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February 09, 2010

Did the fathers of modern obstetrics murder more women than Jack the Ripper?

Latoya Peterson of Jezebel spotted this disconcerting story in Sunday's Guardian:

They are giants of medicine, pioneers of the care that women receive during childbirth and were the founding fathers of obstetrics. The names of William Hunter and William Smellie still inspire respect among today's doctors, more than 250 years since they made their contributions to healthcare. Such were the duo's reputations as outstanding physicians that the clienteles of their private practices included the rich and famous of mid-18th-century London.

But were they also serial killers? New research published in the Journal of the Royal Society of Medicine (JRSM) claims that they were. A detailed historical study accuses the doctors of soliciting the killing of dozens of women, many in the latter stages of pregnancy, to dissect their corpses. [Guardian]

This story has all the makings of an anti-science urban legend. Regardless of the quality of the underlying research, this story is going to get embellished in the retelling and used to bash scientific medicine.

The allegations are already being mentioned in the same breath as documented atrocities like the Tuskegee syphilis study, and Dr. Joseph Mengele's infamous concentration camp experiments.

I checked out Don C. Shelton's original paper. It's a very good read. Shelton raises credible suspicions about where these two doctors got their anatomical specimens. He, shamelessly overstates his case, however. Shelton flatly asserts that Hunter and Smellie were "responsible" for the murders of more women than Jack the Ripper.

The subjects of the anatomy books were women who died in childbirth, or during their final month of pregnancy. Shelton's argument is that there simply weren't enough heavily pregnant and birthing women dying of natural causes in mid-18th-century London to account for all the thirty-plus cadavers that Smellie and Hunter examined to write their respective anatomical classics.

Based on a review of their atlases, Shelton says that the two anatomists came up with a total of 20 cadavers between 1750 and 1754; and that Hunter somehow located another dozen between 1766 and 1774. That works out to four or five such bodies a year for the first stretch and fewer than two a year for the second period.

Shelton concludes that the doctors must have had these women murdered-to-order, a practice known as burking. The term burking is an allusion to the murderers Burke and Hare who smothered their victims in Edinburgh between 1837 and 1838 and delivered them to Dr. Robert Knox, a private anatomy lecturer. 

Shelton acknowledges that there is no research on burking in the mid-18th century.  He doesn't cite any documented cases of burking during that era.

There is no question anatomists of Smellie and Hunter's day got their cadavers from grave robbers. That's how it was done in those dark and superstitious days.

Shelton's case boils down to two rather plausible, but non-dispositive claims: i) very few women died in their 9th month of pregnancy or during childbirth to begin with, and, ii) it's unlikely that ordinary grave robbers would have been able to zero in on these rare cases.

Grave robbers tended to exhume corpses at random, Shelton explains. Or else they targeted the unclaimed bodies of people who died in poorhouses. But he notes that most of those who died in poorhouses were old and sick, not otherwise healthy pregnant women.

Death rates for infectious disease were very high in mid-18th-century London, but Shelton claims that pregnant women would have accounted for small percentage of the death toll. As he points out, they're a subset of the general population and a relatively young and healthy one at that.

Shelton cites statistics to show that the childbed death rate in the mid-18th-century was less than 2%. Based on the birth and death rates and the population of London at the time, he estimates that there would have been about 200 childbed deaths per year.

He argues that women who died in their 9th month of pregnancy would have been rarer still. Shelton suggests that very pregnant cadavers would have been extremely rare because a significant percentage women who suffered lethal illnesses or accidents in their 9th month would have miscarried before they died.

But even at their most productive, the two doctors were only seeing about five of their target subjects a year, on average. Five out of 200 doesn't seem that incredible.

The author also maintains that it would have been very difficult for grave robbers to find these rare specimens: Death notices were rarely published in those days and corpses usually went directly from home to the graveyard without a detour through a funeral home or some other central location that thieves could monitor.

Personally, if I were an 18th-Century anatomist who needed a steady supply of "special" cadavers, I'd start bribing vicars. If you pay for the new church roof, I'm sure it's amazing what you can find out about who's buried where.

So, the paper gives us good reason to doubt that Smellie and Hunter got all their cadavers through the standard grave-robbing channels. But that's hardly proof that the two men commissioned mass murder for hire.

Smellie and Hunter were famous obstetricians. They worked with pregnant and birthing women. In an era where most childbirth was handled at home, they probably served a disproportionately sick patient population.

Let's not forget that primitive obstetrics was really dangerous--no doubt in part because because science was still sketchy on pregnant female anatomy. If anyone was well-situated to tip off grave robbers about dead pregnant women, or take liberties with their corpses, it would have been 18th-century obstetricians.

As the author points out, Smellie and Hunter were rich and well-connected men. He implies that they could have gotten away with murder. On the other hand, if they could have gotten away with murder, they presumably had enough privilege to get what they wanted by less drastic, if socially unacceptable means. 

Shelton claims the following passage, written in 1818, is a smoking gun. The author was describing a plate in Smellie's atlas that features twins:

“Dr MacKenzie being then an assistant to the late Dr Smellie, the procuring and dissecting this woman without Dr Smellie’s knowledge, was the cause of a separation between them, for the leading steps to such a discovery could not be kept a secret."

Smellie died in 1763 and 55 years later, some guy claimed that an associate of Smellie's obtained the corpse by unspecified (but presumably sketchy) means without Smellie's knowledge. This is supposed to be a smoking gun? Really?

Shelton gives us no reason to assume that Smellie and Hunter were monsters. Why immediately jump to the conclusion that they were murderers? There have been killers in