions. The Woman’s Medical College of Pennsylvania in Philadelphia (opened in 1861), the New York Infirmary for Women and Children, and the New England Hospital for Women and Children in Boston (both opened in 1862) provided medical training and employment opportunities for aspiring female doctors (Abram 1985b, 89). The fact that two opened in the midst of the American Civil War probably reflected both the emergency need for physicians and nurses as well as the generalized relaxation of traditional values that customarily accompanies such disasters. From its beginning, the New England Hospital for Women and Children was shaped by the guiding vision and life-long commitment of its founder, Dr. Marie Zakrzewska, who remained at its helm until her death 40 years later. Zakrzewska intended the institution “to provide sick women with medical care from physicians of their own sex, to provide women doctors with clinical training, and to train nurses.” She was successful in the first instance, with eight women physicians devoting entire careers to the

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hospital and with many more trainees founding other women’s medical institutions. Her related goal, to advance the position of women physicians within the general profession, was less successful and indeed eventually detrimental to her beloved hospital. A younger generation of women, trained within the scientific model of the co-educational medical schools, valued, like their male colleagues, clinical and research experience over traditional feminist goals of sisterhood and benevolence.Younger residents at the New England Hospital, like Alice Hamilton, the great industrial health researcher of the twentieth century, were frustrated and resentful at the lack of clinical opportunities and soon left the women-centred institution (Drachman 1984, 174, 178). The two Canadian women’s medical colleges in Kingston and Toronto collapsed partly because of student dissatisfaction with separate education and their mistaken belief that women’s medical education was a permanent achievement. In 1905, R.B. Nevitt, Dean of Toronto’s Medical College for Women, observed: “The women feel that as present situated they have not an equal opportunity with the men of becoming acquainted with the idiosyncrasies of examiners, and that this loss influences their competitive standing.” The Ontario College, which had survived the Kingston College by several years, closed in 1906, and the students transferred to the general program at the University of Toronto. Here they soon faced quotas, lack of funds, and hatred, as Dr. Elizabeth Stewart, a 1907 graduate, noted. Furthermore, without the separatist institutions, few academic employment opportunities were available for female graduates, nor were role models for future female students (de la Cour and Sheinin 1986, 75–76). Although radical in their composition, the women’s teaching hospitals were traditional in intent; they were charitable institutions catering to poor women and their children and as such were outgrowths of the grand scheme of Victorian bourgeois benevolence (Bashford 1997, 206). Public service justified female medical professionalization, while the “respectability” of the clientele also reflected the conservative qualities of the women’s institutions. At the New England Hospital, paying “sisters” had priority over impoverished ones; only the latter were thoroughly interrogated by admitting physicians before being granted a bed (Drachman 1984, 84).9 The conservatism of the early Canadian feminist movement was reflected in the publications and activities of its leaders, including Emily Stowe and Amelia Yeomans, two physicians who advocated “anti-sex” sex education, which taught the young “all the consequences of the transgression,” as well as strict immigration and eugenics policies (Bacchi 1983, 114). A few Canadian universities, and some American universities in the socially freer milieu of the American midwest and western states opened their doors to women and allowed co-education in their medical programs. Syracuse University became co-educational in 1870, as did the

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newly opened University of Michigan in 1871 and the University of California in 1874. Canadian schools followed suit almost two decades later, with co-education at Dalhousie University and Bishop’s University in 1890, the University of Manitoba in 1891, and the University of Western Ontario a few years later. Supporters of women’s medical education raised funds and offered endowments to universities as an inducement to offer seats to female students, such as the $50,000 that Doctors Marie Zakrzewska and Emily Blackwell offered to Harvard University. The institution was tempted, but opposition from its faculty forced it to refuse female applicants until 1945. Women were more successful at Baltimore’s new Johns Hopkins University. When its state-of-the-art medical school was opened in 1893 with William Osler, William Welch, and William Halsted at the helm, the board accepted, albeit with trepidation, the funds and women students. The faculty required assurances from Zurich’s medical educators that co-education could succeed (Duffy 1979, 273, 276; Strong-Boag 1979, 118; Abram 1985b, 96; Bonner 1988, 69). Once Johns Hopkins opened to both men and women in 1893, other new institutions followed. Tulane University, founded in New Orleans in 1894, granted degrees in law and pharmacy along with medicine to women as well as men, while Cornell University in Ithaca, New York, established its medical school in 1898 as a co-educational program. That the position of women in regular medical schools was secure became an understandable belief that undercut the raison d’être for the separate women’s institutions. By 1895, 19 medical colleges exclusively for women had been established in the United States. Five years later, only eight remained. By 1910, the Woman’s Medical College of Pennsylvania and the New York Medical College and Hospital for Women, a homeopathic institution, were the last vestiges of the age of the separate schools (Duffy 1979, 277; Lopate 1968, 15). Once there were a significant number of women physicians, there were calls for professional organization. First advocated by feminists in 1867, it was not until 1893 that women doctors in Toledo, Ohio began the Women’s Medical Journal. In 1915 the National Women’s Medical Association (later The American Medical Women’s Association) was founded. Significantly, when feminist physicians entered the medical societies, they met opposition from many male colleagues and opposition mixed with apathy from many female colleagues (Walsh 1977, 216). Only overt, generalized discrimination, such as the military’s reluctance to enlist female physicians during both world wars, would give the women’s medical organization relevance to a cross-section of twentieth-century female physicians. In other circumstances, women who had not experienced direct discrimination, such as those trained in Europe, often found the feminist rhetoric of the medical pioneers jarring and anachronistic. Ruth Kajander, born

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and educated in Germany in psychiatry, immigrated to Port Arthur, Ontario in 1952. Because she was one of the earliest to use chlorpromazine in psychiatric treatment, she met a frosty reception from her northern Ontario male colleagues. What she recalled most vividly in her 1991 memoir, however, was the reception she received from other women physicians: When I started studying medicine in Berlin in 1943 being female meant nothing. When I went to Finland in 1949 matters were no different, professional women were long since a fait accompli in Finland. Imagine my dismay and total surprise when I came to Canada in 1952! In that year the legendary Lillian Oliver arranged for me to meet the equally legendary Dr. Edna Guest who did me the honour to personally show me around Women’s College Hospital and then serve me tea at her apartment. I still recall with horror the paranoid attitude of “we must show the men,” a thinking that was so foreign to me. The same occurred when Marion Hilliard invited the incoming female medical students of U of T to a picnic to her beautiful residence in Scarborough in 1956 and then gave them a pep talk of “we must impress the men.” Being young, I was disgusted, today I’d smile. (Gold et al. 1995, 19)

With the disappearance of the women’s hospitals and colleges, female physicians, always a minority, were trained and moulded in the “professional” (i.e., male) ideal. Working within a male environment, most were reluctant to rock the boat and threaten their hard-won achievements. This attitude, however, came at a psychological and institutional cost. Sociologist Judith Lorber concluded that in medical schools and hospitals “senior women can’t afford to neglect mentoring their junior women colleagues; nor ... can junior women faculty afford to eschew senior women colleagues as potential sponsors. Increased numbers alone, without coordinated, collective action, will not create power for women in medicine” (quoted in More 1999, 229). Missions — Religious, Military, and Otherwise Many of the medical pioneers were products of ethnic or religious communities that were supportive of women’s higher education and professional advancement. Emily Stowe, Elizabeth and Emily Blackwell, Ann Preston, and others were raised in Nonconformist and evangelical Christian denominations, such as the Unitarians and Quakers (Manton 1965, 50). Jewish women were also among early medical graduates, and North Americans followed the example of their European sisters, benefitting

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from the liberal, even socialist, predilections of their families.10 Regina Lewis-Landau, who matriculated from Bishop’s University in Montreal in 1895, was the first Canadian Jewish woman to obtain a medical degree. She also organized a suffrage group with the typically innocuous title of the Jewish Young Ladies Literary Society (Hacker 1974, 167; Prentice et al. 1996, 137). Mildred Resnick Glube, a 1921 graduate of Dalhousie medical school, studied paediatrics in Montreal and Glasgow and practiced in Halifax for six years after her marriage. Although she retired from medicine in 1930 because “women in medicine were not socially accepted,” her retreat was only temporary. As social conditions changed during World War II, she retrained in New York as an anaesthetist and took up medicine once again (MacLeod 1990, 76). The professional and religious motivations of many medical pioneers found expression in missionary work and situated these women physicians solidly within middle-class Western imperialistic culture (Bashford 1997, 207). Missionary societies channelled these energies, fulfilling the physicians’ spiritual and feminist desires as well as their professional goals. Elizabeth Beatty, one of the first three graduates of the Queen’s University Medical College for Women, led the way in 1884 with her work for the Presbyterian Church. Despite the fact that she travelled in illustrious circles — she accompanied the governor general’s wife to India and secured the patronage of the Maharani of Indore for a women’s hospital — her health suffered from the experience and she returned to Canada (Hacker 1974, 67, 69). Both the Women’s Union Missionary Society of America, whose slogan was “Women’s Work, for Women, by Women,” and the Women’s Missionary Society of the Methodist Church sent medical missionaries to India, China, Korea, and later to Africa (MacLeod 1990, 31, 80; Hacker 1974, 97; see also Brouwer, 2002). The intrepid idealists certainly required their faith to cope with exceptionally challenging and exciting conditions. Annie Hamilton, the first female medical graduate of Dalhousie University in Halifax, left teaching for medicine and subsequently became a missionary to China from 1903 until her death in 1941. Florence O’Donnell, another Dalhousie graduate, ran a woman’s hospital and training school in a very isolated part of Szechwan Province (MacLeod 1990, 9, 27). Unlike Hamilton, O’Donnell’s adventures ended after seven years when she returned to marry and raise three children in Halifax.Yet another Dalhousie graduate, Jemima MacKenzie, ventured to India: Dr MacKenzie traveled on foot and horseback. She rode elephants and camels, and drove in a bumpy two-wheel cart on rough roads to visit patients in the countryside. Often she was threatened by bandits and frightened by wild animals. On one occasion she had to take the reins from a hysterical driver and drive her cart through the

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lonely jungle where panthers could be seen from the track. Twice she shot deadly snakes with a revolver she carried. She had a preventive and curative practice for all emergencies, whether apprehended or real — it was the power of prayer. When danger loomed, she knelt and humbly placed her fate in God’s hands. (MacLeod 1990, 36)

MacKenzie ran a 60-bed hospital and nurse’s training school, adopting 44 orphans (mostly girls abandoned at birth near the Ganges River). She eventually retired to the town of Pictou, Nova Scotia with her two youngest charges. While their colleagues were struggling to set up practices in inhospitable communities or to reconcile domestic and professional responsibilities in their own patriarchal societies, women of faith and adventure lived the lives of storybook heroines. Medical missionaries could find adventures at the home front as well. Some tested the prairie frontier. Margaret Strong, a graduate of the University of Western Ontario in London, settled in Dixonville, Alberta, in the Peace River district in 1931, as “doctor, dentist, preacher, community worker and relief superintendent all rolled into one.” She delivered babies in the frigid northern winters and organized a community garden, a night school, and a church for which she was the preacher every Sunday morning (Light and Pierson 1990, 236–37; see also Jackson 2006). Other medical pioneers lived their adventures in more secular ways — personifying Calamity Jane rather than Jeanne d’Arc. Charlotte Whitehead Ross, a graduate of the Women’s Medical College of Pennsylvania in 1865 (her studies interrupted by the births of several of her eight children), practiced medicine in an isolated logging camp in Whitemouth, Manitoba, and gained respect from the rough-and-ready saloon crowd with her adeptness at sewing up throats slit in bar brawls (Hacker 1974, 83). Her exceptional dedication was recalled by a former patient: “at one birth, she left her own dying five-year-old, knowing there was nothing she could do for him, and walked one and a half miles through snow and slush up to her knees to help my mother” (Nitychoruk and Nicolle 1994, 7). Annie Hennigar was fondly remembered in Cheverie, Nova Scotia as “a grand man with a tooth ... when Dr. Annie hooked on a tooth and pulled, it had to come, even if your jaw came with it.” Bessie Bober sought her own small bit of immortality. At anatomy class at Dalhousie, she “carved her initials on cadavers as well as wooden benches” (MacLeod 1990, 43, 48). The outbreak of the Great War coincided with the battle for female suffrage. Women physicians regarded participation in the war effort as an avenue for asserting their patriotism as full citizens as well as their professionalism as legitimate practitioners equal to their male counterparts (Jensen 1999, 540). They certainly endured personal suffering and displayed

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bravery the match and more of men’s. Irma LeVasseur, the first FrenchCanadian female physician, organized a hospital in Serbia and fought a devastating typhus epidemic. Operating in the midst of battle, she survived the Great Retreat when the Germans advanced and 700,000 civilians died. Other Canadian women physicians volunteered in the Scottish Women’s Hospitals units and the British Women’s Hospital Corps, organized by Louisa Garrett Anderson, and served in the British and French armies. Three hundred and thirty-one Canadian women were officially part of the Royal Army Medical Corps (RAMC ). For her service at the Front attached to the French forces, Mary Lee Edward was awarded the Croix de Guerre (Hacker 1974, 172, 177–78). Both female and male physicians lobbied to serve as officers in both world wars. After the Americans entered the Great War in 1917, the AMA successfully pressed the government to pass the Owen-Dyer Bill, which awarded physicians officer rank in the Medical Corps. The male professional elite were uninterested in sharing this victory with their female colleagues, however, and the military brass had no interest in experimenting with a female medical corps. Despite the lack of welcome, one-third of American medical women expressed their readiness for national service. The American Medical Women’s Association (AMWA), an organization that had been losing ground among a younger generation of female physicians, found new relevance when it organized the American Women’s Hospitals, a joint effort by the AMWA, the Suffrage Association, and the American Red Cross to send female physicians to the Front. Their petitions to Washington were “politely refused” (More 1987, 626; Lopate 1968, 18–19). Despite their chilly reception, 55 female physicians provided medical services by contract to the American Army, while many others volunteered through the Red Cross and other international agencies; without officer rank, these women “would be extremely vulnerable in both their working relationships and their social relationships with men in the military” (Jensen 1999, 541–42, 546). Women’s medical services in World War II were accepted slightly less grudgingly. Florence Anne Griffiths Scott, a psychiatrist, travelled to England in 1942 to be rejected by the Canadian army. She enlisted in the Indian Medical Service and soon was placed in charge of mental health services for the Indian Air Force and the Indian division of the Women’s Auxiliary Corps (Gold et al. 1995, 10). In 1942, Manitoba female medical students entered the Canadian Women’s Army Corps as privates. They completed their studies in uniform, although only earning $33.00 per month while their male colleagues earned $90.00. Male and female graduates became lieutenants in the Royal Canadian Army Medical Corps with equal pay, a result of lobbying efforts by the Canadian Federation of Medical Women, founded in 1924 (Kinnear 1993, 135).

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When the Americans entered the war two years after the Canadians, patriotic women physicians met with a lack of military enthusiasm akin to what they had experienced in World War I but a better reception from the executive branch of government. The AMWA registered 2,000 women in 1940 for service in the American Women’s Hospitals Service in far-flung regions such as the Middle East and the Philippines (Lopate 1968, 18). At congressional hearings for the Cellar and Sparkman Bills (regarding the composition of the Medical Corps), female physicians were ably led by the AMWA’s Dr. Emily Barringer, who emphasized that “the military was not making the best use of American doctors. Noting that the army had taken some of the most skillful male obstetricians abroad and left at home some of the best female plastic surgeons, Barringer dryly added that if there was one type of operation that soldiers did not need, it was a Caesarean section.” President Franklin Delano Roosevelt agreed, and on April 16, 1943, he signed the Sparkman-Johnson Bill authorizing women to serve in the Army and Navy Medical Corps (Walsh 1977, 229). The Canadian Armed Forces’ success in integrating women physicians perhaps reassured the Americans. Gains did not outlast the war, however. American women physicians, like other women war workers, found themselves displaced by returning male veterans and barred from the Medical Reserve Corps. Also like other women war workers, rankand-file women physicians were agreeable, for the most part, to resuming their domestic roles after the war (Lopate 1968, 19).11 Feminist versus Professional Identity Distinctive differences in outlook and values existed between the generation of medical pioneers, who had battled their way into the profession within the context of mid-nineteenth century social reform movements and who regarded feminism as an essential component of professional and social advancement, and their students and successors. The latter were products of the industrial age’s more universal education and adherents of Progressive theories of scientific and objective development (Moldow 1987, 2). They were more likely to have received their medical training in co-educational institutions, either in North America or abroad, and they shared, for the most part, their instructors’ and mentors’ faith in the new tools of science, both physical and intellectual, to make them excellent physicians. These two medical perspectives — the holistic and the objective — produced serious rifts within the small cohort of female physicians. Regina Morantz-Sanchez analyzed how these competing worldviews coloured the careers of two leading American physicians — Elizabeth Blackwell and Mary Dixon-Jones. Blackwell considered women’s con-

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tribution to healing to be based upon “the spiritual power of maternity” and recognition of the importance of environmental influences upon an individual’s health (Morantz-Sanchez 1997, 179). She considered the “microbe hunters” to pose “three fundamental dangers to medicine.” They conceived of a “reductionistic and materialistic” view of disease causation: “Scientific method requires that all factors which concern the subject of research shall be duly considered. [For example] the facts of affection, companionship, sympathy, justice ... exercise a powerful influence over the physical organization of all living creatures.” She opposed the practice of vivisection because medical students would by necessity become hardened and detached from suffering. Finally, she viewed the laboratory as a means by which practitioners could avoid clinical practice, which would “severely threaten the doctor-patient relationship” (Morantz-Sanchez 1984, 528–29). Blackwell, however, was fighting a rearguard battle against the growing influence of science in medicine. An increasing number of younger female practitioners were sympathetic to the goals, if not all of the means, of surgeon Dixon-Jones. Mary Dixon-Jones, a gynaecological surgeon in Brooklyn, New York, was a fervent supporter and energetic practitioner of the new science and of that most controversial of late nineteenth-century women’s medicine, the ovariotomy.12 She was credited in the Dictionary of American Medical Biography as the first American surgeon to “perform total hysterectomy for uterine myoma (growths, usually fibroid) ... but also with describing and identifying two diseases — endothelioma, cancer of the lining of the uterus, and gyroma, a cancerous tumour of the ovary” (Morantz-Sanchez 1997, 184–86). Her persistent self-aggrandizement (in 40 publications, she called “attention to herself both as a technical virtuoso in the operating room and a careful scientist in the laboratory”) led to her downfall in a damaging and widely publicized malpractice trial. Despite her surgical skill, Dixon-Jones’s arrogance and “cool detachment” were unfeminine qualities unacceptable to the late Victorian public and many other physicians. Those young female physicians who, like Dixon-Jones, attempted to adopt the male persona that accompanied the new science, found themselves walking a fine line between professionalism and parody. Dorothy Reed Mendenhall, one of the leading lights of the early Johns Hopkins Medical School, admitted that to survive medical school, she had to cultivate “an arrogance, which was foreign to my original nature.”Yet the rare woman physician who could combine femininity with seriousness was described as possessing “gentlemanly” characteristics (Morantz-Sanchez 1985b, 117, 199). Many women physicians therefore found it difficult and often impossible to accommodate conflicting personality expectations. Dixon-Jones’s and Reed Mendenhall’s male personae paled before the unique example of Canada’s first known (or rather largely unknown)

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female physician, James Miranda Stuart Barry. Barry’s true identity remains murky. Living as a man, conveniently an eccentric and bad-tempered one, for over 40 years, she served as Inspector-General of Hospitals for the colonies of Upper and Lower Canada in 1857. In that capacity, Barry cleaned up the hospitals and barracks and improved the soldiers’ diets before moving on to India and other parts of the British Empire. Her “true” gender was only revealed upon her death, as well as the fact that she had delivered at least one child.13 Despite her gender-bending life, Barry, like many of her more conventional medical sisters, practiced in the area of public health (Hacker 1974, 3, 9). Compared to their late-Victorian sisters, twentieth-century women physicians experienced, if anything, more role conflict associated with the male character of medical training and practice. The failure of the AMWA to prosper was due in part to its image as an embarrassing anachronism for the majority of female practitioners, who preferred to identify themselves with the masculine power structure (Lopate 1968, 16, 20). When the Federation of Medical Women of Canada was organized by six women in 1924, its mandate was professional rather than feminist ideals (StrongBoag 1979, 128). The cohort that had the greatest difficulties in reconciling the goals of womanhood and professionalism were those entering practice at mid-century. By the 1950s, the older feminist generation had largely died off, while North American medical schools had institutionalized strict quotas, reducing all women medical students, as well as Jewish and African-American students to distinct and largely unwelcome minorities. Furthermore, the triumph of domesticity in the larger society placed more social and personal pressures upon those wishing to break the mould and enter professional schools. A 1973 American study of medical schools delineated many of the stresses and challenges women faced: inadequate “on call” rooms and being “forgotten” in surgical scheduling and even being unable to find a bed “to sleep on overnight when we’re on call — the nurses kick us out of their quarters, and the doctors and students out of the men’s sleeping quarters” (Gorham 1994, 187–88, 190). Like Mendenhall a century earlier, many women at the end of the twentieth century who survived masculine residencies such as surgery developed masculine personae. Dr. Sally Abston, of the University of Texas Medical Branch, termed surgery “sort of like being in the Marine Corps, and we thought of ourselves as the best doctors in the house, the hardest working ... we were the ‘meanest man on the mountain.’” Abston, who swore like a Marine, believed that “nurses, medical students, and residents resented her obscenities far more than they would have in a man.” However, once she and her lesbian partner, also a physician, adopted two children, she found greater acceptance from the nursing staff; motherhood, in effect, became her feminine guidepost for social relations

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This material omitted from the electronic edition due to copyright.

FIGURE 6.1:

Doctor and Patient, BC Cancer Institute, 1940s.

Jack Lindsay Photo, City of Vancouver Archives, CVA 1184-1801.

(More 1999, 194–95). Other contemporary physicians, such as Dr. Beverly Walters, Toronto neurosurgeon and co-editor of the Annotated Bibliography of Women in Medicine, consider their retention of “a female style” to be a strength in their careers: “I wear earrings, I laugh out loud, I don’t wear trousers and I work in a male-defined workplace where there is an idea of what is proper, that is, what is proper for a male” (Klich 1993, 24). Careers of Distinction Despite the many obstacles, the medical pioneers often made lasting and international contributions. Dr. Maud Menten, a graduate from the University of Toronto in 1911, created, with Dr. Lenore Michaelis, the Michaelis-Menten Equation, a theoretical framework for the study of enzymes (Prentice et al. 1996, 1370). Dr. Frances McGill, physician and lawyer, became so well known as a criminologist in Canada that McGill Lake in Saskatchewan was named in her honour. Dr. Elinor Black, like McGill a Manitoba graduate, was “the first Canadian woman to be elected to the Royal College of Obstetrics and Gynaecology; first Canadian woman to chair a major clinical department; an executive of the Manitoba Medical Association; and the first woman president of the Society of Obstetrics and Gynaecology” (Nitychoruk and Nicolle 1994, 9). Elizabeth Kilpatrick bequeathed to her alma mater, Dalhousie Medical School, $500,000 following an extremely distinguished career in psychia-

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FIGURE 6.2 :

Maude Abbott with Unidentified Nurse and Child.

Osler Library of the History of Medicine, McGill University, Montreal, Quebec, Canada.

try; she succeeded Karen Horney as the Dean of New York’s American Institute of Psychoanalysis (MacLeod 1990, 56). Then there was Maude Abbott, one of the first arts graduates, or “Donaldas” of McGill University, whom her beloved alma mater refused to admit to its very conservative medical school.14 A graduate of the medical program at Bishop’s University in Lennoxville, Quebec, Abbott took post-graduate training in Vienna, Zurich, and Britain, and eventually left her socially acceptable practice for women and children to research heart murmurs at McGill with male colleagues who recognized her talent. Subsequently she was the first woman to present a paper to the Pathological Society of London and in 1898 began her life-long association with McGill’s medical museum. Her massive and detailed catalogue of the collection became a textbook of lasting influence on gross pathology. She soon added William Osler to her list of supporters and wrote the section on congenital heart disease for his classic System of Medicine. Her tours of the medical museum became so popular with medical students that they became part of the curriculum in 1904. Confronted with the over 100 publications Abbott produced and the international reputation she earned, McGill was finally shamed in 1910 into awarding her an honourary MD and an appointment as Lecturer in Pathology, eight years before the entire institution became co-educational (Hacker 1974, 154–63).

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A leading American light of the nineteenth century was Mary Putnam Jacobi, who embraced both the maternal feminist ideals of the medical pioneers and the pursuit of science. A member of the George Putnam publishing family (another member later married Amelia Earhart), 21-year-old Jacobi displayed her genius by graduating in one year from the Woman’s Medical College of Pennsylvania in 1863. She travelled to Paris and gained admission to the prestigious École de Médecine, where she was trained in the most modern clinical techniques and was awarded the Bronze Medal for her thesis. She taught Materia Medica (pharmacology) for ten years at the Woman’s Medical College of New York Infirmary and in 1873 married one of the most distinguished paediatricians in the United States, German-Jewish émigré Dr. Abraham Jacobi. Tragically, they lost two of their three children, their oldest daughter soon after birth and their son from diphtheria, at the age of seven, a blow from which neither parent “ever really recovered” (Jacobi 1925, 361). Putnam Jacobi worked for suffrage in New York and was active in a variety of causes, establishing the Working Women’s Society, and the Association for the Advancement of Medical Education for Women. Her professional recognition was complete in 1882, when she became a faculty member of the New York PostGraduate Medical School (Abram 1985b, 96). Another leading American light whose career spanned much of the twentieth century was Alice Hamilton, an industrial toxicologist, who first publicized the dangers of industrial pollution. Hamilton had a rocky start to her career, chafing at the limited clinical opportunities available to firstyear residents at the New England Hospital. She did not, however, turn her back upon the feminist network. For many years she was a member of Jane Addams’s famous Hull House social work project in Chicago, which provided health, welfare, and cultural services to impoverished immigrants. Trained as a bacteriologist and pathologist, Hamilton fearlessly entered mines and factories, using her upper-class mannerisms and femininity to shame factory owners into allowing her to investigate lead, TNT , and benzene poisoning. Her textbook, Industrial Toxicology, became the standard, and her work was so distinguished that in 1919 she became the first woman to receive an academic post at Harvard, as Assistant Professor of industrial medicine. To reassure Harvard’s board members, she consented not to insist upon entry to the Harvard Club and football tickets, as was her privilege as faculty. Although she was raised in one of the wealthiest families in Fort Wayne, Indiana, her work in industrial medicine exposed her to the ravages of industrialization and radicalized her views. In later years, Hamilton gave public speeches supporting pacifism, recognition of the Soviet Union, birth control, and civil liberties, and she was rewarded with the “glorious” distinction of gracing the FBI watch-list into her nineties (Sicherman 1984, 1–6).

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Finally, Doctors Helen Taussig and Virginia Apgar were two leading scientists whose work in the field of child health had immeasurable impact upon twentieth-century medicine. In 1945 Taussig and her surgical associate at Johns Hopkins Medical School developed the Blalock-Taussig shunt, or blue-baby operation, which became the standard for the treatment of oxygen-deprived children. Unlike her male colleague, who was elected to the National Academy of Sciences for the achievement and named Professor of Surgery, Taussig was not promoted beyond Assistant Professor of Paediatrics until 1959. She was a superb clinical observer, despite her hearing impairment. In 1962 she was instrumental in keeping the dangerous drug, thalidomide, off the American market (Lopate 1968, 23; More 1999, 177–78).Virginia Apgar, an anaesthesiologist, was another innovator who contributed enormously to the neonatal unit. In 1952, she devised the Apgar score, a rating system for neonatal health that measures “respiratory effort, reflex irritability, muscle tone, heart rate and color” (More 1999, 180). European Connections No exceptional North American medical student during the nineteenth and early twentieth centuries considered her education to be complete without post-graduate training at a European institution. Top universities, hospitals, and clinics in France, Britain, Switzerland, Austria, and Germany set the standards for Western medicine and attracted students from around the world. Europe also led the way in opening its doors to co-education and female practitioners; of particular note were the women physicians of Czarist Russia, who, following their service in the Russo-Turkish War of 1877, were accepted in both private practice and government bureaucracies (Meyer 1997, 153). Those barred from Russian medical schools found their way to Switzerland, whose policies in the late nineteenth century were among the most liberal in the world. Ah, to be a female medical student in Vienna or Berlin in the 1880s, when the future appeared as a panorama of peaceful yet revolutionary transformation. In her colourful memoirs, Prussian-German physician Franziska Tiburtius described the three types of Russian women medical students. Unlike the North American and British medical pioneers, who shared similar bourgeois backgrounds and politics, the Russian contingent represented the class, ethnic, and ideological gulfs that would all too soon consume Europe and end this brief moment of intellectual coexistence. In Vienna or Berlin, women like the Blackwell sisters, Mary Putnam Jacobi, and Maude Abbott encountered aristocratic Russian gentry learning medicine to succour peasants on family estates and middle-class women, including Jews, with ambitions stunted by Czarist totalitarianism. The lat-

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ter included Fanny Berlinerblau, who later emigrated to the United States and practiced as Fanny Berliner at the New England Hospital for Women. However, it was the third group of Russians, termed “the Cossack Ponies,” who opened the eyes of young women from Kansas or Ontario. The Ponies were condemned (celebrated?) in the press for their “short hair, blue-lensed eyeglasses and short, plain black dresses sewn of shiny ‘umbrella-like’ fabrics.” These “nihilists” wore round sailor caps, smoked cigarettes, and wandered the streets en masse — the picture of the radical university student (Meyer 1997, 155). The young North American women who were amused, intrigued, or repulsed by these non-conformists were the feminist generation of physicians later condemned as antiquated by their successors whose self-identification as modern was belied by their conformity. In their memoirs and letters, the medical pioneers recalled their European days with great fondness. Elizabeth Blackwell contrasted her positive experiences at Geneva (she trained twice overseas) with her chilly reception in Philadelphia. Her sister Emily also took two post-graduate years of training in Europe (Abram 1985b, 73). The stellar performances of both Jacobi and Susan Dimock in turn opened doors for other North American women abroad as well as European women heading west. Jacobi was the first woman to be permitted to study medicine in France in 1868; indeed, initially she had difficulties thinking and lecturing in English when she returned to America. Quiet-mannered Susan Dimock spent three years at the University of Zurich. At her oral examination for her thesis on puerperal fever, it was publicly stated, “You have shown by your example that it is possible for women to devote themselves to the medical profession without denying your female nature” (Bonner 1988, 58–59). One of the shining lights of the New England Hospital, Dimock’s life and career were tragically cut short when she drowned in a shipwreck when returning to Europe (Drachman 1984, 106). These luminaries were only four of the estimated 800 American women who travelled to a German-speaking university for a medical education or specialized postgraduate training between 1870 and 1914. There are no similar statistics for Canadian physicians, but surely Maude Abbott’s international stature in pathology was due in no small part to her post-graduate training in Vienna, Berlin, and Britain. Ironically, it was the closed doors of North America’s inferior medical schools that impelled these ambitious women to pursue a first-class European degree, subsequently helping to raise the standards of medical care and training back home.

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African-American Physicians The middle-class composition of the American cohort of female physicians was challenged by another exceptional group of pioneers, AfricanAmerican women, who had a lengthy history as healers. They cared for their fellow slaves on plantations, served as midwives, and occasionally received formal apprenticeships. By the nineteenth century, “Negro women engaged in the general practice of medicine were frequently listed in plantation inventories as ‘Doctor’” (More 1999, 4). Rebecca Lee, trained at the New England Female Medical College in 1864, was the first African-American woman to achieve an M.D. She was followed by other graduates of the women’s colleges, notably Rebecca Cole and Susan Smith McKinney Steward. Although seven African-American medical schools were opened in the later nineteenth century, by 1914 only the Howard University School of Medicine in Washington, DC and Meharry Medical School in Nashville, Tennessee survived. By the 1920s, only 65 AfricanAmerican women were listed as practicing medicine in the American Census. While few in number, they were inspirational role models for their sisters. Pioneers tended to come from higher status families, which were able to provide their daughters with extended education. As Darlene Hine notes, “Outside of the professions of teaching, medicine and nursing, black women possessed scant opportunity for white- or pink-collar jobs as sales clerks, elevator operators, or typists. Ironically, they either entered the profession at the outset or remained mired in service occupations; there was little in between” (Hine 1985, 110). Some extraordinary figures, like former slave Eliza Anna Grier, were able to work themselves through medical school. African-American female medical graduates found even fewer opportunities for residencies and other hospital appointments than their white colleagues due to segregationist policies. Nevertheless, they were able to give back to their communities, organizing hospitals and nursing schools and providing tenement services (Hine 1985, 112). These activities were formalized with the creation of a national sorority founded by Howard University students and alumni, Alpha Kappa Alpha, which established health programs in Mississippi from 1935 to 1942 (More 1999, 110). Unlike many Canadian feminist physicians, whose preoccupations with eugenics, temperance, and immigration policies betrayed their racist tendencies, the founders of the New England College and the Woman’s Medical College of Pennsylvania, who accepted integration, demonstrated their more consistent dedication to social equality and civil rights.

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Challenges and Resistance Prisoners of Love: Familial Obstacles In 1910, Abraham Flexner found it “ironic” that just as American medical schools were opening their doors to women, fewer and fewer were taking advantage of the privilege (Duffy 1979, 277). Certainly the numbers supported his claim. In 1880, almost 3 per cent of American physicians were women. Ten years later, the number increased to 4.4 per cent. Women made up 10 per cent of all students in co-educational programs by 1894, and almost 20 per cent of medical graduates in the United States by the end of that decade were women. Yet this positive trend did not last. By 1904, only 4 per cent of the American graduates were women, and this number fell to 2.6 per cent by 1909. This number would remain in the single digits until the mid-1970s, except for a brief postwar peak at the end of the 1940s. The situation was even less promising for Canadian women. In 1891, 76 or 1.7 per cent of Canadian physicians were female. This number grew slightly to 2.7 per cent in 1911 and then fell back to 1.8 per cent in 1921. By 1941, there was slight growth: 384 women made up 3.7 per cent of Canadian physicians. Not until the 1980s would more than one-third of physicians in either country be female (see Table 6.1). What was happening to thwart the ambitions or otherwise discourage female medical school applicants? There were numerous anti-feminist diatribes published by conservative physicians, clergymen, and others, as well as regulations and quotas established to keep them out of medical schools. However, the most silent, nearly invisible, and effective barriers were the ones imposed by those closest to the ambitious and intelligent — their families. Family members, especially mothers and fathers, encouraged, discouraged, prodded, directed, threatened, and manipulated the life expectations of their daughters. Those who could even conceptualize, let alone strive for a medical career were a very limited group. External factors in the nineteenth century world worked to quash the enthusiasm of even the most supportive parents. There were the streets, for one thing. The rhetoric of the Victorian “lady on the pedestal” belied the very real undercurrents of danger that confronted women in public spaces. These were no less real for women physicians who, as part of their practice, had to deal with night calls, often in seedier urban areas. Before she was able to purchase a horse and buggy in 1865, Marie Zakrzewska, for instance, always travelled with the messenger who called for her or with the local Boston policemen, who would accompany her to the limits of their beat (Walsh 1984, 396). Not that policemen were necessarily safe; Elizabeth Blackwell was accosted by a policeman while hurrying to an emergency call. After a theatrical appeal to his “chivalry,” she was able to rely on his assistance on future forays through the streets of New York.

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TABLE 6.1: Women Physicians in the United States and Canada Year

Grad Class US

CANADA

Med Students US

CANADA

MDs US

1870

5441

1880

2.8%2

1890

4.4%2 76 or 1.7%11

1891 1894 1890s

10% (co-ed classes)1 15-20%3

848 in 72 co-ed, 541 in 7 women’s schools1 73821

1900 1902

1280

1904

254 or 4%5

1905

4%3

1909

162 or 2.6%5

4

196 or 2.7%11

1911 1915

Other Statistics

CANADA

2.6%

3

152 or 1.8%11

1921 1926

992

1927

5.4%5

1929–40

less than 4%5

4

384 or 3.7%11

1941 1942

6%

6

5% (U. of Ottawa grads)7

1945 1949–50

595; either 10.7%8 or 12.1%5 9%6

1950 1959–60

405 or 5.7%

8

6%7 13%6

1960

10%6

1968 1969–70

700 or 6.8%

8

18%6

1970 1971

8.3%

9

9% (U of Ottawa grads)7

8

1974–75

1706 or 13.4%

1979–80

3497 or 23.1%8

1980

43.8% (U, of Ottawa grads)7 37%

6

33+%7

1981 1984–85 1989–90

4898 or 30%

8

5197 or 33.9%

19% Cdn. psychiatrists10 8

1996–97

44% 46%6

1990 1994–95

7

6216 or 39.1%8 6614 or 40%

28% Cdn. psychiatrists10

8

Note: Table 6.1 is compiled from a variety of sources, some of which listed absolute numbers of women, while others listed the percentage of women as part of the total graduates, medical students, or MDs. This table lists both figures. Sources: 1Moldow 1987, 6; 2Furst 1997, 221; 3Moldow 1987, 15; 4Chafe 1972, 90; 5Duffy 1979, 277–78; 6Duffin, fig. 9; 7 Gorham 1994, 184–85; 8More 1999, 221; 9Roby 1975, 171; 10Gold et al. 1995, 23; 11Strong-Boag 1980, 221, n. 29.

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Canadian cities had similar dangers. Maria Angwin went unchaperoned to the disreputable parts of Halifax at night, armed only with a hatpin (Hacker 1974, 78). Zakrzewska also had to face an angry mob after a woman died in childbirth shortly after her infirmary first opened: “An immense crowd collected,” she recounted, “Armed with pickaxes and shovels, they demanded admission, shouting that the female physicians were killing women with cold water. The neighbourhood police ... ordered the crowd to disperse, telling them that they knew the doctors ... treated the patients in the best possible way....” The chilly reception the medical pioneers experienced in medical school continued as they faced a distrustful public. Zakrzewska could not find rooms to rent to open her practice when she returned to New York in 1856. She was equated with the notorious “Madame Restelle,” the city’s most famous abortionist (Abram 1985b, 86, 82). Was this a career for a respectable daughter? Just as some medical pioneers recalled the support they received from their families, others recounted the opposition. Zakrzewska was rewarded for undertaking medical studies in a strange new country and language with a “devastating” letter from her father in Germany “denouncing” her career decision (Abram 1985b, 84). Only strong words from Elizabeth Blackwell and the support of her friends convinced Zakrzewska to defy parental authority. Similar paternal opposition was experienced by a British medical pioneer, Sophia Jex-Blake; Virginia Woolf immortalized her experiences in Three Guineas (1938) as “so typical an instance of the great Victorian fight between the victims of the patriarchal system and the patriarchs, of the daughters against the fathers.”15 Zakrzewska and Jex-Blake, however, were success stories. Far more numerous were those who could not overcome family opposition or lack of resources. Families of limited economic means, in most cases, placed the careers of their sons above those of their daughters, hoping that the latter would make “good” marriages or remain at home to support aging parents. The unconventional profession of medicine was not conducive to securing an eligible husband. In the nineteenth century, it was estimated that only one-fifth to one-third of female practitioners married, and many did not continue to practice. Elizabeth Smith, despite her celebrated struggles to be part of the first class at Kingston’s Medical College for Women, did not continue practicing medicine after her marriage to Adam Shortt and the arrival of her children, although she maintained interests in philanthropy, suffrage, and public health (Strong-Boag 1980, 30–32). The conflicting goals of domesticity and career were familiar to medical women. Dr. Caroline Winslow’s journal, Alpha, published this comment by another female physician in 1886: “A woman who has before her the broad avenues of usefulness, who has ambition and energy to develop her

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powers, will not be satisfied to tie herself down in the soul-cramping marriage ... [woman’s] highest duty to herself and humanity demands her full development as a Woman, not as a Wife or Mother” (Furst 1997a, 231). This was an opinion expressed in the safe haven of a like-minded few and was certainly not part of popular discourse in North America at the end of the nineteenth century. Public opinion of the female doctor was formed or shaped in the literature of the Gilded Age, where the woman doctor was an archetypal New Woman. In the 1880s and 1890s, women’s journals and biographical dictionaries introduced notable medical women to the public, while stories of female physicians became a minor fictional genre. Mark Twain (The Gilded Age, 1873), Henry James (The Bostonians, 1886), Sarah Orne Jewett (A Country Doctor, 1884), Elizabeth Stuart Phelps (Doctor Zay, 1882), and William Dean Howells (Dr. Breen’s Practice, 1881) narrated the adventures and tribulations of the female doctor. The fictional protagonists’ failure at domesticity illuminated the “doctress’s” ambiguous position in Victorian society. While portrayed as ladies, and “by no means mannish,” they were unlucky at love (Furst 1997a, 230; Moldow 1987, 8). In A Country Doctor, Jewett condemns Nan Prince, her beautiful, vivacious, and courageous heroine to spinsterhood in a sacrifice to eugenics; Nan fears her dead mother’s mental instability will repeat itself in her potential offspring. Apparently the rags-to-riches scenario applied only to plucky young American males. In Canadian fiction, the Nan Princes grew up to be “L’il ole Miss Doc,” the heroine of a serial published in Chatelaine in the 1930s. L’il ole Miss Doc Parkins was thin, gruff, and post-menopausal, yet secretly tender-hearted — in many ways she was a secular nun (Strong-Boag 1988, 185). This was consistent with the popular perception of women doctors as “unsexed” or the victims of “some profound emotional disturbance, some secret grief, presumably a disappointment in love” (McGovern 1984, 438). The image persisted for decades. Leading Montreal paediatrician Alton Goldbloom betrays all the stereotypes as he recounts his training by a woman resident, Martha Wollstein: Martha was not overly feminine in either appearance or dress. In the parlance of the day she was a “hen-medic.” Women in our medical schools today [1959] are attractive, youthful, well favored and for the most part marriageable. In the last century medicine was more commonly the refuge of the unmarriageable, the homely, the less feminine. It was the field of the frustrated female rather than of the dedicated woman. Martha was tall and osseous; she was somewhat hirsute, had a swarthy complexion, straight, unattractive hair.... She had considerable personal charm which a little judicious coif-

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fure, smart dressing and a touch of make-up could have somewhat enhanced — but not Martha.16

As late as 1971, American endocrinologist Estelle Ramey commented that the lady doctor was still popularly viewed as a “horse-faced, flat chested female in supphose who sublimates her sex starvation in a passionate embrace of the New England Journal of Medicine” (Walsh 1977, 249). This negative representation of women doctors was extended to all career women by the 1920s and 1930s and was followed by the postwar retrenchment into domesticity. The career “girl” and upper-class “flapper” of 1920’s mass culture and advertising did not threaten traditional domestic values; rather, they served to infantilize female professionals and offer freedom as a short-term escapade between college and wife-and-motherhood. Intellectual prowess was sublimated into consumerism. As The Ladies Home Journal effused in 1929, “Homemaking is today an adventure — an education in color, in mechanics, in chemistry.” Who, in fact, needed to choose medicine when they could choose ammonias to clean their iceboxes? For those who remained to be convinced, there were instructive novels like the best-seller This Freedom (1922), which condemned career women as “traitors to their sex” and declared that “the peace of the home ... rests ultimately on the kitchen.” The cultural attack became a political attack during the Depression, when those women who had jobs were accused of stealing them from unemployed men. Frances Perkins, a leading American welfare reformer, denounced “the rich pin-money worker as a menace to society [and] a selfish, short-sighted creature who ought to be ashamed of herself ” (Chafe 1972, 104, 99, 107). Perkins was appointed by Franklin Roosevelt as Secretary of Labour in 1933, the first woman ever to hold a federal Cabinet post, but apparently she saw no problem with taking that posting from a qualified man. Aspiring women medical students found it increasingly difficult to win family or community support for their ambitions within this conservative climate. The slight jump in admissions that took place during World War II demonstrated the confluence of institutional and societal factors that would not re-emerge until feminism again became a significant cultural force in the late 1960s and 1970s. Yet even the modern feminist revival could not easily overcome the familial, institutional, and structural barriers that faced and continue to face aspiring women medical students. Many faced additional hurdles that were built into the admissions process (beyond actual quotas). University entrance requirements such as GRE s and SATs, based upon high school knowledge, privileged recent graduates over mature students who might have interrupted their academic careers to raise families. Bursaries, scholarships, and other forms of financial assistance also were geared towards full-time study, again discriminating against

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those who had childcare responsibilities. The requirements of at least one undergraduate degree before medical school, as well as the long years of education and residency, acted as special deterrents to women, particularly since these years coincide with child-bearing. Lengthy and expensive education placed medical school out of the reach of working-class women (and most men) and their parents, but it also appeared a frivolous waste of money on a child expected to marry and raise a family (Roby 1975, 172–73, 175; Beshiri 1969, 6). In the early twenty-first century, this situation has not been resolved, despite the growing numbers of women in medical schools and as physicians. A survey of Yale medical graduates from 1922 to 1999 found that 35 per cent of those who never had children felt they had had to choose between medicine and a family, and 46 per cent believed either motherhood or medicine would suffer if they attempted both. Furthermore, an Ontario medical faculty survey showed that women cut short their maternity leaves to avoid unduly inconveniencing their colleagues and threatening their own career advancement. As Susan Phillips, Queen’s University (Elizabeth Smith Shortt’s alma mater) medical faculty member poignantly commented, “Perhaps a popular 1980s’ T-shirt slogan ‘Oops — I forgot to have kids’ should now read ‘I just never had time’” (Phillips 2000, 5). Whether it was parental and social antagonism or the conflicting demands of family and profession, women faced serious barriers to becoming medical practitioners, even without sustained opposition from medical school boards, professional societies, or competitive male colleagues.Yet, indeed, there was such opposition. Professional Resistance

Theories of Female Inferiority To justify its long and bitter resistance to female practitioners, the conservative male medical profession developed an elaborate ideology based upon spurious science. Of trans-Atlantic origins, it was, however, extremely influential, as an ideology developed by a dominant majority is likely to be. German professor Theodor Bischoff first enunciated the theory of the physiological inferiority of the medical woman in his tract published in 1872, in which he stated that women who attempted to study more than nursing and midwifery would damage their reproductive systems through excessive mental strain. Upper-class young women, Bischoff concluded, needed to protect their wombs with quiet domestic activities. He based his “findings” upon research conducted on female dogs (Meyer 1997, 158). More lasting damage was done to the cause of medical co-education by American gynaecologists Horatio Storer and Edward H. Clarke. Storer

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was appointed head surgeon at the New England Hospital for Women and Children but resigned over a dispute regarding his preference for interventionist surgery. With the vindictiveness of a disgruntled ex-employee, he retaliated with a tirade couched in “objective” pseudo-science. Since women were “subject to recurrent waves of mental and physical instability caused by menstruation, they could not be trusted to furnish medical assistance consistently and scientifically” (Vertinsky 1990, 121). Edward Clarke’s Sex in Education introduced the professional debate to the American and Canadian public. A professor of obstetrics at Harvard Medical School, Clarke published his polemic in 1873, one year after Bischoff ’s tract, as a reply to those who would make Harvard co-educational. Despite rapid and furious rebuttals by feminist writers, Sex in Education touched a chord in the nineteenth-century American psyche troubled and fascinated by the potential for domestic revolution: As far away as Ann Arbor, Michigan, it was reported that everyone was reading Clarke’s book. A local bookseller there claimed sales of 200 copies in a single day, chortling: “the book bids fair to nip coeducation in the bud.”... Years later, M. Carey Thomas, the first president of Bryn Mawr College, recalled that “we did not know when we began whether women’s health could stand the strain of education. We were haunted in those days, by the clanging chains of that gloomy little spectre ... Sex in Education.” (Walsh 1977, 124)

Paradoxically, Clarke joined the consulting staff of the New England Hospital in 1873, and Superintendent Marie Zakrzewska displayed her superb diplomatic skills by maintaining her hospital’s association with this leading Boston physician for five years. Perhaps she felt that her actions — preserving the standards and professional integrity of her woman-run institution — would be louder than his words. Nevertheless, his words were welcome fodder to those who wished to maintain an androcentric discipline (Drachman 1984, 55). The Canadian contribution to this conservative debate failed miserably to measure up to the elegance of Clarke’s prose or even to the anthropomorphic meanderings of Bischoff ’s essay. The Canadians, by comparison, used neither logic nor evidence beyond that of a (polite) schoolyard bully. Dr. Francis Wayland Campbell, Dean of Medicine of Montreal’s Bishop’s University (the school from which Maude Abbott was embarrassed to graduate) intoned, “They may be useful in some departments in medicine but in difficult work, in surgery, for instance, they would not have the nerve. And can you think of a patient in a critical case, waiting for half an hour while the medical lady fixes her bonnet or adjusts her bustle” (Hacker 1974, 154). The Canada Lancet piped in, “As wives,

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mothers, sisters and dainty little housekeepers we have the utmost love and respect for them; but we do not think the profession of medicine, as a rule, a fit place for them” (Backhouse 1991, 161). Female “daintiness,” as an essential component of Victorian gentility, was raised by Edward Clarke, John Ware, and others as a fragile attribute which would be brutalized by the “ghastly rituals and blood and agony” of the dissecting room and the anatomy class (Morantz-Sanchez 1985a, 63). In The Medical Profession, British physician W. Rivington criticized the “horrible and vicious attempt [of women medical students] deliberately to unsex themselves — in the acquisition of anatomical and physiological knowledge the gratification of a prurient and morbid curiosity and thirst after forbidden information — and in the performance of routine medical and surgical duties the assumption of offices which Nature intended entirely for the sterner sex” (quoted in Manton 1964, 66). Should women be brutalized in this fashion, Rivington and others argued, civilization would suffer, since it was the delicate nature of women that kept men respectable (Morantz-Sanchez 1985a, 63). The logical shortcomings of this theory were two-fold, which explained its lack of influence relative to that of inherent physiological female disability. For one thing, the conservative writers had no objections to Florence Nightingale and her middle-class nurses encountering and dealing with the most brutal and disgusting aspects of disease and trauma (Vertinsky 1990, 123). After all, the Crimean War, where Nightingale introduced professional nursing, was certainly no picnic on the green. Secondly — and this was an argument put forward by advocates of female physicians — since the delicate flowers of female humanity were often too overcome with embarrassment to expose themselves to male physicians, there was a need for female ones. As an Atlanta physician wrote in 1854 (and he would have been familiar with the Scarlett O’Haras and Melanie Wilkeses of the antebellum South), female physicians were essential to “the safety and happiness” of a large portion “of the most refined and lovely women.” Every practitioner, he wrote, almost daily saw cases that had “become incurable on account of the reluctance of females to submit” to examination. Most female diseases, he asserted, could not be cured because of “the almost insuperable objections of the fair sufferers, to the inevitable exposure of their sexual secrets to a male physician” (Duffy 1979, 274). Perceptions of the inherent inferiority of female practitioners have persisted into the twentieth century. In 1949, American hospital chiefs of staff were quoted as saying, “Women doctors are emotionally unstable ... they talk too much ... they’re always on the defensive ... they get pregnant ... if she is married and childless she is frustrated ... or if she raises a family she is neglecting her practice” (Walsh 1977, 245).

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Theories of a Feminized Profession In 1897, anti-feminists were confronted with very unsettling news. The American Commissioner of Education reported that far from suffering after decades of general co-education, the nation’s young women were winning a disproportionately large number of academic prizes. Even worse, the 1905 report warned that should this trend continue, young men would be forced to buckle down and work and “abandon their manly ways.” “To put the matter in very simple terms,” noted Professor Armstrong, “the boy in America is not being brought up to punch another boy’s head, or to stand having his own punched in a healthy and proper manner” (Walsh 1977, 187). The big boys in the medical profession shared these fears. Growing numbers of successful female colleagues and competitors could feminize the profession, reducing salaries and also reducing certainties about sexual roles. The late nineteenth century was an age of accelerated social changes brought about to a great extent by technological transformations. Traditional crafts had been degraded into industrialized tasks, which could be performed by men, women, or even children, while the women’s movement, public education, and other reforms were equalizing other disparities between the sexes. Subsequently, many of the conventional guideposts of masculinity were in question. The practice of medicine was not immune from these transformations. The decline of heroic therapeutics and the discovery of anaesthetics undercut the characterization of the physician as a physically strong, emotionally detached provider of health through pain. Furthermore, treatments based upon bedrest, hygiene, good nutrition, and the healing power of nature replicated the traditional womanly arts of nursing, child-rearing, and empathy (Morantz-Sanchez 1985a, 60). It is therefore no small wonder that so many male physicians strenuously resisted the admission of women to the ranks of physicians. As the feminist Woman’s Journal commented, the men complained that “Nurses are docile, submissive, and keep their proper place, while once [you] let a woman study medicine and she thinks her opinion is as good as a man’s” (Walsh 1977, 143; emphasis in original).

Theories of Economic Threats There was also the very material concern that a woman physician’s pay packet would be at least as good as a man’s. By the 1850s, the lack of regulations for medical training and the proliferation of homeopaths, naturopaths, eclectics, and other irregular physicians led to an overcrowding of the profession in Britain and North America. This chaotic free market led to the organization of the AMA in 1847, the British Medical Association in 1853, and the College of Physicians and Surgeons of Ontario in 1869 (Vertinsky 1990, 113–14; Gidney and Miller 1984, 65). Over the subsequent decades, members of these associations fought to control numbers, raise

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standards, protect incomes — and keep women out. Female practitioners were a particular problem because there remained a popular consensus that women were by their nature healers and more sensitive to the needs of other women and their children. This perception posed an economic threat to the emerging male specialties of obstetrics and gynaecology just as they successfully supplanted traditional midwifery. It also gave serious concern to general practitioners since the first confinement was often a family’s introduction to a medical practice. As a physician complained in The [British] Lancet in 1862, “Are they to enter into hard and public competition with us?” Another added, a “body of female doctors attending women would displace an equivalent number of male doctors or diminish their incomes” (Vertinsky 1977, 120). By the end of the nineteenth century, financial gain also motivated hospital physicians who prevented women from attaining positions on staff. As Ellen More concluded, senior physicians were interested in monopolizing the private fees they could charge wealthier in-patients for hospital procedures, particularly surgery. Should there be women physicians on staff, female patients were much more likely to request them for gynaecological procedures, many of which, “such as the removal of ovarian cysts and uterine fibroids, and the repair of cervical or perineal lacerations, were among the most expensive of the typical medical fee schedule” (More 1999, 107–08). When male physicians faced another period of economic uncertainty — during the recessions of the 1890s — they blamed an overcrowded profession and moved to end what they considered to be the “experiment” of co-education, just as female physicians were finally breaking into medical societies and attaining hospital appointments (Moldow 1987, 15). Barring Entry to Nineteenth-Century Medical Schools When invoking theories of female delicacy and disability was insufficient to prevent the proliferation of women physicians, the male medical establishment used a variety of techniques, at every level of medical education and practice, to exclude women from the profession. The first line of defence was to bar their entry to medical schools. It was only through persistent petitioning and lobbying of powerful allies that the medical pioneers were able to break into the orthodox medical schools. Emily Blackwell applied to Chicago’s Rush Medical College and was rejected 11 times before she was finally admitted in 1852. After the Illinois Medical Society objected, however, she was thrown out again after only one year of study. Ann Preston also repeatedly lobbied the Philadelphia medical schools to open their doors to women. When, in 1856, she and other women were permitted to attend clinical lectures at the Blockley

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Almshouse, one of the instructors, Dr. Hayes Agnew, tried to embarrass them away by displaying a male patient in the nude. When this didn’t work, Agnew took his complaints to the hospital board, which ended the co-educational experiment (Abram 1985b, 76, 89). The ease with which individual faculty or students could reverse the decision to allow medical co-education demonstrated the fragility of each female advance. Financial considerations — falling male enrollments — opened the doors to women in institutions like Georgetown and George Washington University in the Washington, DC area in the 1880s, but these gains were only short term (Moldow 1987, 2). Neither the grousing of individual lecturers nor the greediness of hospital boards, however, did the most lasting damage to the cause of women in the American and Canadian medical profession. That came from actions affecting the very heart of medical therapeutics, education, and professionalization in North America, following the publication of the Flexner Report in 1910. Abraham Flexner, whose brother Simon was one of the original instructors in the medical school of Johns Hopkins University, used that research-oriented institution as the model of medical education when he wrote his report, which was sponsored by the Carnegie Foundation. Flexner concluded that medical care could not, in a progressive century, continue to be tied to parochial pettiness, archaic therapeutics, and ephemeral arts. The modern physician, rather, should be trained within the context of twentieth-century corporate industrialization — to be, in short, comfortable in the boardrooms of US Steel. This required massive and ongoing capital investments in hospital laboratories and surgical theatres, far beyond the means of most private medical colleges — particularly unorthodox institutions and those catering to women, the working classes, and students of colour (Moldow 1987, 15). Flexner devoted one section of his report to “The Medical Education of Women,” using the model of Johns Hopkins, which was inaugurated as a co-educational institution, as the ideal. He argued that money poured into separate women’s colleges only supported inferior institutions and should instead be allocated to university-affiliated co-educational medical schools. Flexner did not openly oppose the education of women, noting that should female institutions be closed, women physicians must be able to obtain internships on the same terms as male graduates. He put forward, however, an overly rosy and simplistic perspective of the opportunities for female medical education in 1910 North America: Medical education is now, in the US and Canada, open to women upon practically the same terms as men. If all institutions do not receive women, so many do, that no woman desiring an education in medicine is under any disability in finding a school to which she

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may gain admittance ... the Johns Hopkins, if she has an academic degree; Cornell, if she has 3/4s of one; Rush and the state universities, if she prefers the combined 6-year course; Toronto on the basis of a high school education; Meridian, Mississippi, if she has had no definable education at all. Now that women are freely admitted to the medical profession ... they show a decreasing inclination to enter it.... Their enrolment should have augmented, if there is any strong demand for women physicians or any strong ungratified desire on the part of women to enter the profession. One or the other of these conditions is lacking — perhaps both. (Quoted in Lopate 1968, 15–16)

Flexner failed to take into consideration the chilly climate that women medical students and graduates experienced in co-educational programs, in private practice, and within the medical community throughout their careers. Separate women’s schools provided a much-needed supportive atmosphere, the importance of which was not fully appreciated until the schools disappeared. What the Flexner report did accomplish, through the selective allocation of funding from the Carnegie and another philanthropic institution of American corporate hegemony, the Rockefeller Foundation, was to ensure the demise of marginal institutions, like the eclectics, the African-American colleges, and the women’s colleges, which could not afford stainless steel laboratories and state-ofthe-art equipment (Moldow 1987, 15). Unlike Europe, where the raising of standards of medical education did not result in the elimination, but rather the growth, of women students, the corporate revolution in early twentieth-century North American medical schools supported the aspirations of middle-class white males to the detriment of all others (Bonner 1988, 72).

The Nineteenth-Century Medical School Experience Medical education, conservatives argued, had a brutalizing effect upon women, which threatened their essential domesticity and ability to combat inherent male brutality. Both of these arguments were based upon one truth: it was not the exposure to nude models nor unpleasant bodily functions that was brutalizing, but the behaviour of many of the male students and faculty who were not idealized Victorian gentlemen but brutes, thugs, and bullies. The first women entering co-educational programs were often met with “yells, boos and hisses on all sides” (MorantzSanchez 1985b, 113). When Elizabeth Blackwell spent the summer of 1848 at Philadelphia’s Blockley Almshouse, she encountered opposition and sabotage from young residents who refused to leave casenotes at the head of patients’ beds, as was the customary practice. When her sister, Emily, fol-

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lowed her into the medical profession, Elizabeth warned, “A blank wall of social and professional antagonism faces the woman physician that forms a situation of painful loneliness, leaving her without support, respect or professional counsel” (Abram 1985b, 73, 76). In Canada, a country that prided itself on the fiction of gentility superior to Americans, the situation was at least as bad. When in 1870 the Toronto School of Medicine finally surrendered to the petitions of women applicants and admitted Emily Stowe and Jenny Kidd Trout to one session of lectures, the two women “attended classes amidst unrelenting, uproarious manifestations of sexual harassment. Students and faculty alike engaged in classroom discussion deliberately designed to emphasize vulgarity. Filth and garbage were piled upon the women’s seats on numerous occasions; moreover, the anti-female graffiti plastered upon the classroom walls was so vile that the caretakers had to white-wash them four times that session” (Backhouse 1991, 162). At Queen’s University School of Medicine in 1882, following a successful co-educational experience the previous term, medical pioneers Elizabeth Smith Shortt, Alice McGillivray, and Elizabeth Beatty faced a “ribald” group of students and faculty: “Dr Fenwick, the physiology lecturer, had been pleasant and easy the previous year [but had done] a complete volte-face and was now saying that ‘he had no respect for women who studied medicine, and would not have them in his house’ [and gave] the students every opportunity to be lewd and rude and crude” (Hacker 1974, 63–67). When this behaviour failed to dislodge the women, the male students threatened to leave the College en masse and move to Toronto’s Trinity Medical School if the women were not thrown out. The Kingston community demonstrated their support for women by sponsoring separate classes and opening a separate Medical College for women with the financial backing of Toronto pioneer Jenny Kidd Trout and others. The Kingston College only survived until 1895. While it succeeded in graduating 30 students, it could do little to further medical co-education in Kingston or in Ontario (Strong-Boag 1979, 118). Even at august Johns Hopkins Medical School, brilliant women students faced harassment and abuse. When Florence Sabin and Dorothy Reed Mendenhall came in first and second in their class, an achievement that allowed them to have their choice of residency rotations, both resisted academic pressure to allow a male student to walk the halls with Sir William Osler in the most coveted area of medicine. Consequently, the two women faced the wrath of the hospital superintendent, Dr. Henry M. Hurd, “who made an ugly scene and accused them of ‘abnormal sex interests,’ for their willingness to work on the male colored ward” (MorantzSanchez 1985b, 167). When threats, insults, and snubs failed to intimidate female medical aspirants, there was always that standby of patriarchal hegemony — out-

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right violence. The riot was one popular form employed by medical students. At the University of Edinburgh, when Sophia Jex-Blake and four other women were reluctantly admitted to classes separate from the men, the gentlemen engaged in The Riot at Surgeon’s Hall on November 18, 1870, in which a huge mob of male medical students tried to prevent the women from entering their anatomy class by blocking “the women’s entrance into the lecture theatre and as a gratuitous insult [introducing] a sheep into the classroom, saying that they understood that inferior animals were no longer to be excluded.” In her memoir, Jex-Blake wrote that she and her colleagues “fought a true battle of liberty against tyranny [defending themselves] with the constant vigilance of the soldier in time of war” (Gorham 1994, 186; Nettels 1997, 240). An earlier riot at Harvard had been more successful: in 1850 the board admitted a woman and three African-American men to the medical school; the ensuing disorder ended that experiment in co-education, which was not again attempted until 1940 (Duffy 1979, 273). These collective behaviours, which were not identified as sexual harassment until the late twentieth century, included actions ranging from pointed sexual remarks to outright sexual assault ... Micro-inequities range on a continuum from unconscious professional slights or “invisibility” to conscious put-downs, exploitative assignments, and inequitable allocation of resources. To call these subtler manifestations of harassment micro-inequities is not to suggest that their effects are trivial. While they usually are not actionable, they can substantially reduce professional performance, visibility, status, and, most insidiously, self-esteem. Coping with these accumulating stressors has been likened to lifting a “ton of feathers.” (More 1999, 230)

This “ton of feathers” clarifies the situation aspiring women physicians faced in the nineteenth century. First, sexual harassment explains the dwindling pool of applicants Flexner identified in his report. If bright women could become nurses, teachers, and other professionals without facing such abuse (although harassment and exploitation occurred in acceptable careers as well), they were more likely to choose those careers. Second, the high proportion of women physicians who never married may have been partly due to the extra sacrifices they made, beyond the stresses of medical practice itself, to prove their professional competence. Finally, male doctors complained that women patients preferred women physicians, particularly for gynaecological problems. Given the less-thangentlemanly, and widely publicized, behaviour of many medical students,

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was it any wonder that respectable and apprehensive women patients sought the examination tables of female physicians?

Barring Entry to Medical Societies For those intrepid medical pioneers who withstood the medical school initiation, there were further obstacles, one of which was an unwelcoming community of fellow practitioners. As Harriot Hunt, the first American practicing physician, recalled, “If I had had cholera, hydrophobia, smallpox, or any malignant disease, I could not have been more avoided than I was” (Walsh 1977, 2). More organized opposition emerged from the state and provincial medical societies, which after the mid-nineteenth century were using legislation and admitting examinations to ban the practices of irregulars. This placed women physicians and members of other minorities in a nasty “catch-22” situation. Barred from orthodox medical schools, they acquired their education at homeopathic or eclectic colleges or at women’s medical colleges. Those degrees, however, were rejected by the medical societies as inferior, despite the fact that many of their graduates were better trained than some of their white male colleagues (MorantzSanchez 1985a, 62). This situation even extended to women’s “special calling”— the treatment of children. The American Paediatric Society, founded in 1888, banned women members until 1928. The AMA barred women from full membership from the 1850s to 1915, despite the fact that a substantial proportion of its members supported the entry of women. When Margaret Cleaves, appointed to the new position of superintendent of women’s wards at the Harrisburg (psychiatric) Hospital in Pennsylvania, attempted to attend the 1881 AMA meeting in Toronto, she encountered “such petty quibbling” that she was not permitted to attend as an official member, although her counterpart for the men’s wards was (More 1999, 112; Duffy 1979, 275; McGovern 1984, 442). Emily Stowe’s relationship with the Ontario College of Physicians and Surgeons demonstrated the absurdity of the situation. First rejected by the University of Toronto for a regular medical education, she graduated from The New York Medical College and Hospital for Women, a homeopathic institution, in 1867. She set up practice in Toronto and repeatedly applied for admission to the University of Toronto so that she could qualify for licensing by the College of Physicians. She was rejected by the university on the basis of gender and fined $100 every year for practicing without a licence. Nevertheless, she developed a thriving practice and was one of the leading physicians of the city. When, after 20 years, the College attempted to bring Stowe into the fold, thereby cementing the legitimacy of its licensing authority, she spurned the offer. She considered the condition of submitting to full oral and written examinations to be an insult

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and continued to practice medicine without a licence (Backhouse 1991, 161–63). Mary Roth Walsh has made the point that, despite the inequities associated with the medical societies, their existence actually benefitted women who wanted to enter the medical profession: “It is easier to overcome a series of known obstacles than tilt at a series of shadowy spectres” (Walsh 1977, 14–15).

Legal Harassment Legal harassment of female physicians was another tool of the male medical establishment and other anti-feminists. When a Toronto servant, Sarah Ann Lovell, died from an abortion in 1879, a coroner’s inquest led to charges being laid against Emily Stowe. This was particularly serious since one of the libels used against women physicians was that they administered abortions. Stowe, an outsider in the medical community, could not expect assistance from her colleagues. She faced a very hostile coroner and physician-witness, whose evidence was primarily anonymous hate letters. With a courtroom filled with her feminist supporters — all respectable members of Toronto society — and the presence of a fair-minded judge, Stowe was acquitted (Backhouse 1991, 163). Mary Dixon-Jones’s highly publicized malpractice case, however, had a less successful outcome. Unlike Stowe, Dixon-Jones, by virtue of her personality and professional interests, had distanced herself from the feminist community and found the male supporters she had assiduously cultivated evaporate. Her career and reputation in shambles, Dixon-Jones never fully recovered (MorantzSanchez 1997, 189). Barring Entry to Twentieth-Century Medical Schools The nineteenth-century moves to force women out of the medical profession through intimidation, legislation, and organization were crude. The twentieth-century anti-feminists, who learned to keep their enemies close, were far more effective. Educational reforms and the appearance of co-education had succeeded in destroying the women’s colleges, leaving women students at the mercy of professional boards. It did not take long for the tide to turn against them. In 1908, the formerly liberal College of Physicians and Surgeons of Boston signalled the new/old order of things when it invited G. Stanley Hall, an internationally renowned anti-feminist, to address its graduating class. Hall did not disappoint the College, invoking the hoary stereotypes of “feminine hysteria and menstrual disability” (Walsh 1977, 203).Yet this was an antiquated attack: overt, publicized in the press, open for debate. Far more effective were the “shadowy spectres” to which Walsh referred — the whispers in the halls, the closed door meetings, the private consultations in restricted clubs that were the substance

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of the medical school quota system. Women were not, of course, the only targets and victims of admissions quotas, only the first. In the United States, they saw their numbers drop severely in the first decade of the new century; African Americans felt the chill in the 1910s, and Jews in the 1930s (Walsh 1977, 194). Jews posed a particular problem to the white male establishment because they insisted upon applying in disproportionately large numbers and with disproportionately first-class grades. Consequently, in Canada especially, quotas were applied to Jewish applicants well into the 1960s at various institutions. With respect to women, the even chillier climate of the early twentieth century produced its intended results. Only 2.3 per cent of American medical school students were women in 1912, a precipitous drop from a peak of 21.4 per cent in 1894 (Walsh 1977, 194). In the province of Ontario, with the demise of the two women’s colleges by 1906, only the University of Toronto admitted women until the 1920s, and while no qualified applicant, by university policy, could be refused, the proportion of women remained at a fairly constant 10 per cent of the student body by the 1930s (Gidney and Millar 1996, 37). As hard times hit during the Depression, however, another Canadian co-educational institution, the University of Manitoba, made the minorities pay. From 1932 to 1944, Dean A.T. Mathers used a sophisticated quota system to satisfy his own bigotries. The first and largest targets were the Jews, who fell from 28 per cent to 9 per cent of each class, as they were now grouped in a (non-preferred) list. A second list was created for women, while a third consisted of Ukrainian, Polish, Mennonite, and other ethnic minorities not to Mathers’s liking. The fourth, “preferred” list was for Anglo-Saxon, French-Canadian, and Icelandic students. A quota was established for the first three lists, with the remainder of seats being awarded to the preferred, regardless of the academic achievements of the latter. At a public inquiry, the university denied racism and argued that its admission criteria “went far beyond mere scholastic requirements [to include] intelligence, scholarship, character, and physical and ethical fitness.” (Presumably there had to be some benefits for family memberships to restricted golf and tennis clubs). Manitoba’s quota system was well known. As a female graduate from the early 1940s recalled, the faculty “took 60 men. Thirty girls applied and they took four: one Jewish, one French-Canadian and two Anglo-Saxons” (Kinnear 1993, 135). When the quota system was made public in the Manitoba Legislative Assembly in 1944, the medical school was forced to amend its standards to read, “the selection shall be made without regard to the racial origin or religion of the applicant,” yet quotas directed towards women remained. This was justified with old and circular arguments. To the Manitoba Legislature, Mathers argued that “a deterring factor in admitting female students is that some of our hospitals refuse to

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accept women interns” (Nitychoruk and Nicolle 1994, 8–9). Within the medical school, Mathers was generally understood to consider it “a waste of college time, space and money to educate women in medicine [who would be] taking the place of a good man” (Kinnear 1993, 136). The University of Manitoba was not alone in its policies in the 1940s. During World War II, the absence of male applicants forced many schools to open their doors to women, and the women graduates of 1949 were the highest percentage they would be (12.1 per cent) until the 1970s (More 1999, 186). This turned out to be, however, just another short-term wartime solution. By the late 1940s, American medical schools returned to the standard quota of 5 per cent for female admissions, 70 per cent of all hospitals rejected female interns, and medical societies such as the New York Obstetrical Society continued to ban female members (Chafe 1972, 184). Rosie had demonstrated that she could build a missile; she just couldn’t deliver a baby. Women who entered medical schools under these strict quotas felt very fortunate and learned to keep their marginalized heads low. Dr. May Cohen, who graduated from the University of Toronto during the early 1950s, was “grateful” for being one of the 10 per cent admitted to that school: “We were not about to make waves and so accepted, without protest, sexist remarks [and] our apparent invisibility when references to the class were directed only at males” (Gorham 1994, 186).

The Twentieth-Century Medical School Experience The continued minority status of women in medical schools in the twentieth century perpetuated a climate of overt or passive hostility and discrimination. That women were admitted only by sufferance and took up the spaces of qualified men was an attitude shared by faculty and male students alike, and it persists to the present day.17 Consequently, as in the nineteenth century, female students were publicly humiliated with sexist comments and humour. Individual women occasionally challenged the harassment. At the University of Ottawa in the 1960s, a band of women students objected to the techniques of a pathology professor who interspersed his lectures with nude pictures, “including a cartoon showing a physician (male) screwing his female patient with the caption ‘what to do while waiting for the doctor.’” The professor defended his actions by stating that his lectures included many gruesome slides, and he was attempting to lighten things up for his (mostly male) students. The women asked why he didn’t tell “nigger jokes” since the majority of the class was white, and he became “quite belligerent” and complained to the chairman of his department (Gorham 1994, 190–91). Women medical students next faced the gauntlet of obstacles in their rotations, internships, and residencies. Bishop’s University ended coeducation in 1900 because Montreal hospitals refused to appoint female

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physicians in its clinics (Bacchi 1983, 21). In the 1920s, American women graduates were forced to secure internships wherever they existed, rather than within their preferred geographical locale. In 1925, one-half of all these interns trained in nine “widely separated hospitals, one of which was in the Philippines” (Walsh 1977, 223–24). By 1944, 21 per cent of hospitals in the United States had never employed a woman physician (Lopate 1968, 22). Women also faced more uncomfortable physical conditions in the hospitals, which often had a negative impact upon their training. There was the basic problem of physical space. Hospitals were constructed with the model of male physician and female nurse so that there were no separate sleeping or eating facilities for women medical students. The lack of accommodations became a justification for rejecting women from internships well into the twentieth century. Furthermore, in male-dominated rotations such as surgery, women students often found (and find) themselves excluded from significant post-surgery discussions taking place in the locker rooms (Gorham 1994, 193). At the University of Manitoba during the 1940s, women were not permitted to room at the interns’ quarters and had to eat with the nursing staff. Since the interns’ schedules were irregular, however, there were often no meals available for them. The women students’ relationships with the nurses were often strained, due to both groups’ ambiguous social status. Women physicians attempted to draw firm lines between their rank as physicians and the nurses as subordinates, while the nurses, also in the midst of elevating their status, were more likely to resent taking orders from other women than from men. Consequently, the two female groups within the hospital structure were rarely able to form common bonds. Female segregation very occasionally worked to the students’ advantage. At Winnipeg, distinguished gynaecologist Dr. Elinor Black gave private lectures on birth control to the women students in their common room, because “it was illegal to have such a lecture” in postwar Canada (Kinnear 1993, 136).

Glass Ceilings For those steadfast graduates who had weathered difficult medical school experiences, what could they expect in practice? It was unlikely to be the attainment of a senior academic position. Within the American medical school structure in 1965, women were clustered in the lower ranks of instructor, senior instructor, and occasionally assistant professor. Only 13 of over 1,000 department chairs in 78 American medical schools were women in that year (Lopate 1968, 20). By 1982, women comprised 3.5 per cent of full professors at American medical schools, while data for Canada were equally discouraging. A paltry 13.8 per cent of full-time faculty positions in Canadian medical schools were held by women, and these jobs were primarily at the lowest ranks (Gorham 1994, 185). By

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the early twenty-first century, the numbers are very slowly improving. In 2000, 10.7 per cent of women faculty in American medical schools were full professors (31 per cent were male) while fully 50.1 per cent of women faculty were assistant professors (35.9 per cent were male).18 Whether in medical institutions or private practice, women physicians on both sides of the border earn less than their male counterparts, regardless of specialty or years of experience (More 1999, 230). With remarkable similarity to the nineteenth century, women graduates continue to gravitate or be directed to the “special callings” of family medicine, paediatrics, obstetrics, and gynaecology, as well as psychiatry (Gorham 1994, 197), a specialty that included such luminaries as Anna Freud, Helen Deutsch, and Elizabeth Kilpatrick. Certainly the ability to sit quietly and appear empathetic while others relate their problems has been considered a female quality. Nevertheless, the specialties with more patient contact also provide more flexibility for women attempting to juggle family and career responsibilities, as well as emphasizing traditional feminine qualities. Women remain under-represented in the more “manly” specialties of neurosurgery, oncology, and biomedical engineering — areas with less patient interaction (the patients more likely to be either unconscious or enveloped by expensive space-age technology) but also more prestige and material rewards (Gorham 1994, 197–98).

Conclusion Have the elimination of the women’s medical colleges and the sustained marginalization of female physicians influenced the development of the medical profession in the twentieth and early twenty-first centuries? The increasingly right-wing orientation of much of the profession has been one consequence. By the 1920s, the “special calling” of public health and community medicine disappeared from the focus of the American profession, which subsequently rejected socialized medicine (Duffy 1979, 266). Canada’s government health insurance was instituted with varying degrees of reluctant support by the organized medical associations and continues to be threatened by underfunding or, rather, the direction of funding by governmental and professional bureaucratic elites. The two-tiered medical system that North Americans experience in the twenty-first century is likely to be characterized by ever-increasing gender stratification, with general practice as a woman’s area and technologically based specialties remaining a male preserve. At the same time, medical therapeutics has come full circle. Technology and pharmacology have not completely supplanted some of the tenets of the health reform movements from which the women physicians emerged. Concepts such as biofeedback, holistic

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medicine, and stress reduction acknowledge the healing powers of empathy, self-healing, and other components of the healing arts that feminist physicians first enunciated. In specialties such as oncology, for instance, the “male” innovations of surgery, chemotherapy, and radiation increasingly are employed alongside the “female” techniques of nutrition, meditation, and visualization. This integration of paradigms can only benefit medical therapeutics in the future. The spirit and resolve of the female medical pioneers were exemplified by Dr. Elizabeth Bagshaw, founding director of Canada’s first birth control clinic. After her retirement at the age of 95, rendering her Canada’s oldest practicing physician, Bagshaw recounted the challenges of attending medical school and establishing a practice at the beginning of the twentieth century. These challenges steeled her for the later struggles to offer birth control to indigent women over the vociferous objections of the local Catholic bishop and some of her male colleagues. Bagshaw described the bishop’s sermons in which he termed the clinic’s administrators “heretics and devils.” “I was a devil,” Bagshaw stated with a twinkle in her voice (National Film Board 1978). Certainly there were many “devils” that made lasting and vital contributions to the health of North Americans and to the advancement of women in the medical and other professions.

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Notes 1

2

3

4 5

6

7

8

Susan L. Porter, “Mrs. Mott: The Celebrated Female Physician,” Historic New England Magazine (Winter/Spring 2005): 11, http://www.historicnewengland. org/NEHM/2005WinterSpringPage11.htm. In 1998, Women’s College Hospital was amalgamated with two other Toronto hospitals by the provincial government, a measure that was reversed in 2005 by a subsequent government. Women’s College Hospital is again a freestanding institution designated a Centre for Excellence in Women’s Health. See The New Women’s College Hospital, “Our History,” 1–4, http://www. womenscollegehospital.ca/about/history4.html. Before the model of domesticity took hold in the early nineteenth century, “spinster” meant simply “a woman who spun” (cloth). Its subsequent derogatory connotation was of an unlucky or unattractive woman who failed to secure a husband. In the last 20 years, with increasing numbers of financially independent unmarried women in North America, the term has lost its bite. See Wild 1984 and the excellent National Film Board production, “Doctor Woman: The Life and Times of Dr. Elizabeth Bagshaw” (1978). Nor were Quaker fathers alone in their support. English medical pioneer Elizabeth Garrett (Anderson) noted in her autobiography that while her father had initially opposed her wishes to become a physician, he became her strong and persistent advocate in face of the injustice of institutional and societal barriers against her medical education; see Manton 1965, 77. British suffragist Josephine Butler described her consultation with Elizabeth Garrett: “I was able to tell her so much more than I ever could or would tell to any man ... Oh, if men knew what women have to endure and how every good woman has prayed for the coming of a change.... How would any modest man endure to put himself in the hands of a woman medically as women have to do in the hands of men? ... I pray to God that many Miss Garrett’s may arise.” The close ties between the women’s movement and medical education was exemplified in a charming story from Elizabeth Garrett: Emily (Fawcett Davies) noticed Millicent (Fawcett), her younger sister, listening quietly to a conversation between Emily and her close friend, Garrett. “Well Elizabeth, it is clear what has to be done. I must devote myself to securing higher education, while you open the medical profession for women. After these things are done we must see about getting the vote....You are younger than we are, Millie, so you must attend to that.” Emily Davies was instrumental in opening up higher education to women in Britain, while Millicent Fawcett became one of the leaders of the women’s suffrage movement. Manton 1965, 72. Charlotte Perkins Gilman, The Yellow Wallpaper (Boston: Small and Maynard, 1899). See also Gilman, “Why I Wrote the Yellow Wallpaper,” The Forerunner (October 1913). Reprinted in http://www.library.csi.cuny.edu/dept/history/ lavender/whyyw.html. No female physician could save Gilman in 1935, when she learned at age 75 that she had inoperable cancer. She chose to take her own life, writing what could be an axiom for euthanasia: “When one is assured of unavoidable and imminent death, it is the simplest of human rights to choose a quick and easy death in place of a slow and horrible one”; New York City Women’s Biography Hub, “Charlotte Perkins Gilman 1860–1935: American Writer and Feminist,” http://www.library.csi.cuny.edu/dept/history/lavender/386/cgilman.html.

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9 10 11

12

13

14

15

16

17

18

Melbourne’s Queen Victoria Hospital would not admit Aborigine women; see Bashford 1997, 210. See, for instance, the lively autobiography by Aletta Jacobs, Memories: My Life as an International Leader in Health, Suffrage and Peace (1996). British women physicians fared worse; they didn’t receive commissions in the military and membership in the reserves until 1950. They also faced lower salaries and rank and shortened periods of service; Nettels 1997, 251. On the misuse of ovariotomies as a treatment for mental illness in the late nineteenth century, see Mitchinson 1980, 125–44; Barker Benfield 2000; and Warsh 1989. There is also the possibility that Barry was intersexual (formerly known as hermaphrodite, that is, possessing both male and female sex characteristics). Intersexism as a relatively common medical condition has been noted by the intersexed and sexologists; it is estimated that some form of gender variation occurs in 1 out of 2,000 live births, although the opposite sex characteristics may be internal or virtually unnoticeable; see, for instance, Dreger 1998, 24–35. The Donalda Department, which established co-education in McGill’s Faculty of Arts, was due to the $120,000 bequest by railway and fur trade baron Lord Strathcona (Donald Smith). The money overcame the university’s strong resistance to female education, although not in the medical school; Hacker 1974, 150. Jex-Blake’s father, a powerful British doctor, refused to allow her to attend university alongside her brother, and when she defied him by studying at Queen’s College in London without any financial support, he again objected when she tutored mathematics for money to pay for her education; see Nettels 1997, 239. Despite his “unchivalrous” description, Goldbloom termed Wollstein brilliant and worked an extra year under her supervision; see Goldbloom 1959. Many thanks to Chris Lyons at McGill University’s Osler Library for this reference. My daughter’s paediatrician related a conversation she had with a fellow resident, a Saudi male. After a long night on the wards, her colleague said he would be going home for a nice dinner made by his wife and eight hours of sleep. She, on the other hand, who was raising two children while in medical school, said she would have to attend to a myriad of domestic chores before she could go to bed, to which the male resident replied, “That’s why you’ll never be as good a doctor as you could be.” Personal communication, July 2002. AMA Women Physicians Congress, “Women in Medicine: Celebrating Our Past, Present and Future,” http://www.ama-assn.org/ama1/pub/upload/ mm/19/wimmonthpresentation.ppt#256,1.

C H A P T E R

7

Nursing THE SCIENCE OF WOMANLY ARTS

Nursing has been considered the most “natural” occupation

for women, due to the traditional association of women with the healing arts in domestic and community settings. The early organization of nurses in the Western world within Roman Catholic nursing orders further solidified the bond between nursing and submissive femininity. These associations proved to be obstacles to the professionalization of nursing in the nineteenth and twentieth centuries, as educated nurses attempted to adopt the values of objectivity, scientific management, and controlled access to professional knowledge and positions. This chapter investigates the twists and turns of the advancement of nursing over the past two centuries in North America. The first organized nurses in North America were the Catholic orders, which operated in New France and across Catholic America in the lands included in the Louisiana Purchase. Their values and structure inspired Protestant imitators. We will consider the quality of nursing care in the colonial period and how Florence Nightingale’s influential views concerning the roles and character of modern nurses, and the structure of nurse training, were adapted when transferred to North America. Nursing “educa223

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tion,” which entailed more labour than teaching well into the twentieth century, became a battleground for nurse leaders, physicians, and hospital administrators, whose needs and aspirations often conflicted. Registration, to distinguish trained from untrained nurses, was a second battleground, particularly since so much of the content of nursing work consisted of menial tasks or “natural” feminine caring. Once nurses graduated from the challenging programs, they faced a variety of work options, many of which were even more challenging in terms of income and security. The turn of the twentieth century saw the rise and fall of private duty nursing, followed by a return to hospital work. Public health nursing, arising from Victorian philanthropic traditions, offered many unique opportunities. The most challenging work was participation in war; thousands of Canadian and American nurses volunteered and made tremendous sacrifices during their nations’ military adventures. Psychiatric nursing developed in a different fashion from general hospital work, at least in Canada, since asylum superintendents maintained control over the training and oversight of their own employees well into the twentieth century. Regardless of their occupational experiences, nurses encountered gendered stereotypes surrounding their sexuality, use of public space, and intimate contact with male strangers. The development of the uniform, harkening back to the profession’s roots in the convents and in the military, became a limited form of protection against these stereotypes. Uniforms did not, however, afford their wearers automatic uniformity of respect and acceptance, especially when worn by minorities. Rooted in patriarchal submission and ideals of femininity, practiced in the industrial realities of scientific management and economic efficiency, and envisioned in the ideals of professionalism and authoritativeness, nursing’s evolution in the last two centuries reflected that of women in general. This chapter begins with the origins of Catholic nursing in the French and British colonies, followed by nineteenth-century nursing before and during the Nightingale revolution. A discussion of nursing education, professional organization, and registration — vital components of the Nightingale-inspired nursing profession — follows, as do two areas that militated against nursing autonomy: the dilemmas of the private duty nurse and menial or unskilled nursing work. The sub-specialties of hospital and public health nursing are analyzed as well as the uniquely challenging experiences of nurses in wartime. The anomalous position of the psychiatric nurse is investigated, as is the position of all female nurses in terms of their image in popular culture. Finally, minority nurses of AfricanAmerican, Japanese, Jewish, and Native backgrounds are discussed, as well as that tiny minority — male nurses.

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Nursing in North America before 1900 The French presence in North America brought with it a highly developed and centralized social welfare system directed by the imperial authority in Paris, sponsored by wealthy French nobles, and operated by a succession of Catholic orders. In 1639, the Duchesse d’Aiguillon, niece of France’s de facto ruler Cardinal Richelieu, raised funds and garnered support for the establishment of l’Hôpital Hôtel-Dieu in the tiny imperial outpost at Montreal (Jamieson et al. 1966, 158). In 1641, Jeanne Mance, a powerful combination of aristocrat, religious mystic, bureaucrat, and fundraiser, opened Hôtel-Dieu; thus, she shares credit with de Maisonneuve for the founding of the city of Montreal (Coburn 1974, 129; Stewart and Austin 1962, 125). Like many future female missionaries — both domestic and foreign — Mance was able to exert extraordinary influence and independence within the accepted female mantle of religious calling. Other regions of the Franco-American empire, and later of the Canadian francophone diaspora, benefitted from these religious medical institutions. The Ursuline Order provided nursing services in Louisiana, whose swampy, humid environment left its residents susceptible to yellow fever, cholera, and smallpox (Stewart and Austin 1982, 125). The Grey Nuns, a nursing order established in 1738, founded hospitals and provided outreach services throughout the Canadian colonies. In 1859, for instance, three Grey Nuns — Sisters Alphonse, Emery, and Lamy — travelled by oxcart to northern Alberta to offer health care, education, and other social services to the Native and Métis peoples of the territory, both within the convent and through home visits, over 50 years before the region gained provincial status (Ross-Kerr 1998, 74, 6). Yet for all the rightfully lauded ministrations performed by the Catholic nursing orders, there was a darker side. The association of nursing with “saintliness,” “unqualified devotion,” and subservience retarded the growth of professional lay nursing in French Canada (as in France itself), even though its practitioners predated their Anglophone compatriots by centuries (Dumont 1992, 24; Schultheiss 2001, 1, 7). Furthermore, the nursing orders served as the agents of a succession of imperialistic authorities. The same orders that ministered to the health of Native peoples demanded forced assimilation as their price, gathering the peoples at missions and later in residential schools in which generations of children were subjected to neglect, disdain, cruelty, and sexual abuse. When Britain conquered New France in 1763, it quickly realized the value of the female Catholic orders in promoting submission and assimilation. The new imperial authority supported the Catholic orders’ existing health care, education, and social services apparati, and in turn the orders facilitated the transfer of one central authority to another at a grassroots level.

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Religious patriarchy permeated nursing practice. The Order of the Sisters of the Miséricorde was founded at the behest of Bishop Ignace Bourget in 1850 to care for unwed mothers and their infants. The sisters and their religiously and popularly degraded inmates were subjected to verbal and physical abuse: “all too often we were accompanied by deliberate shouting, by organized crowds, by nameless charivaris” (for more on charivaris in early modern France, see Zemon-Davis 1975). Consequently, the Order only attracted members from the working and farming, rather than the middle classes (Danylewycz 1987, 20, 86, 91). The “best” nursing care that it provided did not extend to the single mothers and illegitimate children at the Miséricorde. The mothers were subjected to forced labour and had to prove their penitence to be released, while the often abandoned, malnourished, and neglected infants faced a high risk of early death (Lévesque 1990). By the 1890s, in an increasingly secular environment, the Order professionalized its nursing services and training more in keeping with other late Victorian lying-in hospitals (Danylewycz 1987, 20). Yet, the institution’s earlier abuses, and those that would continue in both Catholic and Protestant residential schools well into the twentieth century, cannot be whitewashed. Only when the statue of Jeanne Mance in Montreal’s Old City is accompanied by a model of an abandoned infant in a basket or a heartbroken Cree child will a truer portrait of both the lightness and darkness of religious nursing be displayed. In the United States, English-speaking nursing orders were founded, but without the structural underpinnings of Versailles and Rome they developed with a uniquely American twist. For one thing, the practitioners were either newly converted Catholics or admirers of the Catholic Church. One of the first to raise the status of nursing to a calling was Mother Elizabeth Ann Bayley Seton, who converted to Catholicism and established the St. Joseph’s Sisterhood at Emmitsburgh, Maryland in 1809. Episcopalian Bishop William August Muhlenberg sought to emulate the Catholic model by establishing nursing orders, or sisterhoods, whose devotees provided charitable health services. His disciple, Sister Anne Ayres, organized the Sisterhood of the Holy Communion in 1853 and operated St. Luke’s Hospital in New York. Unlike the stereotypical hospital nurses of the early nineteenth century, the Episcopalian sisters were expected to conduct themselves in an irreproachable manner and came from the higher social classes. Their impact was lessened, however, by obvious comparisons with the Catholic sisterhoods, which were viewed negatively in the general social climate of anti-Catholicism (Bullough and Bullough 1978, 104, 105–06). Then there was Mother Clare. An Irish convert to Catholicism in 1858, she apparently missed the catechisms on obedience and subservience. In 1861 she founded a new convent, using it as a base for writing letters to

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newspapers advocating women’s equality. She nursed the Irish poor until she left in 1883, “to the clergy’s relief,” to found the St. Joseph Sisters of Peace in Britain. She then spent a short, albeit controversial sojourn in the United States, promoting liberalism and the rights of the poor (Roberts and Group 1995, 62–63). While the Episcopalian sisterhoods stretched the boundaries of Protestantism to practice enlightened nursing, and Mother Clare chafed so much at institutionalized Catholicism her religious commitment was questioned, both paths bore important links to the secular expression of feminism which flowered in the mid-nineteenth century, resulting in the creation of the nursing profession (Bullough and Bullough 1978, 106). Before we move onto the creation of modern nursing, however, let us investigate the nature of nursing in North America in the years preceding the Nightingale Revolution. Pre-Nightingale Nursing The quality and type of nursing care in the late eighteenth and early nineteenth centuries depended on the socio-geographical environment. In pioneer and isolated rural settings, families relied on household and ethnic folklore, community advice, and personal experience, much like the Native families with whom they lived or whom they had displaced. An isolated though literate population could rely upon household manuals and apothecary guides, such as Samuel Thomson’s bestseller Every Man His Own Physician. Wise women who were recognized as particularly skilled within their communities were sought out by others and so developed practices, usually grounded in midwifery. This was institutionalized in New France, where the women in villages elected community midwives. In 1713, for instance, Montreal’s women elected Catherine Guerbin, a local midwife who had proven her exceptional skills in the community. The United Empire Loyalists who arrived at the end of the eighteenth century in the Maritimes and Upper and Lower Canadas brought a similar tradition of American colonial healers. As the pioneer period extended into the late nineteenth and early twentieth centuries in isolated rural and/or northern areas, the individual resources of mothers and grandmothers as well as the identification of skilled healers within communities persisted as the base for nursing care (Coburn 1974, 130, 132). The stereotypical Sairey Gamp — the filthy, drunken, neglectful nurse dramatized by Charles Dickens and others — represented, and was the consequence of, conditions in hospitals prior to the therapeutic revolution. Colonial urban almshouses were receptacles for the aged, infirm, insane, and impoverished, and they usually included infirmaries, which were staffed by other inmates. As the hospitals slowly began their transformation into separate facilities to deal with the sick, some efforts were

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made to improve nursing care. In 1798, the New York Hospital initiated a series of lectures to attendants on caring for the sick (Bullough and Bullough 1978, 104). However, it was the waves of migration from the British Isles to North America in the nineteenth century, and the epidemics that accompanied the sick poor to communities unprepared for their sheer numbers, which led to the establishment of municipal hospitals and the employment of lay nurses. As one might expect, working in fever hospitals or “pest-houses” catering to victims of cholera, typhoid, and typhus was employment of last resort, and the nurses were domestic servants, often from the same ethnic group as the patients. The University Hospital of Montreal paid its nurses $4.00 monthly “if necessary,” but this included room and board —“a bed in the midst of the sick,” and food, the same as the patients, eaten “around the effluvia of the sheds.” The nurses’ mortality rate climbed to 20 or 30 per cent, and the physicians described the women as aged, unkempt, and foul, both in language and odour (Coburn 1974, 130–31).1 As other types of hospitals developed, the clientele and nursing personnel came from the same class and often were interchangeable. For instance, Margaret Gillis gave birth to her first illegitimate child in 1874 at the Boston Lying-In Hospital, and remained there as an employee with the relative security of a variety of housekeeping roles (Reverby 1987, 27). Despite the shortcomings of the early nineteenth-century nurses, they may have been unfairly criticized by later (or competing) generations of trained nurses. In 1830s Toronto, for instance, there were “monthly” or “ladies nurses” and “sick nurses” who advertised in newspapers and appeared in city directories. Monthly and ladies nurses took care of newborns, mothers, and their households for a month after birth, and they were often the attending midwives as well. Some of these women were referred by leading physicians and had careers lasting decades. By the 1860s, advice manuals such as the bestseller, Beeton’s Book of Household Management, stipulated that a monthly nurse should be “scrupulously clean and tidy in her person; honest, sober, and noiseless in her movements; she should possess a natural love for children, and have a strong nerve in case of emergencies” (Young 1994, 284, 288). If these characteristics constituted the clients’ expectations for their nurses and midwives, the distinctions between these working-class women and the new middle-class trained nurses would have been less than the latter asserted. The Nightingale Revolution The woman most responsible for the creation of modern nursing and the imprinting of its most important characteristics was, of course, Florence Nightingale (1820–1910), an iconic figure in the history of health care

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and in the popular culture of the Western world. She embodied noble femininity and self-sacrifice — the secular equivalent (or superior) of the generations of heroic nursing sisters. As a reformer, however, her most significant contribution was the sanitary reformation of the British imperial army. Her improvements to the sanitation, food, and housing conditions of the soldiers, as well as her innovative approaches to efficient distribution of medical services, tremendously reduced non-combat related injuries and diseases, as well as mortality rates for combat injuries.Yet, her accomplishments in this area are not well remembered or recognized because military work was not considered gender appropriate. Contemporary feminist historians have revisited Nightingale and her reforms and offer a new appreciation of a remarkable Victorian woman (Vicinus and Nergaard 1990, 2). Florence Nightingale began her life as a typically insulated upperclass unmarried lady, who was expected to fulfill the social expectations of her parents and the emotional needs of her sister Parthenope. Her early attempts to escape the boredom and intellectual stultification that constituted her social milieu included occasional visits to hospitals and schools and a fascination with government statistical reports. Her first major rebellion was a three-month stint studying nursing at Germany’s Kaiserwerth Hospital, an early innovator in enlightened nursing techniques, and then working in Catholic hospitals. So impressed was she with the experience that she considered becoming a Catholic sister. Parthenope “retaliated” with a nervous breakdown, which had, for Florence, the serendipitous consequence of freedom; Parthenope’s physicians advised against further contact with her sister or, as Florence wrote, “the Devourer might recover health and balance which had been lost in the process of devouring” (Roberts and Group 1995, 16). Nightingale found her energies devoured more productively in 1853, with her celebrated journey to the Crimea, with a band of assistant nurses, to support a British army suffering acutely from endemic diseases, filthy conditions, and a disorganized medical staff hostile to an aristocratic female interloper. As news of the success of her work in dramatically cutting the death rate of Britain’s soldiers was reported in the British press, the public responded with an outpouring of donations totalling £45,000, which formed the core of The Nightingale Fund. This money was used to found the Nightingale Training School for Nurses at London’s St. Thomas Hospital, which opened on June 24, 1860 as Britain’s first non-sectarian nursing school. The structure and philosophy of the Nightingale Training School set the tone — with all its strengths and weaknesses — of nursing education in the nineteenth and twentieth centuries. The nursing students, called probationers, resided in the hospital and were taught and supervised by the nursing “sisters” as well as the house physicians. They worked as

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assistants, performing whatever task was necessary (no matter how menial) to benefit the hospital and its patients, and were evaluated for both their technical prowess and moral character. They were paid room, board, and a small stipend and were provided with a uniform (Lewenson 1993, 21; Roberts and Group 1995, 5). Nightingale’s views regarding the role of nurses as professionals and as women were complex and has rendered her value as a feminist model controversial. As a religious Victorian gentlewoman, she wanted nursing to remain a “calling,” rather than a bourgeois profession absorbed with status and money (Roberts and Group 1995, 7). She trained her nurses to be subservient to the medical staff and was hostile to many of the goals and campaigns of contemporary feminists.Yet her insistence that women rather than men should control nursing has been termed “revolutionary” (Lewenson 1993, 21), and she employed, like the feminists, the model of woman’s superior moral character to justify this independence. This revolution was tempered by the fact that, most of the time, medical staff and especially hospital administrators considered nursing independence a small price to pay for a disciplined, hard-working, negligibly paid labour force (Davies 1980, 104). Among Nightingale’s 15,000 letters, books, and essays are extremely radical commentaries, such as “Cassandra”; in this work, she extrapolated from her own family experiences to critique the stultification of female ambition and education within the Victorian family and the Anglican Church (Showalter 1981, 396). Nightingale’s personal and professional influence was international as pilgrims and colleagues carried the messages of sanitary reforms and modern nursing to their own countries. There likely was a reciprocity of ideas. American medical pioneer Elizabeth Blackwell, who befriended Nightingale before the Crimean War, opened the New York Infirmary for Women and Children in 1857 and initiated free, four-month training sessions for nurses simultaneous with the training of women physicians (Bullough and Bullough 1978, 107). In 1859, Blackwell paid a visit to Nightingale during the creation of the St. Thomas Hospital nursing school. In 1875, Francis T. King, the president of the board of trustees for the new Johns Hopkins Medical School and Hospital, visited Nightingale before creating the Hopkins training school (Davies 1983, 48). Though impressed and inspired by Nightingale, King made significant changes when he transplanted her vision to the United States, and these changes carried over to other North American nursing programs. Nursing Education More than any other occupation or profession, the education of nurses has been, and continues to be, a hard-fought struggle over not only curriculum but standards of behaviour, authority, and subordination. In this

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respect nursing closely resembled the military. When Florence Nightingale opened her London school, the model for other British schools, she insisted that there should be a separate chain of command with the nursing matron or superintendent under the authority of a nursing board, rather than the hospital’s board of trustees. This was a radical measure indeed, considering both the subordinate position of women in Victorian society and the concurrent struggles between lay boards and physicians for control of the hospitals (Bullough and Bullough 1978, 116). Without a leader as culturally dominant and prestigious as Nightingale (or Queen Victoria for that matter), this model did not traverse the Atlantic unaltered. In 1873, when Dr. Alfred Worcester established the “Waltham Plan” in his Waltham, Massachusetts hospital and nursing school, he asserted that the nurse was “first, last and all the while only the doctor’s assistant,” and her training ultimately should be directed by physicians. Francis King hired the Bellevue Nursing School’s Isabel Hampton and Lavinia Dock, and these future nursing leaders fought for nursing autonomy akin to the British model (James 2001, 47–48). They faced an even more dominant male medical leader, Hopkins’ academic chief, John Shaw Billings, who considered the British model unwieldy and its authority too diffuse. A compromise was reached whereby a nurse was made superintendent but answered to the hospital’s board of trustees. As lay trustees were replaced by physicians throughout North American hospitals, nursing authority was further subordinated to the doctors (Bullough and Bullough 1978, 116–17). The Nightingale educational model tempered submission to authority figures with some independence. The North American version did not enjoy this balance, so that nurse training schools became “a place where ... women learned to be girls” (Reverby 1987, 58). Again, the military parallels were striking, as independent thought, autonomy, and creativity were stifled, while discipline, elitism, and ritualistic practices were encouraged. These practices were of critical value in facilitating the rapid expansion of the general hospital. Between 1873 and 1923, the number of American hospitals ballooned from 178 to 6,830, and one-quarter of them incorporated a nursing school. Similar growth occurred in Canada, where by 1909 there were 70 nursing schools (Bullough and Bullough 1978, 127). Just as the Industrial Revolution was underwritten by a continual supply of cheap workers, the hospitals of the industrial age also relied upon the minimally paid or unpaid student nurse, the “hospital machine.” The student nurses lived on-site, worked lengthy, often split shifts, and were expected to submit to multiple authority figures; thus, they were an ideal source of labour for hospitals facing rapid expansion on limited budgets. The close surveillance experienced by the students also was deemed appropriate by parents and others who entrusted their young respectable girls to this public environment (Reverby 1987, 61, 90).

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North America’s first nursing school was founded at New York’s Bellevue Hospital in 1873, and the following year, Dr. Theophilus Mack opened a Canadian school at St. Catherine’s (Ontario) General and Marine Hospital with the assistance of two British Nightingale nurses (Ross-Kerr 1998, 9). Nursing schools rapidly sprang up in the newly colonized Canadian West, with the opening of the Winnipeg General Hospital School in 1887. By 1900, there were 20 hospital nursing schools from Montreal to the Pacific. The Grey Nuns, who had been providing nursing care for centuries, joined the bandwagon by establishing the first Catholic nursing school in Ottawa in 1898 (Stewart and Austin 1962, 242). Simultaneous to these events was the opening of a nurse training program at the New England Hospital for Women and Children in Boston, which was a facility organized and staffed by women physicians. In this groundbreaking feminist institution, however, the feminist outlook did not extend to the training of the nursing staff. Indeed, some nurses found their training inferior to that in traditional male-supervised institutions. The New England Hospital nursing students were unpaid, although they were given room and board and a small allowance for purchasing uniforms and other personal needs. There were no separate nursing residences; like the older Victorian institutions, the nurses lived beside the wards. Furthermore, they answered directly to the physicians until a superintendent was hired in 1878. Most significantly, the women medical pioneers jealously guarded their knowledge and prerogatives to distance themselves from their “inferior” nursing sisters. The nurses performed domestic work, dressed wounds, and gave enemas. As one nurse recounted, “the only bedside or practical instruction we received was from the young women interns who taught us to read and register temperatures [and] to count the pulse and respirations.... Great care was taken that we should not know the names of the medicine given. We had no textbooks nor did we have entrance and final examinations” (Drachman 1984, 81, 82). Once Canadian hospital boards realized the tremendous financial benefits of training schools, their popularity grew. Nurses who opened these schools often found poor hospital conditions. When the Montreal General Hospital applied to Florence Nightingale for five nurses to establish a nursing school in their facility, the nurses found themselves in an institution where they were paid $5.00 to $8.00 less per month than the rat catcher.2 Furthermore, as one of the nurses recounted, “Hospital funds were taken to purchase champagne to be used in building up the reserve forces of patients to be operated upon, while ragged ticks filled with straw were the only beds provided for the patients.” The nurses slept in an old, unheated ward which was often filled with snow (Coburn 1974, 136). Not until Nora Gertrude Livingston, an American nursing graduate (who therefore expected less autonomy for her nurses than the British imports)

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took over was the school established on a firm footing. During her tenure at Montreal General, Livingston created the first three-year nursing program in North America (Dolan et al. 1983, 205). The expansion to a third year did not necessarily result in better education. Many students complained that the third year’s curriculum was simply a repetition of the second, as hospital boards exploited their unpaid trained senior students as long as possible (Coburn 1974, 141). The nursing school experience for incoming students resembled joining the military in some respects. When Mona Wilson left Charlottetown, Prince Edward Island to enter the Johns Hopkins Nursing School, she learned the proper roles of the probationer, or “pinky,” such as “where to sit in the dining room, to stand in the presence of a superior, to obey orders immediately, to keep her room neat at all times and ready for inspection, to ask permission to leave the hospital grounds [or] to have visitors in the dorm, to keep her hair in a bun and tucked under her cap, and when to rise, eat, study and retire.” Probationers were not to fraternize with their superiors, the patients, or the staff “lest such behaviour jeopardize their authority” (Baldwin 1997, 28–29). A significant factor in this preoccupation with dress and behaviour was that the nurse superintendents often came from a higher social class than the students and sought to force bourgeois standards of comportment and behaviour on them (Coburn 1974, 140; see also McPherson 1996, 33–34). This was due largely to the work expected of the nineteenth-century nurse, including “laundering, mending, changing bedding, making up bandages, supervising the kitchen and diets, preparing and administering medicine, keeping wards and equipment scrubbed, and seeing to the toileting, turning, feeding and changing of the patients” (Coburn 1974, 138). The educational component might have made nursing programs more attractive to middle-class women, but this was secondary. At the Toronto General Hospital, considered one of the country’s best, nursing students comprised the entire staff, with none save the supervisors being retained after graduation. In 1891, the lectures on “anatomy, physiology, medical, surgical and obstetrical nursing, communicable diseases and diseases of the eye, ear, nose and throat” comprised only 160 hours in its two-year program (Coburn 1974, 141–42). The bourgeois ideal nurse was not only class but ethnically limited. By 1931, three-quarters of graduate nurses in Canada were of white Anglo-Saxon heritage. After sustained opposition by other students and graduates, Japanese and Chinese-Canadian students were admitted into the University of British Columbia/Vancouver General Hospital School in the 1930s with the understanding that they would be useful in their own communities (McPherson 1996, 118). There were community and ethnically based nursing programs in the American South and in Canadian

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and American Arctic regions, although they tended to be underfunded (Roberts and Group 1995, 92; Meijer Drees 2010). Not all Canadian universities were eager to jump onto the nursing school bandwagon. Dalhousie School of Nursing in Halifax, Nova Scotia did not open until 1949, although nurse training had taken place there since the 1917 Halifax Explosion.3 In 1919, university president A.S. Mackenzie only reluctantly agreed to accept Red Cross funds for nursing education as part of a larger public health initiative. Nurse training continued to be carried out in hospitals; in Nova Scotia in 1937, a hospital with at least 20 beds could run a nurse training school (Twohig 1998, 9–10, 12). Without an accredited diploma, however, these nurses were at a professional disadvantage should they wish to leave their locale or advance in nursing leadership. Many Canadian nursing students therefore went to the United States. New York’s Bellevue Training School produced some of Canada’s nursing leaders, most notably Mary Agnes Snively, who established both the Toronto General Hospital School in 1884 and later the Canadian Nurses Association (Dolan et al. 1983, 206). By World War II, Canada faced a severe nursing shortage. Pushed by professional leaders, provincial governments began pressing the universities to open degree nursing programs. Between 1941 and 1949, Queen’s University, McMaster University, the University of Manitoba, Mount Saint Vincent University, and Dalhousie created nursing degrees. However, nursing instructors were not automatically granted professorial recognition. At Dalhousie, even the head of the nursing school was titled “the Director” and was placed on a lower pay scale than regular (i.e., male) faculty (Twohig 1998, 12, 35). The nursing school experience was a combination of paternalism, surveillance, and scientific management from the administrators’ perspective; the students responded with mildly subversive creativity. The military paradigm began at the selection process, but it had a gendered twist. At the Kingston General Hospital Nursing School in the interwar period, applicants were subjected to extensive physical examinations; tubercular candidates were rejected, but so were those considered weak, shy, or “too short to ever be any good.” They were subjected to gynaecological examinations to check not only for venereal diseases but evidence of sexual activity (Wishart 2004, 2, 7). (Evidently the directive not to flirt with patients or staff was taken very, very seriously.) Upon entry, probationers first became hospital “machines,” performing menial tasks repetitively. By rationalizing nursing procedures, only a small corps of supervisors was necessary for a “large number and high turnover of student nurses. The growing numbers of patients could move in and out of the hospital without getting their charts, possessions, or even their babies mixed up or lost” (McPherson 1996, 89).

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Similar to the military (as well as prison life), there were a multitude of punishments inflicted for a like number of infractions. These included trimming every ward patient’s toenails for rushing a bath, or scrubbing down a ward during off-duty hours for incomplete antiseptic protocols. Besides instilling the student with proper and safe techniques, the penalties — which also included extra work hours or even weeks before one could graduate — benefitted the institution with bonus free labour. Surveillance included the reporting to the supervising nurse of all movements on or especially off hospital grounds and ensuring that students adhered to guidelines such as Kingston’s “Rules for Student Nurses.” For their part, the nurses (like enlisted men or prisoners) developed strategies of subversion and/or emotional and physical survival that promoted camaraderie and loyalty (Wishart 2004, 8, 10, 18).4 Nurses’ memoirs commonly recall, with affection and humour, the favoured windows for crawling through to avoid detection when curfew was broken, the best broom closets for grabbing a smoke or just getting a rest from duties, and the stratagems for hiding illicit after-hours guests in dormitories. The use of charivari practices, such as pranks and plays where the supervisors, physicians, and other authority figures were parodied by students whose identities were hidden, were classic, temporary, and prescribed inversions of power structures, which both released hostility and reinforced the authority they mocked. The nursing school experience was challenging and exhausting. Students customarily worked 12 hours on the wards and then had to sit through lectures considered the “educational” component of their program. This schedule was of minimal benefit at best. As sociologist George Weir noted after observing evening lectures at one Alberta nursing school: “A few who have been long hours on ward duty yield to the weariness of fatigue: first a condition of passive attention, then the glassy stare of mental torpor, reaching its culmination when Morpheus claims its victim!” (quoted in Ross-Kerr 1998, 138). The first university nursing degree issued in Canada — in the whole of the British Empire, in fact — was at the University of British Columbia (UBC ) in 1923. The UBC program was a response to a confluence of health issues common in North America and elsewhere: a high infant mortality rate (25 per cent in Vancouver in 1914) and public appreciation for the activities of nurses during the Great War and the Spanish flu epidemic (Zilm and Warbinek 1994, 17, 19–20). Unlike more tradition-bound eastern Canadian jurisdictions, British Columbia had institutions still fluid enough to permit the dynamic measures of such women as Ethel Johns to take fruit. In just six years as head of the Department of Nursing and superintendent of nurses at Vancouver General Hospital, Johns created a modern accredited program, then moved on to influential positions at the

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Rockefeller Foundation and elsewhere before becoming editor of The Canadian Nurse in 1933 and the author of three books and more than 100 articles.5 Throughout her career, Johns advocated a standardized education and universal nurse registration. She also negotiated an eight-hour workday for her students during their two years of hospital training.6 This led to resentment and hostility from other hospital nurses, who considered the students to be arrogant and pampered (Zilm and Warbinek 1994, 24–25, 27, 49). Whenever alternative employment options were available, such as in the 1920s, the 1940s, and after the 1960s, nursing became less favoured by young women who wished to avoid the low salaries, split shifts, heavy workloads, and menial tasks that had always characterized the profession. Hospital boards and governments then had to confront deficiencies resulting from nursing shortages (Richardson 2001, 298–300). In the 1920s, the Rockefeller Foundation commissioned Josephine Goldmark, a social worker, to prepare a report on the state of nursing education and practice. Goldmark surveyed 72 nursing schools and public health agencies, publishing her final report in 1923 (Buhler-Wilkerson 1983, 383: Donahue 1985, 383). Many nursing leaders anticipated that an objective report, created under the auspices of the same foundation that had professionalized medical schools with the influential Flexner Report, would have a similar effect upon nursing education and practice (Reverby 1987, 164). Goldmark indeed did call for an extended period of education: “All agencies, public or private, employing public health nurses, should require as a prerequisite for employment the basic hospital training, followed by a post-graduate course including both class work and field work, in public health nursing” (Donahue 1985, 383). Other recommendations included “the maintenance of high educational standards, including more basic science courses; a properly funded training school with a graded curriculum of 28 months; and the endowment of a university-based school of nursing to train the profession’s future leadership” (Reverby 1987, 164–65). A controversial recommendation, given the registered nurses’ persistent battles to maintain a monopoly over the work, was that a new category of “assistant” or “helper” be established. As always, however, the subsequent return of an over-supply of nurses ensured that all positions, no matter how low-paying, were filled by trained nurses (Buhler-Wilkerson 1983, 98; Reverby 1987, 165). Canada faced similar challenges and took similar measures. In 1929, the Canadian Medical Association and the Canadian Nurses Association commissioned Dr. George M. Weir to investigate nursing schools. His 1932 Survey of Nursing Education in Canada noted that hospital training schools often provided inadequate education and recommended that nursing education be part of a government-supported university program. As

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FIGURE 7.1:

Nurses Studying, Hôtel-Dieu Hospital, Campbellton, New Brunswick.

Provincial Archives New Brunswick, Religieuses Hospitalières De Saint-Joseph Photo, P24-21.

the Depression deepened, many of the smaller hospitals and their training schools closed, so that when the financial situation improved, and as the federal and provincial governments took over more of the responsibility for health care and education during the postwar period, there were new opportunities to implement some of the findings of the Weir and other reports.7 By the end of the twentieth century, the professionalization of nursing continued to be confounded by the variety of educational paths available to be considered a nurse, as well as the housekeeping and other unskilled work that remain under the purview of the nursing designation. In the United States, prospective nurses could become a practical nurse in one year, a licensed registered nurse in two, or a baccalaureate nurse in four. Nurses with degrees could take academic or supervisory positions, but by the 1960s, they increasingly were replaced in these positions by applicants with masters’ degrees or doctorates. Baccalaureate nurses then attempted to define themselves as superior in terms of patient care, but these arguments were not particularly convincing to hospital administrators concerned with the bottom line (Bullough and Bullough 1978, 197). In Canada, career paths were somewhat more organized. There were trained registered nurses and registered nursing assistants, but there were also untrained or minimally trained practical nurses, nurses aids, and orderlies. There were community college diploma as well as university degree programs. The existence of national health care in Canada led to increased

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federal government intervention into nurse training and practice. When a government Task Force on the Costs of Health Services in Canada reported that registered nurses should not be performing unskilled tasks, the Canadian Nurses Association recommended the expansion of the new designation of nurse practitioner to supplement and in some instances replace the functions of the physician (Bullough and Bullough 1978, 229). The nurse practitioner position met the opposition of the medical establishment by the 1980s, when there was a perceived oversupply of physicians (at least in favoured urban areas). Due both to a persistent ideology of medical authority, and more likely to the competition for government Medicare dollars (Canada’s physicians are paid on a fee-for-service billing structure, not by salary) the nurse practitioner is only slowly gaining a significant footing within the health care system. Instead, many of the more skilled duties of the nurse practitioner, such as taking histories and performing physical assessments, have become part of the registered nursing program. Regular nurses, once again, took on more responsibilities without a corresponding increase in salary or autonomy (Angus and Bourgeault 1998/99, 56, 61, 64).

Professional Organization and Registration The lack of movement by governments and hospitals to improve working conditions and salaries for nurses was frustrating for the corps of nursing leaders who organized, lobbied, and in diverse ways worked for professional advancement. Johns Hopkins Hospital produced three leaders in nursing organization: Isabel Hampton Robb, Lavinia Dock, and Adelaide Nutting (Roberts and Group 1995, 82). Hampton Robb, who founded the American Society of Superintendents of Training Schools in 1893 and the Nurses Associated Alumnae of the United States and Canada in 1896, was described by Dock as a visionary at organization. When Canadian-born Hampton established the nursing school at Johns Hopkins, she invited Dock to join her there; she later became an administrator and educator at Columbia University. Hampton advocated a three-year training program and a workday limited to eight hours, with the hospital trainee reconfigured from unpaid labourer to student (Dolan et al. 1983, 211). Hampton’s colleagues were “dismayed” when she married surgeon Hunter Robb, because they knew that fin-de-siècle society precluded her full participation in public affairs as a married woman (Roberts and Group 1995, 86). Despite their fears, Hampton Robb’s Nurses Associated Alumnae successfully lobbied many state legislators to enact nursing registration, to separate trained from untrained nurses, and to protect the livelihoods of graduate nurses. In 1901, the two organizations were merged into the

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American Federation of Nurses, which participated in the International Council of Nurses (Dolan et al. 1983, 265). No constraints of domesticity followed Lavinia Dock, a “small, short sort of roly-poly little person with curly hair” and revolutionary ideas similar to public health nurse and social worker Lillian Wald with a touch of anarchist Emma Goldman (Roberts and Group 1995, 86). Dock was born to a prosperous family in Harrisburg, Pennsylvania and graduated from the Bellevue Training School for Nurses in 1886. She volunteered with Wald at the Henry Street Settlement, and was committed to the amelioration of urban poverty. Dock first worked to empower nurses; her book, Materia Medica for Nurses, helped its readers know the names and characteristics of medications physicians were prescribing and nurses were administering. Dock also worked to empower other women as well, including the poor and women of colour. She helped organize a woman’s local of the United Garment Workers of America, assisted Ada Thoms in the establishment of a national association for African-American nurses, and walked the picket lines with the predominantly Jewish women strikers in the shirtwaist strike of 1909. She crusaded against unjust venereal disease legislation and saw the inequities in nursing as part of patriarchy in general. Dock was jailed on a number of occasions for attempting to vote or taking part in militant suffrage rallies, and she helped to promote the suffrage cause in immigrant communities (Roberts and Group 1995, 83, 84). What a contrast there was between Dock and her student and colleague in nursing administration, Adelaide Nutting, who promoted nursing education and administration as a twentieth-century profession rather than an outgrowth of feminist ferment (Roberts and Group 1995, 86). Nutting, a Canadian, was also from a privileged background, attending private ladies schools in Montreal, Boston, and Ottawa (Dolan et al. 1983, 211). In 1907 she was appointed the first professor of nursing at Columbia University.8 From that position she worked at raising the standards for nursing education, securing the independence of nursing schools through financial support separate from hospital boards, and coordinating American nursing services during the Great War. Considering these Canadian influences, it is not surprising that the development of professionalized nursing in Canada was integrated with events and personalities in the United States and Britain. The Canadian Nurses Association (CNA) was founded in 1908 and joined the International Council of Nurses (Dolan et al. 1983, 212, 266).The CNA was created through the merger of the Canadian Society of Superintendents of Training Schools for Nurses, founded by Mary Agnes Snively in 1907, and the Canadian National Association for Trained Nurses, also founded in 1908, following the American model of embracing both student and

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graduate nurses. In “A Uniform Curriculum for Training Schools,” Snively challenged hospital administrators to accept an updated uniform curriculum and quality control through accreditation and registration (Lewenson 1993, 78). All of these professionalizing strategies, however, did not protect nurses once they had graduated from the training schools. Private Duty Nursing The group most seriously affected by lack of registration was the private duty nurses. With the growth in hospitals and recognition of the cost benefits of a student labour force, the numbers of nursing graduates exploded between the 1880s and the 1920s. In 1880, 157 nurses graduated from American nursing schools, while in 1926, there were 17,522 (Dolan et al. 1983, 303, Table 14.1; the numbers are slightly different in Lewenson 1993, 27–28). At the same time, however, the number of untrained nurses climbed, so that by 1920, there were approximately 150,000 of each group noted in the American Census (Lewenson 1992, 28). Many nursing graduates, tired of the rigours, rules, and close supervision of the hospitals, were eager to embrace the freedom of private duty nursing. In reality, however, they were confronted with the freedom to starve. The hospital training programs, which provided large numbers of cheap labourers, only functioned financially if there were a constant in-flow of students and out-flow of qualified, relatively expensive graduates. Only a handful of graduates remained in the institutions in supervisory or administrative roles (Reverby 1984, 455). The rest joined a growing over-supply of graduates as well as uneducated competitors competing for a limited pool of private patients. The nurses approached druggists, physicians, and former patients and relied upon word of mouth to obtain work. Urban nurses and physicians set up central registries to dole out the work; applicants suffered from the “nerve-wracking morale-destroying effects of long periods of unemployment ... during which she remain[ed] in a condition of feverish anxiety wondering whether she will be called up on another case before her money is spent.” According to Canadian statistics, in 1916, a private duty nurse could earn $21.00 per week, but the work was not steady; the annual income averaged $600.00 (Coburn 1974, 145–46). The work, when available, ranged from demeaning to exploitive and often heroic as well as menial, and there was little recourse for complaints, because a troublesome nurse could be blackballed from a registry. Within the household, the private duty nurse, regardless of background or qualifications, was not the equal of the employer (or even the cook), but she was a rank above the domestic and often clashed with other servants. She was on call 24 hours a day, slept in the patient’s room, and worked from 84 to 168 hours per week, performing whatever domestic tasks were

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required as well as nursing. She had to work, in isolation, without the tools or hygienic environment of the hospital. When the assignment was over, she lived again in anxious alienation, without the social support of fellow nurses that had characterized the training years. Inevitably, nurses suffered a higher death rate than other women their ages (Reverby 1987, 15; Reverby 1983, 137; Reverby 1984, 455–457). The onset of the Depression in the 1930s was devastating for the private duty nurses, as they became luxuries families could no longer afford. In Canada, respondents to the Weir Survey shared fears of economic survival in old age, as most were unmarried and insufficiently paid to put money away for retirement (Coburn 1974, 146). Throughout North America, graduate nurses began returning to the hospitals, to work virtually for room and board and in reduced, job-sharing shifts (Dolan et al. 1983, 309). In the United States, the creative measures of Roosevelt’s Works Progress Administration included the employment of nurses in public health and other welfare programs and in nationwide immunization campaigns (Bullough and Bullough 1978, 167). The tenuous position of the private duty nurse reflected the ambiguous nature of the profession itself. Nursing as Womanhood or Nursing as Labour? In colonial and early industrial North America, as indeed in most societies that lack institutional alternatives, women were expected to care for their family members and friends during periods of illness or accident, which were fairly common. If they became renowned in their community for their particular skills, or at least if they were willing to do so, they could be asked or employed to care for others. This “natural” fit between nursing and womanhood became an intractable problem which successive generations of nurses confronted. Susan Reverby articulated the anomalous position of the nurse with her statement that “nursing is a form of labor shaped by the obligation to care.” Caring, as simultaneously “an emotional and a material activity,” was difficult to extract as a vocation separate from one of the perceived virtues of womanhood (Reverby 1987, 1, 13). The postulate that nursing was the natural role for, in the poet Longfellow’s words, “A noble type of good/Heroic womanhood” (“Santa Filomena,” quoted in Bullough and Bullough 1978, 109) was one of Florence Nightingale’s legacies. Heroic women, including nurses, were expected to have the qualities of “caring, nurturing, compassion, tenderness, submissiveness, passivity, subjectiveness and emotionalism” (Lewenson 1992, xvi-xvii). These characteristics were valuable in asserting the moral superiority of nurses, but several of them — submissiveness and passivity in particular — undermined the assertion of professional superiority. They did, however, serve the needs of providing high quality, constant,

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and affordable nursing care without threatening the gender-based professional and authoritative aspirations of male physicians, regardless of the latter’s competence. Just as the “good wife” was expected to silently and diplomatically diminish her husband’s failings and advance his career from the sidelines, the “good nurse” in the hospital family was required to counterbalance any deficiencies in the doctor’s expertise or practice and support his self- and community image of power and knowledge. This “doctor-nurse game” remains a contentious area for nurses striving for professional recognition of their own (Baumgart and Larsen 1992, 78; Lewenson 1992, 28). The feminine values that all nurses were purported to share also worked against their professional aspirations in another manner. When there was a shortage of nursing staff or a lack of funds, physicians and hospital administrations called for the employment of non-trained or non-registered nurses or hospital attendants to perform the menial and housekeeping duties that comprised a significant part of the workload. These calls were justified on the basis that most women, by their “nature,” were nurses. In 1905, an editorial in Hospital magazine asserted that “Ability to care for the helpless is in women’s distinctive nature. Nursing is mothering. Grown up folks when very sick are all babies” (Versluysen 1980, 181–82). In 1921 in Pictorial Review, Dr. Charles Mayo of Minnesota’s famed Mayo Clinic called for “100,000 country girls as sub-nurses” to deal with the perceived nursing shortage (Reverby 1987, 163). These calls, which continue to be revived periodically, reflect the tenuous footing of a profession founded both upon what were considered subjective, emotional, and feminine values, and upon the traditional function of women to be nurses for their families and neighbours. At the end of the nineteenth century, American nursing leaders confronted these gendered values that were crippling professional growth. They lobbied state legislatures for control of examination boards and registration and the raising of educational requirements. Registration, which entailed the completion of an accredited program and passing a standardized examination, was considered by the nursing leadership to be an essential component of professionalization. Nurse graduates from training programs could not expect to be properly compensated and fully employed with adequate working conditions so long as untrained nurses, or semi-trained graduates of correspondence schools or other unaccredited facilities, flooded the market along with a steady output from the recognized hospital schools. Persistent lobbying in the United States resulted in the passage of legislation for nurse registration in a number of states by 1903, and Ontario nurses began that process in 1905. Nova Scotia passed the first Canadian law to register nurses in 1910, followed by Manitoba in

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1913, New Brunswick and Alberta in 1916, and British Columbia in 1918 (Whittaker 1984, 315–16). These efforts faced powerful opposition from other stakeholders. Hospital boards and the governments underwriting many of them obviously sought a continuous supply of cheap labour. Physicians regarded nursing professionalization as a direct threat to their power and autonomy within hospitals and clinics, and used terms like “nursing bosses” and “nursing trusts” to associate the profession’s leaders with trade unionism and unfair restrictions on the free market in nurses. There also was opposition from older nurses who had not been trained to contemporary standards or in recognized schools. With complaints from so many quarters, it is not surprising that the early examining boards and registration regulations had little power to prevent hospitals and physicians from employing non-registered nurses (Reverby 1987, 126–27). The legislation was weak in Canada as well; the Ontario Nurses’ Association, for instance, did not fully control admission and certification until 1951, and the grand-mothering of those already in practice meant that non-registered nurses continued to be a significant component of the labour force for years to come (Coburn 1974, 152). Hospital Nursing Despite competition from non-registered nurses and the difficulties of private duty nursing, the movement of graduate nurses out of the private market and back into the hospitals was not immediately favoured by most nurses, who considered it a regression to the close supervision and lack of personal autonomy of the training schools (Bullough and Bullough 1978, 167). However, by the 1940s, the work environment was changing, reflecting the scientific transformations of twentieth-century medicine. Nurses were responsible for extensive record-keeping of patient data and hospital stores; diagnostics; preparation for surgery (surgical nursing itself would become a prestigious specialty); administering “counter-irritants,” such as enemas and douches, as well as poultices and foments to treat infections in the pre-antibiotic period; cleaning and sterilization; and the personal bedside care of patients. All of these duties, as well as care of deceased patients, indicated the application of both the germ theory of disease through antiseptic and aseptic measures and the principles of scientific management and efficiency (McPherson 1994, 74–80). By the 1940s, hospital nurses began to enjoy more power and recognition. As a pre-war oversupply became a postwar shortage, hospitals were forced to enact measures, including increased salaries and better working conditions, to attract and retain qualified staff. With the return of the ideology of domesticity in the postwar era, nursing was one of the

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few areas where women asserted their expertise and autonomy (Melosh 1983, 158). Technological advancements in medicine also required a highly skilled nursing staff, and in areas such as intensive care and coronary care, specialized nurses became the colleagues and virtual equals of the physicians in their units. As Barbara Melosh graphically described, “No critical care nurse would call a doctor to report meekly, ‘Mr. Brown’s pulse appears to have ceased.’ She would yell for emergency equipment, pound the patient’s chest, inflate his lungs, initiate closed-chest cardiac massage, perhaps even begin to administer the drugs used in resuscitation. In turn, doctors recognized and depended on the skills and judgment of these nurses” (Melosh 1982, 491).

Public Health Nursing and the Sanitary Ideal At the beginning of the twentieth century, the alternative to private duty nursing, and its superior in terms of wages and autonomy, was nursing in the area of public health. Public health nursing was more than a specialty; it was the daily confrontation of the worst excesses of industrial capitalism. Those involved responded in ways that spanned the political spectrum. Nowhere was this more apparent than in the relationships between professional public health nurses and philanthropic lay visitors. Many of the laywomen involved in charitable ventures such as child welfare and health initiatives for the poor operated within the context of social or maternal feminism. They considered it woman’s special talent and responsibility to uplift conditions for the poor and helpless. Professional nurses, on the other hand, when involved in these endeavours for urban improvement, were concerned with protecting and enhancing the roles of nurses in any institutional structures created for this purpose. Both groups shared the belief in the principle of the sanitary ideal first propagated by Florence Nightingale: that through efficient management by enlightened leadership (that is affluent, educated, and/or professional women), backward living and health conditions could be improved (Armeny 1983, 15–17). There was tension between the two groups, however, when the professionalizing strategies of the nurses clashed with the traditional nursing and visiting activities of the predominantly evangelical laywomen. In Canada, this ambivalence was apparent in the rhetoric and work of the National Council of Women (NCW), a coalition of women’s charities and organizations. Two affiliates of the NCW, the Order of the King’s Daughters and the Toronto Nursing-at-Home Mission, considered home nursing of the poor as an opportunity to spread not only the middle-class gospel of hygiene and nutrition but the Christian Gospel as well, and they were reluctant to surrender this chance to proselytize to professional

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nurses (Boutilier 1994, 18). American public health nursing came into its own in the 1920s, as the devastating human costs of the Great War led to support throughout the Western world for pro-natalist measures. Insurance companies, foundations, and other private agencies underwrote various projects. On the federal level, the passage by Congress of the SheppardTowner Act in 1919 created a national and imaginative, albeit short-lived network of mother and child care programs (Davies 1980, 112). Many nurses who did not obtain hospital work in the interwar period preferred public health nursing to the isolation, low pay, and long hours of private duty work. It became an esteemed specialization, as it provided autonomy, varied practice and authority, and regular payment by government and other agencies. Working to improve the health and living conditions for the impoverished, immigrants, and rural dwellers also offered opportunities for the nurses similar to the nineteenth-century lay visitors they replaced. As medical missionaries, they satisfied their own benevolent impulses while providing a form of cultural imperialism. Bourgeois, white, native-born practices became the normative values of “right living” for their clients and patients (Melosh 1984, 486, 488). On the other hand, the human misery that was the urban slum radicalized many public health nurses, such as Lillian Wald and Mary Brewster, who founded the Henry Street Settlement House in New York’s Lower East Side (Roberts and Group 1995, 69).9 In her memoirs, Wald recounts the transformational event that occurred when she was presenting a bedmaking class to a group of mothers: A little girl ... told me of her sick mother, and gathering from her incoherent account that a child had been born, [I had her lead me] over the broken roadways ... between tall, reeking houses ... past odorous fish stands for the streets were a marketplace, unregulated, unsupervised, unclean, past evil-smelling, uncovered garbage cans and perhaps worst of all, where so many little children played.... The child led me through a tenement hallway, across a court where open and unscreened [water] closets were promiscuously used by men and women, up into a rear tenement, by slimy steps whose accumulated dirt was augmented that day by the mud of the streets, and finally into a sickroom. All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it. The family to which the child led me was neither criminal nor vicious ... and although the sick woman lay on a wretched, unclean bed, soiled with a hemorrhage two days old, they were not degraded human beings.... That morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them.... To my inexperience

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it seemed certain that conditions such as these were allowed because people did not know, and for me there was a challenge to know and tell. (Quoted in Donahue 1985, 344–45)

Wald’s memoirs reveal not only her horrified concern for the poor but also her continued faith in the weapons of Progressivism: knowledge, efficiency, and communication. Founder of the National Organization for Public Health Nursing in 1912, she initiated classic Progressive campaigns for urban improvement, including better housing, city parks, clean milk, and child protection. In 1896, Lavinia Dock joined the Henry Street Settlement, and she too adopted a “revolutionary coloring” after seeing firsthand “the downtrodden, miserable existence of the world’s workers” (Lewenson 1992, 65–66, 124). Considering the later divergence of political philosophies of health care in the United States and Canada, it is noteworthy that the development of public health should have radical roots south of the border and elitist imperialist roots in the north. The governor general’s wife, Lady Ishbel Aberdeen,10 was a key lobbyist in overcoming medical opposition to the creation of the Victorian Order of Nurses (VON ) in 1898. Lady Aberdeen based her support upon the traditional rhetoric of woman’s special powers of healing, juxtaposing the natural abilities of women to convince their sisters to adopt modern hygienic practices against the physicians’ scientific and technological expertise. The VON met with strong resistance from the medical profession, so that the organization had to frame its mandate to emphasize the subordinate role of the nurse vis-à-vis the physician, even in remote areas with no convenient access to medical practitioners (Stuart 1994, 52, 54, 56). This contrasted with the relative autonomy of the American public health nurses, who carried their own caseloads and consulted physicians “only when necessary” (Lewenson 1992, 124). In reality, of course, rural and northern public health nurses carried on de facto medical practices, and many of the VON , notably Elizabeth Smellie, who came from an upper-class Ottawa family and followed her leadership of the VON with heading the Canadian Women’s Army Corps during World War II, pursued challenging and independent paths (Dolan et al. 1983, 229). But this was not encouraged nor openly supported by their sponsors. Great faith was put upon the powers of public health nurses to reduce infant mortality and promote family welfare in rural as well as urban areas (for more on outpost nursing, see Elliott 2004: 303–26). The Ontario Board of Health, for instance, cited the province’s relatively high infant mortality rate in its promotion of pilot public health nursing projects for smaller communities.11 Furthermore, the Board made the economic argument that “a dead baby is a liability till its funeral is paid. But a living

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baby is an asset and liable to grow into a good Canadian.” Between 1920 and 1923, the Board sponsored more than 100 “demonstrations” of public health, and the nurses involved (one per demonstration) had a very full plate; their tasks included: obtaining lists of all births within the previous two years; visiting all “registered” and expectant mothers at home; making a special effort to find “unregistered” babies; giving mothers “council and demonstrations in all matters pertaining to health, sanitation, hygiene and healthful living; gathering all information possible on cases of tuberculosis, “mental deficiency,” communicable disease, and bad sanitary conditions, and report all such findings to Head Office; directing and coordinating the work of voluntary agencies and workers in the event of epidemics, and carrying out bedside nursing “in case of absolute emergency;” teaching by demonstration a member of the family; holding clinics for preschoolers; and inspecting all school children after getting permission from the local Board of Education. She was to send daily and monthly requests back to Head Office and also make visits to the surrounding towns and villages. (Stuart 1989, 119)

Because of the public health nurses’ broad mandate, local boards of health and physicians, who objected to provincial interference in municipal affairs, resisted the demonstrations (Stuart 1989, 113). However, the experiment likely raised the consciousness of local health officials with respect to proper record-keeping and provision of services. The expansion of public schools and compulsory attendance laws provided a window of opportunity for public health education and inspection. The ill-health and lack of personal hygiene of many workingclass and immigrant youngsters was both a shock and an eye-opener to middle-class teachers and school administrators, and handwashing drills and toothbrushing lessons became part of the curriculum. The regular inspection of students by physicians and school nurses was first instituted in Montreal in 1906 in an attempt to combat epidemics such as diphtheria, scarlet fever, and tuberculosis, which thrived in the slums and close atmosphere of the public schools. Urban public health nursing also exposed many Canadian middle-class nurses to the terrible living conditions that rapid immigration, low wages, and absence of a sanitary infrastructure had generated (Bates et al. 2005, 112–13, 115). In the new province of Alberta (proclaimed 1905), the government hired three public health educators in 1916 and established a Department of Public Health in 1919 subsequent to the Spanish flu epidemic. Due to lengthy lobbying by the United Farm Women of Alberta, the province expanded its mandate to include home visits to new mothers and mea-

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sures to educate them about the prevention of childhood diseases (RossKerr 1998, 75–77). During the interwar period, Alberta also created the Travelling Clinic to service infants and pre-school-aged children whose families had been enticed “into frontier areas [the government] knew itself incapable of servicing” (Richardson 2002, 246, 249). The Travelling Clinic staff, which serviced a far-flung frontier area during the short northern Alberta summer, included a surgeon, anesthetist, dentist, up to four nurses, and truck drivers. The medical caravan conquered the great distances and transportation challenges by using trucks, barges, wagons, or railroad trolleys. Families travelled for days to have their children’s heart and lungs checked and have tonsils pulled and teeth filled; they camped outside the makeshift hospital ward until the children were ready to be taken home (Richardson 2002, 251, 254). While the Travelling Clinics were considered vital to the health of pioneer families, the provincial government did not maintain the expense more than a few years. Female welfare workers, philanthropists, and public health nurses who wanted to establish well-baby clinics, or gouttes de lait, in Montreal met opposition not only from local physicians but clergy members who resisted the women’s public involvement in such ventures. The women of the Fédération nationale Saint-Jean-Baptiste successfully operated several clinics until 1916, when their management was taken over by local physicians, and this arrangement continued until 1953 (Bates et al. 2005, 114). The assistance maternelle program, originated by Caroline Leclerc Hamilton in 1913, provided free medical care and prenatal and postnatal advice and assistance to the most impoverished. In Quebec, the Metropolitan Life Insurance Company also provided a visiting nurse service to its workingclass policyholders who were ill or pregnant. The nurses provided prenatal care, advice on hygienic home conditions, and helped the new mother with her baby in the week after birth (Baillargeon 1999, 76). While the clergy and medical profession tried to maintain control of public health measures, the value of the public health nurse was recognized. In 1925, l’Université de Montréal opened a School of Public Health Nursing and offered courses for both religious nursing orders and a growing contingent of lay nurses (Stewart and Austin 1962, 246). Religious agencies also recruited nurses to serve in outreach areas. The Canadian West was one region of interest, as the Anglican Diocese of Athabasca, established in 1873, followed the example of the Catholic nursing sisters to place “women workers” as nurses in pioneer regions. Mary Newton of the Anglican mission near Edmonton was reportedly the first lay nurse in Alberta. Between 1898 and 1937, 22 mission hospitals, staffed largely by graduates of Toronto’s United Church Training School, were founded in Alberta and British Columbia (Ross-Kerr 1998, 9–10).

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Yet colonialist mandates from the eastern churches were often rewritten within the context of life in the isolated Canadian West. In the second half of the nineteenth century, health care reciprocity or “open commons” existed between missionaries, who provided modern medicines and first aid to Native peoples who in turn offered obstetrical and first aid services to missionary families (Burnett 2006, 114). Native female healers, who were skilled at harvesting, preparing, and prescribing plant remedies for a variety of ailments, were an essential aspect of health care not only for their own communities but for pioneer settlers. A woman in the Moosomin District of Saskatchewan in the 1880s, for instance, owed her child’s life to a local Native woman: She pushed aside the terrified mother and picked up the ailing child. By signs she indicated hot water from the kettle on the stove. Into it she put a pinch of herbs from the pouch slung around her waist. She cooled the brew and forced some of it between the blue lips of the infant. Soon the gasping subsided, and sweat broke to cool the fevered skin. The baby relaxed into a peaceful, natural sleep, cradled in the arms of the crooning Indian woman. That mother to her dying day remained grateful. (Burnett 2006, 91)

Female Native healers, like the Protestant female missionaries and the Grey Nuns, learned their skills through experience, practice, and, for many, a long period of apprenticeship as well. They provided the foundation of health care in isolated regions well into the twentieth century. In the 1960s, the Elders of British Columbia’s Sechelt Nation were sharing remedies for rheumatism, arthritis, and tuberculosis with their non-Native neighbours (Burnett 2006, 143, 94). At the end of the twentieth century, the most isolated public health assignments were northern or outpost nursing, which provided a challenging combination of physical and social isolation, latitude in responsibilities and roles, and ambivalent relations with the client population. Outpost nurses performed diagnostic tasks and minor surgery, midwifery, and dentistry; they also prescribed medications. They prided themselves on their ad-hoc roles as meteorologists, air-traffic controllers, veterinarians, auto mechanics, plumbers, and TV satellite repairpersons. Yet they often remained temporary outsiders to their communities; in recent years, Native women were trained as outpost nurses on their own reserves or communities, completing, in many ways, the circle of the Native female healer (Smith 1994, 14, 15). Since the 1980s, First Nations self-government on Canadian reserves has brought more Native health care workers, who incorporate Western and Native practices into public health work (Kelm 1995).

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Wartime Nursing The Nineteenth-Century Experiences The challenges faced and commitment required for public health work paled beside the conditions of wartime nursing. Women’s aid in military expeditions in the Canadian colonies predated Florence Nightingale’s adventures in the Crimea. The first large-scale Canadian military experience for nurses occurred in the battles that culminated in the British Conquest of New France in 1760. Nursing sisters from the Augustine and Ursuline orders tended the wounded with few facilities or supplies (Landells 1995, 1). A century later, many American women, including graduates of the newly opened Women’s Medical College, were inspired by Nightingale’s work with the British military forces to volunteer as nurses during the American Civil War (Bullough and Bullough 1978, 109). The majority of the 2,000 women who provided unpaid nursing care in dismal, unsanitary conditions during this war were untrained, and their experiences provided the impetus in the postwar period to establish nurse training programs throughout the United States (Lewenson 1992, 20). Iconic figures emerging from the war were Mother (Mary Ann) Bickerdyke, “the General in Calico,” and Clara Barton (Bullough and Bullough 1978, 112; Dolan et al. 1983, 173). While women could not officially serve in the military or the federal government, some of the leading figures in the emerging medical and public health fields offered their services and thereby created powerful positions for themselves in the midst of the domestic conflagration. Dorothea Dix, for instance, was appointed Superintendent of the Female Nurses of the Union Army and later became the leading lobbyist for asylum reform in the United States (Dolan et al. 1983, 175). Elizabeth Blackwell and Louisa Lee Schuyler organized the United States Sanitary Commission, which provided relief supplies, nursing, and sanitary improvements to the troops through female fundraising efforts (Lewenson 1992, 20). Louisa May Alcott’s evocative war letters from “Nurse Periwinkle” inspired many young women to take up the career of professional nursing following the war (Dolan et al. 1983, 180). During the Riel Rebellion in 1885, 12 nursing sisters from Ontario and Winnipeg received the wounded from the Battle of Batoche and accompanied some of them on the arduous 1,000-mile water route of the Saskatchewan River and Lake Winnipeg to Moose Jaw. Because of their efforts, they were awarded the “North West Canada, 1885” campaign medal along with members of the militia (Landells 1995, 2, 5; Stewart and Austin 1962, 243). Typifying the gendered reporting of the exploits of military nurses, historical accounts noted that even nuns had bad hair days: “During the lake voyage from Owen Sound to Port Arthur, the mother superior, having experienced difficulty in dealing with her long hair in

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the confined space of her cabin, and realizing the problem of managing it ‘in a battlefield hospital in the wilderness,’ cut off the long black tresses and threw them overboard, an example which the other sisters followed” (Landells 1995, 5). By the time the Spanish-American War broke out in 1898, American nursing had been professionalized to the point where the nursing elite lobbied the military to employ only trained nurses and establish a nursesupervised, ranked service in military hospitals. However, the American nurses who sought for recognized and autonomous authority within the military structure confronted similar obstacles to the British, where “the spectre of female parallel power haunted military medical officers” (Summers 1988, 4). The fact that the women were elite or middle-class women further muddied the lines of authority and subservience to the point where male medical military officers agitated against full integration of nurses in the military. While the nursing profession only slowly overcame these obstacles, and raised the standards of military hospital care to that of civilian institutions, they themselves were influenced by military values and regimens, which continue to make their mark upon nursing education and practice (Armeny 1983, 17; Summers 1988, 4–5). Imperialist conflicts accelerated at the end of the century, with the outbreak of the South African (Boer) War in 1899. The first group of Canadian volunteers joined the Queen Alexandra Imperial Military Nursing Service of Britain. Shortly thereafter, as Canada sought to differentiate its military contribution from the efforts of the mother country, the government founded the Army Nursing Sisters Corps, with members awarded the rank of junior officers (Stewart and Austin 1972, 243).12 As in future Canadian military expeditions, there was a large pool of volunteers, four of whom were selected to accompany the 2nd Battalion, Royal Canadian Regiment (Nicholson 1975, 33–34; Landells 1995, 5). Among the volunteers were Georgina Pope of Prince Edward Island, a graduate of New York’s Bellevue Hospital Training School, and Margaret MacDonald of Nova Scotia, a graduate of Halifax’s Mount Saint Vincent College and the New York City Hospital Training School. MacDonald also served with the American military during the Spanish-American War and in 1914 became Matron-in-Chief of the Canadian nursing sisters in France during the Great War. The Boer War experience was “good” training. With scarce food and medical supplies, and a shortage of pure water, there were thousands of cases of enteric fever and dysentery among the troops, civilians, doctors, and nurses. The four nurses worked in a 600-bed tent hospital at Rondebosch for six months, “having at times very active service; sometimes covered with sand during a ‘Cape South-Easter’ ... and at all times in terror of scorpions and snakes as bed-fellows” (Landells 1995, 5–6).

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The Great War/World War I In 1914, Canadian women who wanted to participate in their country’s medical services in the Great War had two options: enlistment in the Canadian Army Medical Corps (CAMC) Army Nursing Service or in the Voluntary Aid Detachments (VADs). At the war’s outbreak, there were 80 nurses in the CAMC Army Nursing Reserve, distributed across the country. On August 17, the newly appointed Matron of the Nursing Service, Margaret Macdonald, was ordered to mobilize 100 nursing sisters for the first two military hospitals created for the First Canadian Contingent of 23,000 troops, who would be leaving soon for Britain. Macdonald’s task was not finding the nurses but weeding the applicants. There were thousands of Canadian and some American nurses who applied to be military nurses for reasons including patriotism, love of adventure, professional advancement, and the financially precarious condition of the graduate nurse labour market. Of all the combatant nations, the nursing sisters from Canada were in the best position, because they enjoyed military rank and control. Nurses in the British Expeditionary Forces, for instance, were considered outside the military framework. When the two allies worked together, this created some clashes. The British nursing sisters tended to be from the gentry and were accustomed to subservience; colonial, often working-class Canadian nurses nonetheless had the rank of lieutenant and so trumped them in authority (Nicholson 1975, 49–50, 52). Regardless of background, however, the nurses who were sent to the fronts experienced some of the same horrific conditions as the soldiers they treated. Following the battles at Ypres, for instance, “in an atmosphere of filth and pain, nursing sisters washed, fed, dressed wounds and made patients as comfortable as possible.” Canadian nursing sisters were considered skilled at administering anaesthetics in the makeshift operating rooms. On the cliffs outside of Le Treport, France, the No. 2 Canadian General Hospital erected a 1,040-bed tent hospital run by 58 nursing sisters in March 1915. On the Eastern Front, on the Greek island of Lemnos, Canadian nursing sisters worked in primitive sanitary conditions, requiring helpers “to fan vigorously to keep the flies away from open wounds.... The delirious were tormented by swarms of insects in a temperature of 100 degrees” (Landells 1995, 8). Two of the Canadian nurses died of dysentery, while at least 21 others were killed in 1918 when the German military began targeting hospitals and hospital ships. These included the sinking of the hospital ship “Llandovery Castle” off the Irish coast on June 27, with its contingent of 14 Canadian nursing sisters: “A sergeant, who had taken charge of the lifeboat carrying the nursing sisters, praised the fortitude of the fourteen sisters who unflinchingly and calmly, as steady and collected as if on

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parade ... faced the ordeal of certain death [in] a matter of minutes — as our lifeboat neared the mad whirlpool of waters where all human power was helpless” (Landells 1995, 10). Other Canadian women who were not trained nurses could volunteer as VADs. With basic First Aid and Home Nursing courses, 1,199 joined the St. John Ambulance Brigade and served both in Canada and overseas in the British military hospitals. Because physicians and trained nurses were part of the military structure, both groups did not want “amateurs” to threaten their positions or undermine discipline in the hospitals. Therefore, only a very small number made their way to the hospitals overseas. Most had non-medical jobs such as telephone operators, messengers, and entertainers in the Red Cross Recreation Huts. The last role added a prurient touch to the popular image of the VADs (and the nurses generally), who performed intimate tasks on young males in loose, unchaperoned surroundings. The image of the nurse was somewhat mitigated by her association with the Madonna figure or mother-substitute for prostrated soldiers, but the VADs in particular were targeted in cartoons and postcards as smoking, drinking, and otherwise cavorting with the soldiers in their care. This image did a great disservice to the young women who, unlike the nurses who were continuing and improving upon their professional credentials with war work, had given up pre-war wages and job security for their patriotic adventure (Quiney 1998, 190–98; Quiney 2002, 15). When the United States entered the Great War in 1917, nurses, dietitians, and other health care workers were quick to volunteer for service, with the American Red Cross providing the lion’s share of servicewomen. By Armistice in 1918, 18,000 out of 23,868 graduate nurses who served in the war were American Red Cross nurses, who provided health and sanitation services at home and nursing care in base hospitals, hospital trains, and field units in France.13 World War II When war was declared again in 1939, Canadian nurses volunteered in such great numbers that their enlistment was halted after only 10 days. Almost 4,400 women served in military operations in Britain and Europe, the Mediterranean and Hong Kong, as well as in Canada, Newfoundland,14 the United States, and South Africa. Their experiences ranged from the relative comfort of domestic military hospitals to field surgical units under fire to imprisonment in internment camps. Traditional nursing sisters were joined by physiotherapists, occupational therapists, and dietitians. These health care professionals were part of a wartime therapeutic revolution that would set the course for health care for the rest of the century. They helped to develop new surgical techniques for burns, the reconstruction

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of faces, and the saving of limbs. The introduction of the new miracle drug — penicillin — as well as widespread use of blood products and intravenous solutions also improved the prognoses for thousands of wounded. All of these innovations had to be carried out in conditions as close to the battles as possible, as it became apparent that immediate transfusions of blood and plasma substantially lowered mortality rates (Toman 2003, ii, 1, 6, 121). The costs to the nurses were considerable, ranging from death to imprisonment, tuberculosis and diphtheria to permanent psychiatric disorders. May Walters and Kay Christie, two nurses posted to Hong Kong in 1941, were caught in the Boxing Day invasion of Hong Kong by the Japanese and ended up in a harsh Japanese prison camp for 21 months. Other nurses were raped and beheaded as part of the horrific Rape of Nanking. Conditions throughout the various theatres of operation were extreme. Nurses liberally doused themselves with DDT to combat lice and fleas. In Rome, their medical units included overflowing toilets, live grenades, and destroyed plumbing and electricity. Nursing Sister Van Scoyoc, stationed in Holland, heard screaming at night, and thought it was from a psychiatric hospital. She was, however, hearing the victims at the Belsen death camp (Toman 2003, 123, 155, 159, 161). Along with experiences often paralleling those of the soldiers, the nursing sisters also were expected to use their sexuality and femininity to advance the war effort. The plastic surgery unit at East Grinstead, Britain, for instance, which treated soldiers who had had their faces blown off, chose the most beautiful nurses to “validate [the patient’s] ego” and assist “his recovery.” Nurses were also expected, after their shifts ended, to forego sleep and relaxation to go to parties for the troops: “They knew and we knew that some of them would come back as patients; some of them wouldn’t come back. So it was an emotional time, but they had to talk to somebody” (Toman 2003, 186–87). Cynthia Toman evocatively described battlefield nursing care: It is difficult to imagine the work involved with the care of mangled and burnt bodies where there were multiple wounds, missing limbs and other body parts, faces without features or lower jaws, whole wards of colostomy patients, exposed lungs and intestines, and more. Besides trauma, the bodies were just as likely to be filthy and lousy. Conditions were not necessarily much better further back the line where patients arrived foul-smelling and maggots in their wounds after ten to thirty days of the Trueta method whereby dressings were intentionally left unchanged for extended periods. It is difficult to imagine work that was any more stressful than the long stints on duty in wards or operating theaters during a battle, or working

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under enemy fire. It is hard to imagine work that was more repetitive or routinized than the assembly line medical care required for one hospital unit to admit and evacuate 1,200 casualties in twentyfour hours. (Toman 2003, 230–31)

American nurses experienced similar conditions after their country entered the war in December 1941. They lobbied successfully for the full military rank Canadian nurses enjoyed. By order of President Roosevelt, on July 12, 1944, the 40,000 members of the Army Nurse Corps were commissioned at the rank of second lieutenant and were thus made the military superiors of the medical corpsmen (attendants) and many patients (Dolan et al. 1983, 312; Melosh 1983, 164). There was no provision for male nurses under this order, so that they could not receive military rank, an anomaly that was remedied in 1955. World War II also was the impetus for a large infusion of federal money for nursing education. With the passage of the Bolton Bills by the American Congress in 1941, millions of dollars were appropriated for refresher courses, expansion of facilities, and instructor training, as well as the creation of the Cadet Nurse Corps (Dolan et al. 1983, 311, 313). One of the most significant long-term effects of the nurses’ involvement in World War II was that the federal government officially recognized nursing as a profession, positioning its leadership in a position of strength for dealing with hospital administrations, the medical profession, and state legislatures in the postwar era (Bullough and Bullough 1978, 176). Another group of nurses, those who worked in psychiatric hospitals, however, had a more difficult road to take to achieve autonomy and professional authority.

Psychiatric Nursing In many ways, institutional psychiatry was the stepchild of medicine and so too was psychiatric nursing. In Canada, this led to anomalies in the specialty’s development. The Ontario asylum system established the first training schools for psychiatric nurses at the beginning of the twentieth century, when Charles Kirk Clarke, superintendent of the Toronto Hospital for the Insane, organized programs at the Toronto and Kingston (Rockwood) Asylums. The provincial government supported this move and the concept of general nurses in the asylum system and, in 1909, instructed the other hospitals in its purview to establish a three-year standardized program. Psychiatric nursing was a particularly uncomfortable “fit” for the professionalizing aspirations of organized nursing. Asylum work, due to its long hours, low pay, difficult patients, and occasionally violent envi-

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ronment, traditionally had been an occupation of last resort. Half of the nursing staff was male orderlies, hired for their physical strength as much as healing abilities, which posed a conceptual problem: they were not traditional Nightingale nurses. Furthermore, the medical superintendents maintained firm control over their geographically isolated institutions in a pyramid administrative structure, while coping with low revenues and high admissions. The employment of expensive, female registered nurses who answered to their own professional organizations as well as to their institutional overseers was not a welcome innovation to the medical superintendents, whose determined opposition fended off professional nurses for decades, especially in the western provinces. In the 1950s, psychiatric nursing in Canada developed into two distinct certifications: a specialty within registered nurses in Ontario and points eastward, and a separate occupation called registered psychiatric nursing (RPN) in western Canada. The Graduate Nurses’ Association of Ontario (GNAO) was proactive in ensuring that the province’s psychiatric nurses remained part of their bailiwick. They recognized the nursing schools established by the individual asylums for the benefit of their own employees but mandated a lengthy rotation in the general hospital training programs for the mental health nurses to qualify for registration. The psychiatric nurses therefore had the option to pursue alternative nursing careers, rendering the field more attractive to enter. The medical superintendents, on the other hand, were loathe to surrender even partial control of their programs to the general nursing schools, particularly since they lost valuable staff members during their external rotations, and graduates with more education and more options were more likely to either demand more money or leave for more profitable or congenial work. The nurses prevailed, however, and the mental health nurses remained affiliated with the registered mainstream (Tipliski 2004, 255, 257). A different situation developed in western Canada, however, as the later settled region, without the provincial social welfare infrastructure of Ontario, allowed individual medical superintendents considerable freedom. The Brandon (Manitoba) Hospital for Mental Diseases was established in 1921, as the mental wreckage of the Great War overwhelmed the general hospitals. Dr. Arthur Barager, Brandon’s first Medical Superintendent, created his own nursing school by renaming his female attendants “pupil nurses,” hiring registered nurses for supervisory positions, and copying the general hospital training programs as much as possible. Because he acted unilaterally, however, the Manitoba Association of Graduate Nurses (MAGN) refused to accept his nurses in the nurse-controlled general hospital rotations, so that the mental health nurses could not be registered. The subsequent mistrust and power struggles between the nursing associations and Barager and other western medical superintendents meant

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that western psychiatric nurses developed their own institutionally and regionally limited specialty (Tipliski 2004, 259–60). A fascinating denouement to the story is that the western nurses, despite being rejected professionally and looked down upon personally by registered nurses (RN s), created their own professional identity. In the 1920s they affiliated in a trade union with the male attendants. With the onset of the Depression, trained nurses, teachers, and other educated women were attracted by the room, board, and wages offered by the psychiatric institutions. These women, who retained their bourgeois aspirations, responded to the charges by RN s that their work was not “real” nursing by arguing that mental nursing required more personal, caring, and flexible skills. The two views found some reconciliation by the end of the 1930s, when psychiatric care became more somatic. Two new practices, insulin and metrazol shock therapies, entailed the administration of insulin, recording of vital signs, drawing of blood, and caring for coma patients. These tasks required conventional nursing skills and practices, thus offering much personal satisfaction for the nurses (Dooley 2004, 242–46). In the early twenty-first century, Brandon University in Manitoba offers a Bachelor of Sciences in Psychiatric Nursing while the universities of British Columbia and Manitoba offer post-baccalaureate programs in Registered Psychiatric Nurses, for those interested in receiving the RPN designation.15 In the other Canadian provinces and in the United States, psychiatric nursing increasingly came under the purview of organized nursing. It became part of diploma and baccalaureate nursing curricula after the 1920s, and with federal support for advanced nursing education with the passage of the National Mental Health Act of 1946, American nurses were able to obtain a Master’s degree in psychiatric nursing. Hildegarde Peplau established the first such program at Rutgers University in 1954. With the de-institutionalization of the majority of North American mental health patients after the 1970s, psychiatric nursing is now often practiced in a separate stream of community mental health work.16 Despite their increased educational credentials and levels of specialization, psychiatric nurses, hospital nurses, military nurses, and other women in nursing have faced 150 years worth of stereotypes based upon the occupation of young women of public space.

Sexuality and Popular Culture The nurse’s image, because of her gender, has never been only scientific. The containment of female sexuality within the confines of the domestic environment has been a hallmark of patriarchal cultures. Those women, particularly the young, fertile, and unmarried, who ventured into

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public spaces, were often treated with suspicion, denigration, or worse. Domestic service, for instance, was carte blanche for sexual harassment and abuse. Teaching and nursing, new occupations for middle-class women in the nineteenth century, were viewed with some doubts. Teaching, at least, replicated the domestic role of women with children. Nursing, however, which required intimate contact with male strangers, invited negative responses. The fact that Florence Nightingale’s new profession originated with the care of (prostrated/emasculated) soldiers in combat situations — furthest afield from the Victorian domestic ideal — only heightened the fascination, repulsion, and erotic undercurrents of the popular imagery of nursing. The Victorian construct of the young, middle-class, morally impeccable Nightingale nurse juxtaposed with the middle-aged, working class, morally corrupted untrained nurse added respectability to the former at the expense of the latter. In Victorian paintings, poetry, and novels, the new nurse was sanctified (read de-sexualized) and heroic, therefore unthreatening to the social order. However, chastity and sexual unavailability only becomes an issue in its reverse, and the overtly chaste image of the nurse who nonetheless “walked” unchaperoned in public spaces inhabited by men was counterpoised with another type of streetwalker (Judd 1998, 9–10, 23, 46–47). Consider Longfellow’s famous paean to Nightingale, which has been noted for its “subtext of prostitution imagery”: Lo! In that house of misery A lady with a lamp I see Pass through the glimmering gloom, And flit from room to room. And slow, as in a dream of bliss, The speechless sufferer turns to kiss Her shadow, as it falls Upon the darkening walls. (Quoted in Judd 1998, 46)

Nursing superintendents attempted to be the gatekeepers of student nurses’ sexual expression to combat these popular perceptions. Part of the rationale was that these young women, many in their teens or early twenties, were leaving the protection of their homes for the first time and needed surrogate parenting. Another rationale was that sexual virtue was seen as one of the professional traits separating the trained nurses from the Sairey Gamps of old. There was also the nursing leaders’ consciousness that the public had ambivalent feelings about young women being in public space, in intimate contact with male physicians, and even more intimate contact with male patients. The uniform and the veil, after all, while recalling the heritage of the convent, were not being worn

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by women who had taken vows of chastity. Consequently, fraternization with males, flirting, and open or secret dating, met with not only chastisement but severe penalties in nursing schools and hospitals (Reverby 1987, 54–55). On the other hand, a little romance among the upper classes could have benefits for all. In 1878, when the famed Johns Hopkins surgeon, William Stewart Halsted, found that his scrub nurse and fiancée, Caroline Hampton, had developed dermatitis from the harsh disinfectants, he commissioned the Goodyear Rubber Company to develop thin gloves to protect his beloved’s soft skin. Subsequently, rubber gloves became standard gear for all surgical teams (Bullough and Bullough 1978, 153). The fascination with nurses’ sexuality persisted in the popular culture of the twentieth century. Novels, short stories, poems, films, and radio and television programming presented a succession of archetypes of the nurse (Kalisch and Kalisch 1982, 5). These included the saintly “Angel of Mercy,” dealing with the crises of war and epidemics in the first 20 years of the century; the subservient “Girl Friday,” reflecting the overcrowding and deteriorating status of the profession in the 1920s; the decisive “Heroine,” paralleling the improved status of women in general during the Depression and into World War II; the passive “Mother Image,” reflecting the re-domestication of women in the postwar period; and from the mid-1960s onwards, both the hedonistic (but unthreatening) “Sex Object” and the domineering (and perversely man-like) “Big Nurse” (Ross-Kerr and MacPhail 1991, 50–52; Melosh 1983, 168). These stereotypes underline the close relationship between the images of nursing and womanhood in general, since they are consistent with popular images of women in the mass media and commercial advertising in those decades.17 The development of nurses’ uniforms continued the association, since what could be more equated with women and mass marketing than fashion? Uniforms As nurses took on intimate roles with their patients, uniforms were created to differentiate the nurses from the physicians — their superiors — and non-trained nurses or domestics — their inferiors — as well as to signify both femininity and chastity (McPherson 1996, 37). The fetishization of uniforms is a striking aspect of nursing history literature. This is partly due to professional nursing’s military origins. Civil War Army nurses, immediately predating the establishment of nurse training schools, were required to be “over thirty, plain-looking, dressed in brown or black with no ornamentation — no bows, no curls, no jewelry and no hoop skirts” (Dolan et al. 1983, 175). An early account of Canadian nurses’ Boer War experiences frequently digressed from the battlefield to the fashion runway:

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FIGURE 7.2 :

Unidentified Nursing Sister, No. 5 Canadian General Hospital, 1915-19. Major Matthews Photo, City of Vancouver Archives, CVA 371–1871.

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The distinctive khaki uniform issued to the Canadian nurses consisted of a short bicycle skirt worn with a Russian-type blouse equipped with shoulder straps and service buttons. The military motif was further maintained by the addition of a brown leather belt and brown leather boots. A sailor hat of khaki, adorned with a cockade in the form of a little red brush, alternated with the English nursing service cap, which matched the white collar and cuffs with the apron and bib. (Nicholson 1975, 36)

By 1907, nursing fashionistas would be gratified to know that their full dress uniform was “a waist and skirt of dark blue serge, a cape of scarlet cloth reaching to the elbow, and white adjustable cuffs and collar, and a white cap.... For working dress nurses wore a waist and skirt of ‘pale blue butcher’s linen,’ cuffs and collar as above, and a white apron.... For very cold weather there was also a Persian lamb cap with red brush on the side and fur gauntlets.” The Great War was an opportunity to combine fashion with function. The muddy conditions of the clearing stations required the issuance of “shorter skirts, gum boots, waterproof hats and raincoats,” while the “scarlet satin linings of greatcoats and capes” were replaced by a “less brilliant shade of cherry” (Nicholson 1975, 44, 60, 117). The preoccupation with dress endured well into peacetime, indicating other motivations beyond practicality. Nursing, like the military, comprises the disjuncture between noble ideals and ignoble realities; moral character, discipline, and camaraderie are instilled as injury, death, and hardship are inflicted and courted, and while the performance of menial, repetitive tasks in conditions ranging from pleasant to horrendous are required. Whatever the reason, the reminiscences of nurses are replete with detailed descriptions of their uniforms, including caps and pins, and these material artefacts have been preserved in many personal and institutional collections. The recently organized Canadian Nursing History Collection includes 37 uniforms and 267 caps from nursing schools across Canada (Bates 2004, 378–80). Military discipline and rank, so useful for the efficient administration of hospital wards, were emphasized in hospital uniforms by the 1930s: Stripes on one’s cap reflected status. A probationer had no cap; after this period the “capping” ceremony occurred, and the first-year student wore a plain cap; the second-year student donned a cap with one stripe; and the third-year student cap was adorned with two stripes. Dress review became part of the daily activities of the nurse, who had to stand for uniform inspection. Shoes had to be polished, the uniform had to be spotless and the cap was not to be worn at a “sexy” angle. (Dolan et al. 1983, 309)

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Once nurses were back in the military in World War II , naturally distinctive uniforms were developed. The Royal Canadian Army Medical Corps (RCAMC) attire included three types of uniforms, including a lion’s head brass belt buckle and a white veil (Toman 2003, 189–90). The nursing sisters not only appreciated the status and respect their uniforms afforded them, but also the opportunity to wear such sumptuous clothing after the financial straits of the Depression. On the other hand, other military ranks did not wear aprons and veils, the latter of which, to this day, signifies the presence of a subservient female in public space in the fundamentalist Islamic world. In similar fashion, the veil permitted the nursing sisters to travel to combat zones, to traverse public spaces unchaperoned without interference, and to have intimate contact with male bodies. Canadian uniforms were superior to those issued to American nurses. The United States Army Nurse Corps was not properly outfitted by its military, whose supply chain was unprepared to provide the thousands of uniforms eventually needed. The ad-hoc provision of uncomfortable and unattractive uniforms resulted in morale and discipline problems (Toman 2003, 190, 194–95). By the permissive 1960s, most of the “privileges” associated with the veil and nursing uniforms in general seemed anachronistic. Nursing students “resisted [the] collective authority” embodied in the school uniforms (Bates 2004, 384), as did potential recruits to voluntary agencies like the St. John’s Ambulance Brigades. Isobel MacAuley, Nova Scotia’s Superintendent of Nursing Division, was preoccupied with dress, impeding recruitment to the Brigade from a new generation: “She was adamant about the way you wore your hat, the way you wore your veil, in the former years.You had to have your skirt a certain length from the floor ... the shoes had to be spit and polished. It was a very military thing, that’s what turned a lot of people off, I think” (Gregor 2004, 366). By the end of the twentieth century, as the content of hospital nursing work improved, and included more real authority, the assumed authority of the uniform lost its significance. For some nurses, however, real authority depended upon the colour of their skin rather than their uniform.

Minorities in Nursing While African-American women were stereotyped as effective, if superstitious, folk-healers, they encountered formidable obstacles when attempting to make the transition to professional nursing. Many in the white nursing establishment shared the racist views of their class or region, or made the deliberate differentiation between themselves and their AfricanAmerican nursing sisters to promote their own self-interests. 18 There were exceptions, and important allies, particularly within certain institu-

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tions and philanthropies, but for the most part the African-American and African-Canadian nurses fought their own hard battles into the profession. Consequently, the history of the African-American nurse includes warriors whose stories became the myths of African-American history. Harriet Ross Tubman, labelled the “Moses of her people,” was the most famous. Tubman was a fearless abolitionist who, after escaping from the Maryland plantation where she was enslaved, made 19 secret forays into the slave south to lead over 300 slaves north to freedom on the Underground Railroad. During the Civil War, she joined the Union Army as a nurse, spy, and battalion leader: “Col. Montgomery and his gallant band of 300 black soldiers, under the guidance of a black woman, dashed into the enemy’s country [and] struck a bold and effective blow” (Carnegie 1995, 8–9; Dolan et al. 1983, 181; Roberts and Group 1995, 89). Sojourner Truth, freed by the New York State Emancipation Act of 1827, was no less famous or courageous. Truth, a preacher for abolition and women’s rights as well as Christianity, made forays on the Underground Railroad and served as a Union Army nurse. During post-Civil War Reconstruction, she assisted freed men in finding homes and work in the northern states (Carnegie 1995, 7–8). The late nineteenth century was a period of increased racial segregation in the United States, and the stereotype of the African-American nurse, common until after World War II, was that she was both “an essential and competent provider of health care in Black communities,” and “an inferior member of the nursing profession when compared to her white counterparts” (Hine 1989, 177). Most early nursing schools would not admit African-American students. The New England Hospital for Women and Children, created by and for women physicians, was one institution that crossed the colour bar, albeit tentatively. Its charter “stipulated that only one Negro and one Jewish student each year would be accepted” (Roberts and Group 1995, 92). In 1879, the New England Hospital’s Mary Eliza Mahoney was the first African-American woman to graduate from a school of nursing (Dolan et al. 1983, 193). The advancement of African-American women in nursing received significant financial and political support from three Gilded Age philanthropists: Standard Oil (Esso)’s John D. Rockefeller, U.S. Steel’s Andrew Carnegie, and Sears, Roebuck’s Julius Rosenwald. Rockefeller and his wife, Laura Spelman Rockefeller, underwrote the creation of the first African-American nursing school with their 1881 endowment of Spelman College, formerly the Atlanta Baptist Female Seminary, which developed a nurse training program. The Julius Rosenwald Fund contributed a “small fortune” to further the advancement of African Americans, including access to trained nurses (Hine 1989, 8). Separate schools opened at Chicago’s Provident Hospital in 1891 and in the segregated Howard

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University and Freedman’s Hospital in 1893. Of the 37 segregated nursing schools operating by 1920, 24 became accredited, but the lack of funds for modern facilities proved crippling. The colour bar was not removed in most American nursing programs until 1951 (Bullough and Bullough 1978, 190–91). Some particularly industrious and creative leaders promoted the advancement of African American nurses in the profession as the twentieth century progressed. In 1908, Martha Franklin, with the assistance of Lavinia Dock, established the National Association of Colored Graduate Nurses (NACGN), an organization that, while never numerically significant, became an excellent lobby group during World War II when both male and female African Americans challenged the Roosevelt government to fully integrate the armed forces. The NACGN’s Mabel K. Staupers was an indefatigable worker in this battle. After the American Red Cross refused her protegé, Mary Elizabeth Carnegie, entry to the Navy Nurse Corps, Staupers lobbied politicians, nursing leaders, military officials, African-American civil rights leaders, and philanthropists, among others. A combination of Eleanor Roosevelt’s support, the backing of the National Nursing Council for War Service, and the severe shortage of nurses eventually won the day (Roberts and Group 1995, 90, 92).19 The victory had limits, however, within the United States itself. With the declaration of war against Japan following the attack on Pearl Harbor, Japanese nationals (Issei) and Japanese Americans (Nissei) on the west coast had their property confiscated and were incarcerated in internment camps in the American interior for the duration of hostilities. Japanese Canadians faced similar experiences. Many Nissei internees turned their horrific experience into a new future. Physicians and nurse supervisors in the camps dealt with their shortage of health care workers by training some of the younger Nissei women as nurses’ aides. After their release from incarceration at war’s end, many of these women pursued nursing careers and broke out of traditional role expectations. However, the colour bar remained as high as ever for African-American nurses, who were not encouraged to seek employment in the internment camps alongside white nurses (Smith 1999, 596–98). North American Jewish women who took up nursing usually followed that career path through the hospitals endowed by Jewish philanthropies and communities, such as New York’s Mount Sinai, Philadelphia’s Jewish Hospital, Montreal’s Jewish General, and Toronto’s Mount Sinai. In the late nineteenth and early twentieth centuries, Jewish women’s involvement in nursing reflected their marginalized ethnic experience. First- and second-generation and assimilated North American Jews retained their memories of European persecution and experience of ambivalent North American acceptance. Unlike most native-born contemporaries in the

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profession, they were less wary of espousing radical solutions to the terrible conditions of the urban slums. As we saw above, Lillian Wald, a second-generation, middle-class Jewish American of German background, graduated from the New York Hospital School of Nursing to become one of the leaders in the American public health movement. Her work at the Henry Street Settlement set the standard for the adaptation of health and welfare initiatives to the realities of the immigrant poor, rather than viceversa. Through her ethnic connections, Wald was able to secure substantial funding from wealthy German-Jewish American philanthropists, such as Jacob Schiff. Backed by Nathan Straus, another New York philanthropist, Henrietta Szold adapted Wald’s model to establish the Zionist organization Hadassah, which first provided health care services in Mandate Palestine. Jewish German-American Emma Goldman’s work as a nurse and midwife in tenement slums informed her Anarchist speeches and writings (Roberts and Group 1995, 88). Whether hobnobbing with millionaires or organizing trade union rallies, this generation’s collective sense of Jewish “otherness” meant that they could never distance themselves philosophically, to any great extent, from the marginalized communities to which they provided health care. Similar self-identification leading to health services administered by rather than to communities occurred for Native nurses. However, directives from above influenced actions below for reserve and other Native districts supervised by federal government agencies. In 1952, Mt. Edgecumbe Tuberculosis Hospital and School in Sitka, Alaska, for instance, began training local Natives (and sometimes patients) as practical nurses and dental assistants, when the Alaska Department of Health recognized that it “would appear feasible and desirable for having the Natives participate in ... the program and [adjust] services and operations to the needs and attitudes of the Natives.”20 Some of the Mt. Edgecumbe graduates remained at the institution, while others returned to their home villages to become Health Aides, disseminating public health education and therapeutics. After the program ended in 1961, aspiring Native nurses were encouraged to enter the Registered Nursing course at the ANS hospital in Anchorage (Meijer Drees 2010). By contrast, the Charles Camsell Indian Hospital in Edmonton, an institution created to treat tubercular patients from northern and western Canada, did not have the training of Native nurses as part of its mandate. Although located in the province of Alberta, the Camsell was a federal institution run by the Department of Health and Welfare, whose interest in the self-administration of health care by Native communities was fleeting. Camsell only offered informal nurses’ aid training in bed-making, cleaning, and bedside nursing, although former patients worked in the kitchens or as cleaners, and some were trained in the technical occupations

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of x-ray technician, laboratory assistant, and orderly. Native nurses did work at Camsell, but they had been educated at nurse training programs in non-Indian Health Services hospitals. The graduate nurses experienced first-hand the inferior conditions of these hospitals. Kathleen A.J. Steinhauer-Anderson of Saddle Lake First Nation recounted her first days at Camsell’s paediatric ward in 1954: “The conditions there were pretty bad. The babies were all dried with the same towel! I had to petition hard to get separate towels and towel racks for each baby patient. Some FIGURE 7.3 : Jean Cuthand, things were just improper.” The Canadian Canada’s First Aboriginal federal government only took measures to Registered Nurse. train and support Native Community Health Representatives in the 1970s, after the emergence of the Indian Rights movements (Meijer Drees 2010). Male Nursing Male nurses, while no longer a curiosity, remain a tiny minority of the profession. The American Nurses Association organized the Men Nurses Section in 1940, and in the postwar period, their numbers began to rise, first in the area of psychiatric nursing, where they always had been present, but referred to as attendants or orderlies, with varying degrees of training or skills. There were 1,916 men enrolled in American baccalaureate programs by 1975. As salaries and working conditions improved, nursing became more attractive an option for men; indeed, salaries traditionally have been higher for male than for female nurses (Bullough and Bullough 1978, 216). By 2000, there were 146,902 male RNs in the United States, constituting 5.4 per cent of the profession.21 Canadian statistics were virtually identical, with men comprising 4 per cent of nurses by 1995.22 This included substantial growth during the 1980s, when the numbers almost doubled from 3,936 to 7,316 (Baumgart and Larsen 1992, 49). The status of male nursing may not have increased substantially however. In the popular 2000 comedy, “Meet the Parents,” the protagonist’s choice of nursing over medicine as a profession was viewed as evidence of his mediocrity.

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Conclusion Nursing has held many attractions for North American women (and some men) over the last two centuries despite its inequities, hardships, and stresses. For the middle class who would become its leaders, nursing meant “entry into a female world of almost unparalleled autonomy, control and professional status.” For non-elite nurses, it meant “entry into a skilled craft that combined the sanctity of a feminine ‘calling,’ the promise of economic self-support, and a taste of the freedom of the urban working world.” For all nurses, it meant “the possibility of constructing lives with meaningful, easily accomplished, and socially sanctioned connections between private interests and public concerns” (D’Antonio 1999, 274). Nurses displayed considerable loyalty to their alma maters. When McGill University threatened to close its Nursing School during the Depression, a fundraising campaign directed at alumni netted a substantial $20,000.00, which maintained its existence and impressed the school’s administration (Ross-Kerr 1998, 252). The history of nursing over the last two centuries, like the history of women in general, has been a blend of ambivalent advancement, courageous battles in isolation, setbacks, and retrenchment. The specific issues of nursing — professional recognition, adequate and equitable compensation, and accepted avenues of authority — remain constant.

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Notes 1

2 3

4

5

6

7 8 9 10 11

12

13 14 15 16 17 18

Dr. Charles Seward made similar complaints in 1832, when the cholera epidemic reached Toronto: the nurses “were so unfit in every respect to assist him, that unless others were hired, his health must be sacrificed” (Young 2004, 286). The rat catcher earned $20.00, the nurses $12-$15 (Coburn 1974, 141). The Halifax Explosion occurred during the Great War, when a munitions ship collided with another vessel in Halifax Harbour. The explosion levelled the city’s downtown and killed over 3,000 people. So great was the blast that it was used as the measuring rod when the atomic bomb was later developed. These features of the “total institution” were first outlined in Erving Goffman’s classic study Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961) as well as Michel Foucault’s Madness and Civilization: A History of Insanity in the Age of Reason (1973) and other works. Johns supported the Winnipeg General Strike. Like other nurses who had been involved in public health work, she was sensitive to the association of illness and poverty. The UBC program, copied by other Canadian schools, incorporated two years of university courses, two years of hospital work, and one more year at the university (Zilm and Warbinek 1994, 30). Such as The Proposed Curriculum for Schools of Nursing in Canada, published in 1936 (Stewart and Austin 1962, 247; Coburn 1974, 142). Dolan states she was the first professor of nursing in the world (Dolan et al. 1983, 212). Wald expressed support for the Russian Revolution and the modernizing efforts of the Bolsheviks (Bullough and Bullough 1978, 146). Due to her industry and dynamic personality compared to her retiring husband, Lady Aberdeen has been termed Canada’s first woman governor general. In 1916, Ontario’s infant mortality rate was 107 per 1,000 live births, while the British rate was 90 and the New Zealand rate, the world’s recorded lowest, was 50 (Stuart 1989, 112, 114). English-French relations, strained by the execution of Métis leader Louis Riel, were further exacerbated by the Dominion’s involvement in the Boer War, which French Canadians viewed as another aggressive, British imperialist adventure. “Nursing,” American Red Cross, http://www.redcross.org/services/ nursing/0,1082,0_389_,00.html. The British Crown Colony of Newfoundland joined Canada in 1949. “Psychiatric Nursing,” Registered Psychiatric Nurses of Canada, http://www. rpnc.ca/pages/about.php. “Psychiatric Nursing History,” The Psychiatric Nursing Teachers Home Page, http://www.scs.unr.edu/~chaffina/psychnsg.html. For an analysis of changing female images in advertising in North America and Britain, see Warsh and Tinkler 2007. That feminism could “trump” racism was a peculiar feature of first-wave feminism, particularly in Canada. Judge Emily Murphy, for instance, saw no contradiction between promoting the rights of women as “persons” before the law and promoting the sterilization of the socially “unfit.” She also wrote one

part iii: professions

of the most blatantly racist tracts in Canadian literature, The Black Candle, which demonized the west-coast Asian community. Until very recently, Canadian and feminist historiography has treaded lightly and apologetically around the racism, nativism, and anti-Semitism of first-wave feminism. 19 Like the American Red Cross, the International Red Cross, despite its humanitarian mandate, was morally deficient, particularly during World War II. The international society, based in Switzerland, refused to enter the concentration camps in occupied Europe, deeming them an “internal German problem.” 20 Alaska Native Health Service, “Discussion points related to transfer of Alaska Nursing Service to Alaska Department of Health, 1955,” quoted in Meijer Drees, 2010. 21 US Government, Health Resources and Services Administration (HRSA), Bureau of Health Professions, Division of Nursing, “The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses: Table 1,” March 2000, http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/ rnss1.htm. 22 Statistics Canada, “Male Registered Nurses 1995,” http://www.statcan.ca/bsolc/ english/bsolc?catno=82-003-X19960022828.

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Epilogue THE CASE FOR CHAOS

From native girls contemplating their futures in their first

menstrual huts to contemporary 40-year-old women nervously filling out fertility clinic questionnaires, women have confronted their reproductive experiences with the weight of centuries of socio-cultural attitudes and expectations. New technologies and interventions have opened many doors and provided many cures, yet mysteries remain. Why do some women (or indeed most women at different times) have regularly timed menstrual cycles while others vary from month to month? Why do some women have no problem conceiving children while others, with no apparent health problems, have difficulties? Why do some women have numerous unpleasant or painful symptoms during menstruation or menopause, while others sail through the events with none? Traditional medical therapeutic models dealing with these anomalies — which can’t, for the most part, be termed illnesses since they are part of the normal functioning of the body — have relied upon an Aristotelian, binary, and linear paradigm; that is, you can’t be both sick and well, blood indicates illness, and health equals regularity. These therapeutics have not always been successful and may present new medical problems of their own. Perhaps the use of a new model — chaos theory — will better explain why linear approaches have been unsatisfactory models for the development of disease models and therapeutics, including pharmaceuticals. Chaos or complexity theory, as introduced by Henri Poincaré in 1890 and Edward Lorenz in 1963, seeks to explain the unpredictable nature of natural and man-made events such as weather systems, traffic jams, epidemics, and cardiac problems. In examining weather patterns, Lorenz found that complex behaviour arose from “supposedly simple equations; 271

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also, the behaviour of the system of equations was sensitively dependent on the initial conditions of the mathematical model.” This “implied that if there were any errors in observing the initial state of the system, and this is inevitable in any real system, prediction as to a future state of the system was impossible.” Lorenz evocatively termed this the “butterfly effect,” citing the proposition that “a butterfly flapping its wings in Hong Kong can affect the course of a tornado in Texas” (Lorenz 1963, 130–141). In 1993, A.B. Cambel listed various features of chaos, all of which find resonance in female reproduction: complexity can occur in natural and man-made systems, as well as in social structures and human beings. Complex dynamical systems may be very large or very small, indeed, in some complex systems, large and small components live cooperatively. The system is neither completely deterministic nor completely random, and exhibits both characteristics. The causes and effects of the events that the system experiences are not proportional. The different parts of complex systems are linked and affect one another in a synergistic manner [and] there is positive and negative feedback. The level of complexity depends on the character of the system, its environment, and the nature of the interactions between them. (Cambel 1993, 3–4)

Chaos theory, or the synergistic relationships of all that comprise and affect a woman’s body, may explain some of the mysteries that remain in the area of women’s health issues and the discoveries that run counter to long-held beliefs, such as the course of a woman’s ovulatory cycle. That the heightening of female hormone levels at mid-cycle is an indication of a woman’s peak period of fertility is now universally accepted medical knowledge, which led to the creation of contraceptive and fertility advice and technology in the twentieth century.Victorian physicians incorrectly advised female patients desiring to control reproduction because they did not know this, as feminist and medical historians have commented (see, for instance, Bullough and Bullough 1977, 92, 104). But what if this accepted truth was only part of the story? At the University of Saskatchewan in 2003, researchers Roger Pierson, Gregg Adams, and Angela Baerwald used ultrasound technology to “peer” into female reproductive organs. They found that of 63 women with normal menstrual cycles, only 50 had normal ovarian cycles: “Thirteen of the women ovulated multiple times, in various different ways. And of the other fifty, 40 percent had up to three waves of activity by the follicles, any one of which could result in the production of an egg.” They concluded, “The hormones do what they are going to do and the ovaries just follow their merry path. We always thought menstrual cycles and ovarian cycles were one and the same. It

epilogue

turns out they’re just like two political parties — sometimes they go along hand in hand for the good of the country and sometimes they go their separate ways” (Baerwald et al. 2003, 116–22).1 Similarly, by the end of the twentieth century, premenstrual syndrome remained misunderstood yet generally (in fact too generally) accepted. From an original definition of premenstrual tensions and anxieties, by 1968, in classic chaotic fashion, over 150 different symptoms were cited as somehow associated with the menstrual cycle (Johnson 1987, 341). Childbirth has been most thoroughly subjected to mechanistic models and procedures over the last two centuries, yet women continue to experience their pregnancies, labour, deliveries, and recoveries in countless ways, with extreme variations occurring for a single woman in a succession of birthing experiences. How much pain she will be subjected to in labour, whether she will be a victim of eclampsia (a condition which also remains a “mystery”), whether she will bounce back from her delivery or suffer extended bouts of postpartum depression — all of these again vary ad infinitum. What all these uncertainties have in common is that, at numerous times and in numerous ways, they were “explained” as being the woman’s fault. By her intemperate habits or ambitions, past risky behaviours or unhealthy attitudes, hereditary taint or physiological deficiencies, she must have in some way brought about the condition that upset the binary apple cart. However, a surgical procedure, psychiatric treatment, or pharmaceutical regime was promised to regain her equilibrium. As has been shown, there often were serious costs associated with this “equilibrium.” Moreover, women have faced the challenge of attempting to fit their own career and personal goals within the structures of male, increasingly science-oriented medical and nursing professions and hospital systems. Expectations of feminine empathy and submissiveness conflicted with those of masculine “objectivity” and authority, often to the detriment of their relations with other women — patients, midwives, and each other. Uncertainties, irregularities, mysteries, and unexpected consequences — the stories of women’s health, as indeed life itself, are complicated, messy, and even chaotic. Perhaps it is time to embrace the chaos instead of prescribing what the norms of a woman’s life should be.

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Note 1

Pierson’s use of ultrasound imaging in reproductive research was named one of the top 100 scientific discoveries of 2003 by Discover Magazine. See http:// www.usask.ca/research/100yrsinnovation/5_healthy_horizons.php.

References

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Warsh, Cheryl Krasnick. 1989. Moments of Unreason:The Practice of Canadian Psychiatry and the Homewood Retreat, 1883–1923. Montreal: McGill-Queen’s University Press. ——, and Veronica Strong-Boag, eds. 2005. Children’s Health Issues in Historical Perspective. Waterloo: Wilfrid Laurier University Press. ——, and Penny Tinkler. 2007.“In Vogue: North American and British Representations of Women Smokers in Vogue, 1920s–1960s.” CBMH, 24, 1. Weideger, Paula. 1976. Menstruation and Menopause:The Physiology and Psychology, the Myth and the Reality. New York: Alfred A. Knopf. Welter, Barbara. 1976a. “The Cult of True Womanhood.” Dimity Convictions:The American Woman in the Nineteenth Century. Athens: Ohio University Press. ——. 1976b. “The Feminization of American Religion.” Dimity Convictions:The American Woman in the Nineteenth Century. Athens: Ohio University Press. Whiting, Beatrice B. 1974. “Folk Wisdom and Child Rearing.” Merrill-Palmer Quarterly 20 (January). Whittaker, Jo Anne. 1984. “The Search for Legitimacy: Nurses’ Registration in British Columbia 1913–1935.” In Barbara K. Latham and Roberta J. Pazdro, eds., Not Just Pin Money. Victoria: Camosun College. “Wife of Norwegian.” 1914. “Care of Mother.” Letter to editor. Grain Growers Guide, 1 April: 14. Wild, Marjorie. 1984. Elizabeth Bagshaw. Markham: Fitzhenry and Whiteside. Williamson, G. LaVerne. 1993. “Postpartum Depression Syndrome as a Defense to Criminal Behavior.” Journal of Family Violence 8, 2. Wishart, James M. 2004. “We have worked while we played and played while we worked: Discipline and Disobedience at the Kingston General Hospital Training School for Nurses, 1923–1939.” CBMH 21, 2. Wood, Susan F. 2005. “Women’s Health and the FDA.” New England Journal of Medicine 353, 16 (20 October). Worthington-Roberts, Bonnie, and Sue Rodwell Williams. 1997. Nutrition in Pregnancy and Lactation, 6th ed. Madison, WI: Brown and Benchmark. Yeo, SeonAe, Michael Fetters, and Yukio Maeda. 2000. “Japanese Couples’ Childbirth Experiences in Michigan: Implications for Care.” Birth 27, 3 (September). Young, Judith. 2004. “Monthly’ Nurses, ‘Sick’ Nurses, and Midwives in Nineteenth-Century Toronto, 1830–1891.” CBMH 21, 2. Zilm, Glennis, and Ethel Warbinek. 1994. Legacy: History of Nursing Education at the University of British Columbia, 1919–1994. Vancouver: University of British Columbia School of Nursing. Zivi, Karen D. 2000. “Who is the Guilty Party? Rights, Motherhood, and the Problem of Prenatal Drug Exposure.” Law and Society Review 34, 1.

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Index American Academy of Obstetrics and Gynaecology, 112 American Center for Disease Control, 133 American Children’s Bureau, 98 American College of Nurse-Midwives, 106 American College of Physicians and Gynaecologists, 125, 145 American Dispensatory, 28 American Federation of Nurses, 239 American Medical Association, 155, 208, 214 American Medical Women’s Association, 190, 191, 193 American National Center for Health Statistics, 143-144 American National Institute of Health, 69 American Paediatric Society, 214 American Psychiatric Association, 44 Ames, Azel, 27 amniocentesis, 163, 164-165 anaesthesia, 120-123 Twilight Sleep, 121-122, 123 unborn child and, 120-121, 122 Anderson, Elizabeth Garrett, 27, 184, 221nn5,6 Anglican nursing sisters, 248 Angwin, Maria, 202 Anne of Green Gables, 53 Anthony, Susan B., 180 antibiotics, 112 antiseptic birth rooms, 90, 91, 92 Apache female puberty ritual, 8 Apgar,Virginia, 122, 197 Apple, Rima, xiii, 86 Arikara women, 43 Aristotle, 15, 44 Armstrong, Elizabeth, 148-149 Arnold, A., 57 Arnup, Katherine, xiii assistance maternelle, 248 Asylums (Goffman), 10 Avis, Nancy, 63-64 Ayers, Hamilton, 57 Ayerst Laboratories, 70 Ayres, Sister Anne, 226

Abbott, Maude, 195, 195, 197, 198 Aberdeen, Lady Ishbel, 102, 246, 268n10 abortion, xiv, 134 19th century, 155-156 British Common Law, 154 cases, 157 “defective” foetus, 164-165 medical decision, 157, 170 midwives and, 81-82, 96-97 Native female healers, 83 pro-life lobbies, 158 slavery, 82 for teenagers, 139-140 unequal access, 158 Abraham, G.E., 42 Abston, Sally, 193 abuse causing disorders, 43 Adams, Gregg, 272 Adamson, Sarah, 183 Addams, Jane, 196 addictions and foetus, 158-159 adolescence, myths, 11 African Americans, 49, 64, 65, 66 birth rates, 118 female physicians, 199 maternal mortality, 107, 108, 118, 133 nurses, 239, 262-264 single mothers, 139 student quotas, 216 aging cultural markers, 48-55 dependency, poverty, 54-55 reproductive status, 48-49, 51 visual images, 50, 51-54 Agnew, Hayes, 210 Ahi, Louise, 94 Aitken, Kate, 99 Alberta, public health, 247-248 alcohol and birth defects, 159 Alcott, Louisa May, 250 Alexander the Great, 15 alienists. See psychiatrists Allbutt, Sir Clifford, 21 Alpha (Winslow), 202-203 alternative birth, 131, 144-146, 150, 151 amenorrhea, 16, 28, 40-41

baby blues, 141 Bacon, Lena Kernen, 102 305

306

index

Baer, Ellen, xiv Baerwald, Angela, 272-273 Bagshaw, Elizabeth, 182, 220 Baillargeon, Denyse, xiii Baker, Josephine, 95, 179 Baltimore Dispensary, 179-180 Banta, David, 126 Barager, Arthur, 256 Barringer, Emily, 191 Barry, James Miranda Stuart, 193, 222n13 Bart, Pauline, 65 Barton, Clara, 250 Battey’s Operation, 29 Beatty, Elizabeth, 188, 212 Beecher, Catherine, 177 Bellevue Nursing School, 232, 234 Benedetti, Thomas, 125 Benjamin, Alice, 131 Benoit, Cecilia, xiii-xiv Berliner[blau], Fanny, 198 Berman, Edgar F., 38 Bernhardt, Sarah, 51 Berryhill, Elizabeth, 106 Best, Sophie, 94 Bewitched (TV series), 53-54 Billings, John Shaw, 231 birth and death registration, 97 birth control, xiv, 182 by the 1940s, 117 Canada vs. US, 118 Catholic Church, 220 midwives, 81-82 Native female healers, 83 pill and menstruation, 32 slavery, 82 tubal ligations, 128 birth rates, 118 Birth Without Violence, 147-148 birthing coaches, 153 birthing rooms, 150, 152n16 birthmarks, folk beliefs, 84 Bischoff, Theodor, 205 Bishop’s University, 186, 206, 217-218 Black, Elinor, 194, 218 Blackfoot people, 56, 82 Blackwell, Elizabeth, 89, 180, 230 feminism, 191-192 social activism, 179 support networks, 183-184, 200, 202 training, 198, 211-212 work for troops, 250 Blackwell, Emily, 186, 187, 211 female physician’s role, 179 rejections by colleges, 209 training, 198 blood-letting, 15, 22 blood taboos, menses, 4-7, 15-16

blue-baby operation, 197 Blue Books, 181-182 Blundell, James, 87 Boas, Franz, 9 Bober, Bessie, 189 Boer War, 251, 268n12 Bolton Bills (US), 255 bone density screening, 71 Book of Secrets, 59 Bourgeault, Lynn, xiii Bowditch, Henry, 183 Brandon University, 257 breastfeeding, 83, 143 Breckenridge, Mary, 105-106 Brewster, Mary, 245 bride-price and virginity, 11 Brochu, M.D., 88 Brotherson, Louis, 40 Brumberg, Ruth, 20 Buchan, William, 59-60, 61 Butler, Josephine, 177, 221n6 Cabot, Samuel, 183 caesarean sections, 127-132 by 21st century, 133, 134 emotional responses, 131-132 income and race, 133 maternal mortality, 128, 129, 130 rates, 119, 125, 128-129, 130-131, 132 reasons for preference, 129-130 relative safety (1980), 130 calcium, 72 Caldeyro-Barcia, Robert, 149 Calenda, Costanza, 175 Cambel, A.B., 272 Campbeilh, Louise, 94 Campbell, Francis Wayland, 206 Canadian Federation of Medical Women, 190 Canadian Medical Association, 102 Canadian Mother and Child, 111 Canadian Mother’s Book, 99, 112 Canadian Nurses Association, 234, 236, 238, 239 Canadian Practitioner, 30 Canadian Practitioner and Review, 122 Canadian Suffrage Association, 181 Candib, Lucy, 126, 143 Carastro, Anna, 94 cardiovascular disease claims for ERT, 70, 71 risk factors, 72, 72-73 Carmody, Mrs. Francis X., 122 Carnegie, Andrew, 263 Carnegie, Mary, xiv Carrier people of BC, 8-9 Catholic Church birth control, 220

index

nursing orders, 223, 225-227 on tampons, 14 Caton, Donald, 120 celibacy and dysmenorrhea, 29 Channing, Walter, 90-91, 120 chaos theory in women’s health, xvi, 271-273 charivaris, 36 Charles Camsell Indian Hospital, 265-266 Child Welfare Division (Canada), 98-99 childbirth, xiii, xv, 182, 273 better experience sought, 118-119 birthing positions, 149-150 “designer” births, 134 doctor’s involvement, 153-156, 167-170 family involvement, 132 father’s role, 149, 153 folk beliefs, 84 hospital births, 91-93, 98, 132-134 pain control, 120-123, 133 recovery time, 84-85, 132, 141 technology and mother’s role, 151 traditional practices, 80-83 childbirth advice popular magazines, 85-86 preliterate societies, 85 Children’s Health Bureau (US), 107, 156 chloroform, 90, 120, 121, 122 chlorosis, 20-22 chlorpromazine, 187 Christie, Kay, 254 cities, unsanitary conditions, 94 Clare, Mother, 226-227 Clarke, Edward H., 25-26, 205, 206, 207 Cleaves, Margaret, 214 Clouston, T.S., 26 Cole, Rebecca, 199 College of Physicians and Surgeons of Ontario, 208 Comacchio, Cynthia, xiii Complete Book of Birth, 149 contraception birth rates and, 140 fertility and, 166 Cornell University, 186 Cosmopolitan magazine, 54 cottage hospitals, 102, 110-111 Country Doctor, A, 203 Cree people childbirths, 136 menopause, 56 Crime Scene Investigation, 161 Crone Circle Women of BC, 57 Crowell, F. Elisabeth, 95 Currier, Andrew, 57 Dalhousie University, 186, 234 Dalton, Katharina, 39, 42 Daly, Mary, xiii

Davies, Emily, 221n6 Davis, Dona Lee, 56 Davis, Natalie Zemon, 36 daycare, mother-child bonding, 140 de Kergaradac, Lejumeau, 154 Del Zio, Doris, 167-168 DeLee, Joseph B., 123 depression menopausal, 61, 65, 66 postnatal, 141-142 premenstrual syndrome and, 38 Deutsch, Helen, 64 Dewees, William Potts, 22, 155 Dewey, John, 26 Dick-Read, Grantly, 147, 148 diethylstilbestrol (DES), 41, 69 Dimock, Susan, 198 disabled mothers, 137-138 discharge times, 132, 141 dispensaries, 179-180 Dispensary, Toronto, 181 Dix, Dorothea, 250 Dixon-Jones, Mary, 191, 192, 215 DNA, 161 Dock, Lavinia, 231, 238, 239, 246, 264 doctors. See female physicians; physicians Dodd, Dianne, xiv Doe v. Boulton, 157 Domestic Medicine, 59-60 Dominion Medical Monthly, 61 Donegan, Jane, xiii Donnison, Jean, xiii Donovan, Bonnie, 126, 134 Down’s syndrome, 164-165 Drachman,Virginia, xiv Drake, Emma, 57 dress for pregnancy, 83-84 dysmenorrhea, 28, 33, 39-40 celibacy and, 29 endometriosis, 40 and lost worktime, 37 eclampsia, 88, 114n9, 273 Edward, Mary Lee, 190 Ehrenreich, Barbara, xiii electrotherapy, 29 Emergency Maternity and Infant Care Program, 99 “empty-nest syndrome,” 65, 66 endometriosis, 28, 40 English, Deirdre, xiii The Englishwoman’s Journal, 184 environmental hazards, 166 epidural anaesthesia, 122-123 Episcopalian nursing sisters, 226-227 episiotomies, 124, 133 estrogen, 3, 4, 54 carcinogenic properties, 69, 70

307

308

index

as cosmetic, 73 dangers of treatment, 69-70, 74 replacement therapy, 67-68, 69-71 synthesized (1930s), 67 estrogen, and PMT, 42 ether, 91, 120, 121, 122 “ethinyl estradiol,” 69 eugenics movement, 57 Evans, David, 18 Eveleigh, Susan, 94 Every Man His Own Physician, xiii, 227 Everyman His Own Doctor, 57 Eve’s Daughters, 29 fainting, 177 family doctors vs. obstetricians, 142-143 Farm of Tennessee, 144 Farnham, Eliza W., 58 fathers, role in delivery, 149, 153 Fawcett, Millicent, 221n6 Federation of Medical Women of Canada, 193 Feldberg, Georgina, xiv female physicians, xv-xvi, 26, 27, 89, 174, 175-220 African-American women, 199 ancient and medieval, 175 bars at colleges, 204-205, 209-211, 215-217 distinguished, 20th century, 194-197 effect on medical profession, 219-220 European training, 197-198 feminism and. See feminism in fiction, 203-204 glass ceilings, 218-219 Great War, 189-190 internships and residences, 217-218 legal harassment, 215 medical societies and, 214-215, 217 military service, 189-191, 222n11 missionary work, 188-189 numbers, 200, 201t nurses and, 218, 232 opportunities, 176-177, 179, 179-180 opposition, 176, 178, 179, 180, 200, 202-219 parents, 200, 202, 204-205 professional organization, 186 quotas, 180-181, 185, 193, 216-217 specialties, 219, 220 student experience, 211-214, 217-218 support, xiv, 176, 181, 183-184, 186, 215 women’s medical colleges, 180-181, 211 See also nurses feminism 19th-century, 58, 184, 227 1960s and today, xiii, 182, 204 female anti-feminism, 186-187, 191-194

Florence Nightingale and, 230 nursing, 227 supporting women doctors, xiv, 180, 184, 221n6 Fenwick, Kenneth, 24, 28, 29 fertility contraception and, 166 peak period, 272 rates. See birth rates fertility treatments, 167-168 fetoscopy, 162-163 First International Congress on the Menopause, 64 Fisher, Seymour, 34 Flexner Report (1910), 210-211, 213, 236 foetal alcohol syndrome, 159 foetal monitoring, 125-127, 132, 133 foetus and mother, 154, 156, 159-160, 164-165 and physician, 154, 155, 170 folk beliefs childbirth, 84 menstruation, 4-5, 6-7, 16-17 follicular phase, 3-4 Food and Drug Administration (US), 41, 42, 74 forceps, 90, 123-124 Fortnightly Review, 27 Foucault, Michel, 10 Frank, Robert T., 33-34, 42 Franklin, Martha, 264 Freud, Sigmund, 34 Freund, John, 17 Frontier Nursing Service, 105-106 Fryer, Mary, xiv Gallie, Gordon, 122 Gardner, William, 19-20, 87 Garrett, Elizabeth, 27, 184, 221nn5,6 Gaskin, Ina May, 144 Gauss, Carl, 121, 122 genetic engineering, 153 genetic testing, 161-162 George Washington University, 210 germ theory, 93 GIFT (gamete intrafallopian transfer), 167 Gilman, Charlotte, 184, 221nn7,8 Giving Birth in Canada, xiii Glube, Mildred R., 188 Goffman, Erving, 10 Goldbloom, Alton, 203-204, 222n16 Golden, Janet, xiii Goldman, Emma, 239, 265 Goldmark, Josephine, 236 Gordon, Margaret Blair, 181 Gorham, Deborah, xiv gouttes de lait, 248 Graduate Nurses’ Association of Ontario, 256

index

Grain Growers Guide, 85-86 grandmother role, 51 granny midwives, 107-111 Arkansas, 107-108 folk beliefs, 108 Georgia, 108-109 practices, 109-110 Great Plains tribes, 8 Great War female physicians in, 189-190 social movements following, 75n2 Green, Ellen, 85 Greenberg, Roger, 34 Greene, Raymond, 42 Gregory, Samuel, 89 Grey Nuns, 225, 232, 249 Grier, Eliza Anna, 199 Guest, Edna, 187 gynaecology, 17, 18 examination, 135 surgery, 29 Haberlandt, Ludwig, 34 Hahnemann, Samuel, 115n19 Hale, Mamie, 108 Halifax Explosion, 268n3 Hall, Archibald, 90 Hall, G. Stanley, 215 Haller, John, xiii Haller, Robin, xiii Halloween, 36, 51 Halsted, William S., 259 Hamilton, Alice, 185, 196 Hamilton, Annie, 188 Hampton Robb, Isabel, 231, 238 Harland, Marion, 29 Harvard University, 186, 213 Health and Welfare Canada, 42 health insurance access, 118, 133, 157 coverage, xi-xii maternal mortality, 118 medical societies, 219 and nursing, 237-238 health manuals on menstruation, 20, 28 Our Bodies, Ourselves, xiii, 58, 182 on sanitary pads, 13, 14 health reformers, xiii, 177-178, 219-220 Hennigar, Annie, 189 Henry Street Settlement, 245, 246, 265 herbalists and abortions, 82 Hildegard of Bingen, 16 Hilliard, Marion, 49, 187 Hine, Darlene, xiv, 199 Hippocrates, 5, 15, 18 Historia Naturalis, 15-16 Holmes, Oliver W., 91, 135

Holmes, Peggy, 101 home births hospital birthing rooms, 150-151 opposed by physicians, 145-146 homeopathy, 115n19, 178 Hôpital St-Sacrement de Québec, 106-107 Hôpital Ste-Justine (Montreal), 180 hormone replacement therapy, xii, 67-74, 70 alternatives, 73-74 dangers, 74 marketing, 70, 73 osteoporosis, 71-72 and smoking, 72-73 hormones and female irritability, 44 and menstrual mood swings, 42-43 and menstruation, 3-4 prostaglandins, 39 therapy for PMS, 34 Horney, Karen, 34, 195 Hospital magazine, 242 hospitals childbirth in, 81, 119-134 childbirths moved to, 91-93, 98 facilities and equipment, 165 free care, 94 growth (1873-1923), 231 innovations, 147-151 nursing in, 93, 243-244 hot flashes, folk beliefs, 57 Howard University School of Medicine, 199 Howell, Mary, 182 HRT. See hormone replacement therapy humours, 5, 18, 57, 59-60 Hunt, Harriot, 178, 179, 184, 214 Hunt, Sarah, 178 Hurd, Henry M., 212 Huss, Kathryn, 123 Huter, C.C., 120 hygiene movement, 14 hypnosis, 147 Indigenous peoples beliefs on menstruation, 4-5, 6 cures for menstrual disorders, 43 puberty rituals, 8-9 respect for older women, 56, 58 tampons, 7 traditional birth practices, 81 Industrial Toxicology, 196 infant mortality antibiotics, 112 Canadian government measures, 98-99 connected with maternal mortality, 102 decline 1940s to 1970s, 117 disparities in rates, 113 indoor plumbing helps, 96 lowered by trained midwives, 110

309

310

index

Native women, 136 numbers aiding midwives, 143-144, 145 rates, 92, 94, 96, 97-98, 268n11 reduced by improved sanitation, 98 infertility, 154, 165-166 intercourse and menstruation, 15, 16 International Council of Nurses, 239 Inuit birthing clinics, 137 childbirth practices, 80 older women, 56 osteoporosis, 71 preparation for menarche, 8 “involutional melancholia,” 61 Irish women (1960s), 65 iron deficiency, 20-22 Iroquoian society, older women, 56 isolation in puberty rituals, 8-9 Israeli women and menopause, 56 Jackson, Gussie, 109 Jacobi, Abraham, 196 Jacobi, Mary Putnam, 26, 29, 58, 177, 184, 196, 197, 198 Jamieson, Elizabeth, xiv Japan, leave during menstruation, 38 Japanese-American women, childbirth, 137 Japanese ritual for menarche, 11 Japanese women and menopause, 66 Jarrett, Elizabeth, 95 Jean Lobstein the Younger, 71 Jesuit Relations, 4-5, 6 Jesup expedition, 9 Jewish women early medical graduates, 187-188 and menopause, 58, 65 nurses, 264 Jews, university quotas, 216 Jex-Blake, Sophia, 202, 213, 222n15 Johns, Ethel, 235-236, 268n5 Johns Hopkins University, 186, 210, 212 Johnson & Johnson Company, 13 Johnson, Halle Tanner Dillon, 109 Journal of the American Medical Association, 123 Kaiser, Barbara, 135 Kaiser, Irwin, 135 Kajander, Ruth, 186-187 Kealey, Linda, xii Kellogg, William H., 60 Kennedy, Evory, 154-155 Kilpatrick, Elizabeth, 194-195 Kimberley-Clark Corporation, 13 King, F.A., 23 King, Francis T., 230, 231 King, John, 28 Kingston General Hospital Nursing School, 234

Kingston Women’s Medical College, 180-181, 185, 202, 212 Kirschbaum, Megan, 138 Kitzinger, Sheila, xiii Klaus, Hana, 64 Knockwood, Isabelle, 10 Koeske, Randi Daimon, 63 Kotex, 13 Koyukons, childbirth practices, 80-81 Kraepelin, Emil, 61 Kronin, Bernhardt, 121 Ladd-Taylor, Molly, xiii Ladies Book, 28-29 Ladies Book of Useful Information, 20 Ladies Home Journal, 204 Lagemann, Ellen, xiv Lamaze, Fernand, 147, 148 Lancet (British), 209 Lancet (Canada), 206-207 Lange, Johannes, 20-21 Langtry, Lillie, 51 Lanham Act (US), 99 Laycock, Thomas, 23 Leavitt, Judith, xiv, 85 Leboyer, Fredrick, 147-148 Lee, Rebecca, 199 leeches, 15, 22, 62 leucorrhea, 29 LeVasseur, Irma, 180, 190 Lever, John C., 88 Lévesque, Andrée, xiii levonorgestrel, 158 Lewenson, Sandra, xiv Lewis-Landau, Regina, 188 life expectancy, 47, 48-49, 51 liminal period. See menarche Lindee, Susan, 161 linear progress, xvi literature, aging women in, 53 The Little Mermaid (film), 53 Livingston, Nora Gertrude, 232-233 Lockhart, F.A.L., 91 Longshore, Joseph, 183 Longshore-Potts, A.M., 60 Lorber, Judith, 187 Lorenz, Edward, 271-272 Love (Michelet), 20 Lydia Pinkham Company, 62, 66-67 MacAuley, Isabel, 262 MacDonald, Margaret, 251, 252 MacDonnell, Robert, 29 Mack, Theophilus, 232 MacKenzie, Jemima, 188-189 MacMurchy, Helen, 98, 102, 111, 112, 114n18, 181-182 Madwoman, 64

index

Mahoney, Mary Eliza, 263 male nurses, 266 Maliseet, older women, 56 Mance, Jeanne, 225 Manitoba Association of Graduate Nurses, 256 Manual of Obstetrics, 28, 29 marking an infant, 80, 81, 84, 99 Martin,Vera, 9-10 Materia Medica for Nurses, 239 maternal feminism, 155 maternal mortality African-American, 107, 108 causes, 84, 91, 117-118 decline in 20th century, 49, 117 discrepancies in rates, 133 disparities in rates, 113, 118 early 20th century, 85, 97, 111 fall with antibiotics, 112 link to infant mortality, 102 MacMurchy survey, 102, 111 sanitation reducing, 92, 98 and trained midwives, 110-111 Maternity Center Association, 106 maternity ward (Canada, 1998), 133 Mathers, A.T., 216-217 Maudsley, Henry, 27, 61 maximum hours laws, 27 Mayan women in Mexico, 56, 71 Mayo, Charles, 242 McClellan, Mark, 74, 158 McClure’s Magazine, 121 McGill, Frances, 194 McGill University, 195, 222n14, 267 McGillivray, Alice, 212 McKinney Steward, Susan, 199 McLaren, Angus, xiv, 118 McLaren, Arlene, 118 McPherson, Kathryn, xiv Mead, Margaret, 35, 56, 58 Medicaid. See health insurance medical establishment masculinity, 44, 207 opposition to females, 205-209 Medical Letter, 69-70 medical missionaries, 188-189 The Medical Profession, 207 medical schools entry bars for women, 209-211, 215-217 women as students, 211-214 medical societies, refusing females, 214-215, 217 medical technology, 161-165 Medicare, xi-xii, 118 Meharry Medical School, 199 Meigs, Charles D., 120, 127 Melosh, Barbara, 244 menarche, 4, 7-13

age of, 18, 20 as medical concern, 18-20 myths in Europe, 10-11 North American prudery, 11-13 related to environment, 17 rituals marking, 7-9, 11, 19 seclusion, 8-9 Mendenhall, Dorothy Reed, 192, 212 Menninger, Karl, 34 menopausal mania, 61 menopause, xv, 2 cultural differences, 55-58 drug industry, 70, 73-74 experience, not disease, 55-59 hormone replacement, 67-74 as madness, 64-66 medical model, 47-48, 67-70 medication for, 64-65 patent medicines, 66-67, 70 in popular culture, 52-54 research approaches, 63 sexuality, 48-49, 51 stresses, 65-66, 68 taboo and disease, 59-66 twentieth century, 62-64 universal symptoms, 64 Victorian views, 59-62 Menopause and Aging, 69 menorrhagia, 29 menstrual (bleeding) phase, 3 menstruation, xiv, xv, 2 ancient and medieval, 15-16 Biblical words, 5-6, 16 birth control pill and, 32 blood-letting and, 5, 7 blood taboos, 4-7, 15-16 as “disease,” 15-17, 22-30, 38 dress fashions and, 21, 30 education for, 7-9, 11, 12, 19 electricity and, 23-24 environmental hazards and, 37-38, 41 folk beliefs, 4-7, 16-17 ignorance among girls, 12-13, 19 intercourse during, 15, 16 irregularities and medication, 41 leave during, 38 menstrual disorders, 42-44 moon’s influence theorized, 23 ovulation and, 24-25, 272-273 phases, 3-4, 39 residential schools, 10 sexually transmitted diseases, 43 stigma reduced, 13 tampons, 7, 14 Victorian views, 22-25 “weakness” of women, 25-26, 37-38 Menten, Maud, 194 Michaelis, Lenore, 194

311

312

index

Michelet, Jules, 20 microcephaly, 160, 171n6 Middleton, Clara, 101-102 midwives, xiii-xiv, xv, 80 birth control and abortion, 81-82 challenging conditions, 96 decline in 20th century, 93-97, 111-112 early 19th century, 88-89 facing charges, 145-146 government refusal to license, 101 granny midwives, 107-111 legalization in some places, 144, 145 Native women, 81, 136, 137 in New France, 227 in Newfoundland, 110-111 opposed by nurses, 146-147 and physicians, 88-89, 90, 94-95, 96, 176 practices in 19th century, 84 regulations, 95, 103-104 training, 84, 89, 95 See also nurse-midwives Midwives Monitor and Mother’s Mirror, 89 mifepristone, 158 military nursing, 224, 250-255 Boer War, 251 Great War, 252-253 Riel Rebellion, 250-251 Spanish-American War, 251 World War II, 253-255 missionaries female doctors, 188-189 nurses, 223, 225-227, 248, 249 Mitchell, S. Weir, 177 Mitchinson, Wendy, xiii Mittelschmerz, 39 Modess, 13 Muhammad Ali, 41 Mohawk women and menopause, 65-66 Moldow, Gloria, xiv Montreal General Hospital, 232 Montreal, Royal Victoria Hospital, 128 mood swings, 39, 42-43, 44 Morantz-Sanchez, Regina, xiv, 191 More, Ellen, xiv, 209 Morgentaler, Henry, 157-158, 170 Mormons, training of midwives, 104 morning-after pill, xii, 69 morphine, 121 Mosher, Clelia, 30 Mosher, Eliza, 177 mother “bad” mothers, 158-161 diversity in mothers, 135-142 and foetus, 154, 156, 159-160, 164-165 Native mothers, 136-137, 138, 139, 140 partnership with physicians, 113 responsible for baby’s health, 154, 157 “scientific motherhood,” 86

Mott, Elizabeth, 178 Mott, Richard Dixon, 178 Mount Sinai Hospital (Toronto), 145 Mt. Edgecumbe Tuberculosis Hospital, 265 Muhlenberg, Bishop William, 226 Mulroney, Mila, 134 multiple births, assisted, 168 Murphy, Judge Emily, 268n18 Napheys, George, 18-19, 21-22, 60 National Council of Women, 102, 244 National Mental Health Act (US), 257 National Organization for Public Health Nursing, 246 National Twilight Sleep Association, 121 National Women’s Medical Association, 186 See also American Medical Women’s Association Native American women birth experiences, 136-137 female healers, 83, 249 menopause, 58 nurses, 249, 265-266 single mothers, 138, 139, 140 Natural Childbirth, 147 natural childbirth movement, 147-148, 153 naturopathic medicines, 73-74 nausea in pregnancy, 88 Navajo people, 8, 84, 135 Nelkin, Dorothy, 161 neonatal mortality, 140, 143 Nevitt, R.B., 185 New England Female Medical College, 89, 178, 199 New England Hospital for Women and Children, 183, 184, 232 admission of minorities, 263 conservatism, 185 help for patients, 182 New England Journal of Medicine, 69, 70 New France Catholic nursing orders, 225 midwives elected, 227 New York Infirmary for Women and Children, 179, 184, 230 New York Maternity Hospital, 91 New York Medical College for Women, 180, 186 Newfoundland, outport midwives, 110-111 Newton, Mary, 248 Nightingale, Florence, 207, 223, 228-230 model for nursing schools, 231 new image of nurse, 258 nurses’ values expected, 241-242 Nine Months for Life, 156 nitrous oxide, 121 North American Menopause Society, 73 A Not Unreasonable Claim, xii

index

Nufer, Jacob, 127 nurse-midwives, 105, 106 dependence on physicians, 143 favourable statistics, 143-144 revived in 1960s and ’70s, 112 training programs, 105, 112 vs. lay midwives, 147 nurse practitioners, 238 nurses, xiv, xvi aid to doctors, 230, 231, 242 birth training poor, 103, 112 career paths, 237-238 doctors oppose registration, 243 early 19th century, 227-228 education, 223-224, 230-237 employment by WPA, 241 female physicians and, 218, 232 government and (Canada), 237-238 hospital-based, 93, 243-244 hospital births, 92-93, 113 male nurses, 266 minorities as, 262-266 northern or outpost, 249 nursing as labour, 241-243 nursing orders, 223, 225-227 opportunities, 267 opposing midwives, 97, 146-147 organization, 238-239 popular images, 257-259 private duty, 92, 224, 240-241 psychiatric, 224, 255-257 public health, 92-93, 224, 244-249 registration, 224, 237-240, 242-243 rural, 103, 246 sexuality, 258-259 stereotypes, 224, 259 uniforms, 224, 259-262 virtues expected, 241-242 wartime, 224, 250-255 womanhood, 241, 242 Nurses Associated Alumnae, 238 nurses studying (photo), 237 nursing assistants, 237 nursing schools degrees, 235 by early 19th century, 231 ethnic limits, 233-234 hospital labour, 231, 232-233, 240 late 19th century, 232-233 student experience, 233-235 Nutting, Adelaide, 238, 239 nymphomania, 61 O’Barr, Jean, xiii obstetricians, xv efforts to improve skills, 124 vs. family physicians, 142-143 obstetrics

19th-century deliveries, 88-92 19th-century prenatal care, 86-88 early 20th century, 96 training for nurses, 112 octuplets, xii Odent, Michel, 149 O’Donnell, Florence, 188 Of Woman Born (Rich), xiii older mothers, 118, 140-141 Oliver, C.B., 128 Oliver, Lillian, 187 On Generation (Hippocrates), 15 oncology, 220 Ontario Board of Health, 246-247 Ontario College of Physicians and Surgeons, 145 Ontario Medical Association, 180 Ontario Nurses’ Association, 146, 243 Ontario Women’s Medical College, 180, 185 opium, 64-65 oral contraceptives and ERT, 69 risk factor for CVD, 72, 73 Orr, Bobby, 40-41 Osler, Sir William, 175, 195, 212 osteoporosis causes and treatment, 72 HRT use, 71-72 incidence, 71 prevention, 72 Our Bodies, Ourselves, xiii, 58, 182 outport women, 49, 56-57 outpost nurses, 249 ovarian cycles and menstrual cycles, 272 ovaries and menopause, 61 ovariotomies, 29-30, 192, 222n12 and menopause, 70-71 ovulation, 4, 24-25, 272-273 ovulatory phase, 4, 39, 40 Owen-Dyer Bill (US), 190 pain in childbirth, 120-123 Painless Childbirth (Lamaze), 147 patent medicines, 28, 62, 66-67, 70 patriarchal attitudes, xiii, 10-11, 27 See also female physicians; women Peplau, Hildegarde, 257 Pergonal, 167 Perkins, Frances, 204 Peter Pan (Barrie), 11 Pfluger, Edward Friedrich, 24 pharmaceutical industry, 2, 48, 70, 73-74 pharmacists’ resistance to Plan B, 158 Phillips, Susan, 205 phlebotomy. See blood-letting Physical Life of Woman, 18-19 physicians consultations on menopause, 63

313

314

index

early obstetricians, 86-88 female. See female physicians and foetus, 154, 155, 170 hospital births, 113 and midwives, 88-89, 90, 94-95, 96, 176 role in childbirth, xv, 153-156, 167-170 vs. alternative birth, 144-146 Pierson, Roger, 272 Pima women in Mexico, 71 Plan B, 158 Playfair, William, 57 Pliny the Elder, 15-16 PMS. See premenstrual syndrome Pope, Georgina, 251 post-menopausal women, 54-58 postpartum depression, 141-142 poverty facing the elderly, 55 Power, John, 24 prairie childbirth, 100-105 pregnancy manuals, 156-157 pregnancy tests, 156 Premarin, 69-70, 73 premenstrual syndrome, 33-37, 273 as a disease, 35 and criminal action, 38-39 culture and, 35-36 depression and, 38 frequency, 34-35 hormone therapy, 34 inversion of behaviour, 36 labelled a psychosis, 44 Marxist analysis, 36 media portrayal, 36-37 as psychological disorder, 33-34 psychosocial factors, 43 real grievances as cause, 44 seen as female weakness, 37-39 seen as psychosis, 38-39 severity, 35 premenstrual tension (PMT), 42, 273 premenstruum, common symptoms, 39 Prenatal Care, 98, 111, 156 prenatal care early 21st century, 153, 161 late 20th century, 142-143, 148-149, 160 mid-20th century, 93, 99 19th century, 86-88 Preston, Ann, 177, 183, 184, 187, 209-210 preventative medicine, 179 Primrose, James, 27 Pritchard, J.C., 33 private duty nursing, 92, 224, 240-241 progesterone, 3, 4, 42 progestin, 70 Progressivism, 246 prostaglandins, 39 psychiatric nursing, 224, 255-257 psychiatrists, female, 179, 219

puberty rituals, 8-9 public health, 98, 179, 181 public health nurses, 92-93, 224, 244-249 puerperal fever, 84, 91, 92 puerperal psychosis, 38, 142 Quaker community, 183 Quebec birth rate, xiii fertility rates, 118 public health, 248 Queen’s University, 212 quotas, university, 180-181, 185, 193, 216-217 racialism, 18-19 Ramey, Estelle, 204 rape of Persephone, 10-11 Rapp, Rayna, 163 Reagan, Leslie, 96 record-keeping by nurses, 247 Red Cross, 253, 269n19 Red Riding Hood, 11 reproductive status and aging, 48-49, 51 reproductive technologies, xii, xiv, 161-170 residential schools, 225, 226 menstruation in, 10 Reverby, Susan, xiv, 241 Rich, Adrienne, xiii Richardson,Val, 138 Richmond, John Lambert, 127 rituals for menarche, 7-9, 11, 19 Rivington, W., 207 Robb, Hunter, 238 Rockefeller Foundation, 236 Rockefeller, John D., 263 Roe v.Wade, 157, 170 role loss in menopause, 65 Root, Eliza H., 95 Rosenberger, Nancy, 66 Rosenwald, Julius, 263 Ross, Charlotte Whitehead, 189 Ross-Kerr, Janet, xiv Rothman, Barbara, xiii Rowe, George, 23 rubber gloves, 259 rural childbirth, 99-111 frontier childbirth, 100-105 Frontier Nursing Service, 105-106 Rush, Benjamin, 87 Russell, Lillian, 51 Sabin, Florence, 212 Saklavsky, Mrs A., 94 salpingitis, 160, 171n7 Samoa, 35 Sanders, Jill, 126 sanitary napkins, 13-14 alternatives, 14

index

sanitary products industry, 14-15 standards not enforced, 41-42 Sarah (Hebrew Bible), 49, 75n5 schools and public health, 247 Schuyler, Louisa Lee, 250 “scientific motherhood,” 86 scopolamine, 121 Scott, Florence, 190 Scott, W.A., 122 Scoyoc,Van, 254 Seaman,Valentine, 83, 89 Semmelweis, Ignaz, 91 Seton, Mother Elizabeth, 226 Seward, Charles, 268n1 sex education, 7-9, 11, 12, 13, 19-20 Sex in Education (Clarke), 206 Sex in Industry (Ames), 27 sexual harassment, 211-213, 217 sexuality of aging women, 49, 51 sexually transmitted diseases, 160 menstrual problems, 43 Shainess, Natalie, 34 Sharpless, Amy, 104-105 Sheppard-Towner Act (US), 98, 105, 107, 245 Sherwin, Susan, xiv Shroen, Daniel, 40 Sicherman, Barbara, xiv Simpson, James Young, 120 Simpson, Sir James, 91 Sims, J. Marion, 177 single motherhood, 138-140 slavery, birth control and abortion, 82 Smellie, Elizabeth, 246 Smith, Donald C., 69 Smith, Lapthorn, 29 Smith-Rosenberg, Carroll, xiii Smith Shortt, Elizabeth, 181, 202, 212 Smith, S.L., 42 Smith, Tyler, 62 smoking and HRT, 72-73 Snively, Mary Agnes, 234, 239, 240 Snow, Eliza R., 104 Snow, Sir John, 120 social class and medical care, 130 sodium secobarbital (Nembutal), 122 sodium thiopental (Pentothal), 122 Solinger, Rickie, xiv sonogram of foetus, 137 Sontag, Susan, 51, 52 Sorensen, Hannah, 104 Sparkman-Johnson Act (US), 191 Spelman College, 263 spinster, word origin, 54, 221n3 Spiritual Midwifery, 144 St. John’s Ambulance, 253, 262 Stanton, Elizabeth Cady, 180 Staupers, Mabel K., 264

Steinhauer-Anderson, Kathleen, 266 stethoscope, 154-156 Stevens, W.L., 26 Stewart, Elizabeth, 185 Stewart, John, 178 stilbestrol, 123 The Stone Angel, 53 Storer, Horatio, 205-206 Stowe, Emily, 178, 180, 183, 185, 187, 212, 214-215 Stowe-Gullen, Augusta, 181, 182 Strecker, E.A., 142 Strong-Boag,Veronica, xiv Strong, Margaret, 189 suffrage, 180, 181, 188, 239 Sullivan, William, 159 Sunset Boulevard (film), 53, 75n3 surrogate motherhood, 169 Survey of Nursing Education in Canada (Weir), 236 Syracuse University, 185 Szold, Henrietta, 265 Tait, Lawson, 24 Tampax, 14 tampons, 7, 14, 41-42 Taussig, Helen, 197 Tebutt, Sarah, 88 teenage mothers, 138-140 television images of aging women, 53-54 Textbook of Gynecology, 37 textbooks, medical and nursing (1960s), 135 thalidomide, 197 Canadian Nurse, 236 Thomas, Martha Corey, 26 Thoms, Ada, 239 Thomson, Samuel, xiii Tiburtius, Franzisca, 177, 197 Tierno, Philip, Jr., 42 Tilt, Edward John, 60, 62 Todd, James K., 41 Toman, Cynthia, 254-255 Tone, Andrea, xiv Toronto General Hospital nursing school, 233, 234 toxic shock syndrome (TSS), 41-42 toxins in tampons, 42 traditional birthing practices Inuit, 80 Koyukons, 80-81 Native Americans, 81 Travelling Clinic in Alberta, 248 Treatise on the Diseases of Females, 155 Trenholme, E.H., 87-88 Trout, Jenny Kidd, 178, 180, 212 Truth, Sojourner, 263 tubal ligations, 128 Tubman, Harriet Ross, 263

315

316

index

Tulane University, 186 “Twilight Sleep,” 121-122, 123 two-tiered medical system, 219 ultrasound, 162, 163-164 Umansky, Lauri, xiii umbilical cord, 137 Underwood, Elizabeth, 85 Université de Montréal, 248 University of British Columbia, 235, 268n6 University of California, 186 University of Edinburgh, 213 University of Manitoba, 186, 216-217, 218 University of Michigan, 186 University of Toronto, 180-181, 185, 212, 216, 217 University of Western Ontario, 186 Ursuline Order, 225 Utian, Wulf H., 73, 74 vacuum extraction, 124-125 VADs, 253 vaginal lubricants, 74 Valenti, Carlo, 164 Valium, 54 Van Wyck, H.B., 128 Vancouver General Hospital, 128 Vavandal, Jean, 21 venesection, 15, 22 Victoria, Queen of England, 33, 141-142 Victorian Order of Nurses, 97, 102, 246 Victorian views on menstruation, 22-25 Virdimura, 175 virginity and bride-price, 11 visual symbols of aging, 50, 51-54 vitalism, 57, 75n4 Wald, Lillian, 239, 245-246, 265, 268n9 Walker, Morton, 149 Walsh, Mary Roth, xiv, 215 Walters, Beverly, 194 Walters, May, 254 Wanatee, Adeline, 9 wartime nursing. See military nursing Webster, J.C., 25 Wedel, Helen, 103 Weir Survey, 236, 237, 241

welfare institutions for the aged, 54 well-baby clinics, 248 Wellness movement, 178 What a Woman of Forty-five Ought to Know, 57-58 What to Expect When You’re Expecting, 156, 157 white women birth rates, 118 birthing experiences, 83-86 osteoporosis, 71-72 The Whiteoaks of Jalna, 53 Widmer, Christopher, 88, 89 wild yam cream, 74 Williams, J. Whitridge, 96 Wilson, Mona, 233 Winslow, Caroline, 202-203 witch image, 50, 51 Wollstein, Martha, 203-204, 222n16 Woman’s Journal, 184, 208 Woman’s Medical College of Pennsylvania, 183, 184, 186, 199 women doctors and, 153-156, 167-168, 170 as inferior, 25-27, 37-39, 44, 205-207 as vessels for birth, 153 women doctors. See female physicians Women’s College Hospital (Toronto), 181, 221n2 “women’s culture,” 11-12 Women’s Health Initiative, 74 women’s health reform movement, xiii Women’s Medical Journal, 186 Worcester, Alfred, 231 work environment for women, 27 work loss and menstruation, 37 World Health Organization, 35 World War I. See Great War World War II female physicians, 190-191 home birth to hospital birth, 99 The Yellow Wallpaper, 184, 221n7 Yeomans, Amelia, 185 Zakrzewska, Marie, 178, 183, 184-185, 186, 200, 202, 206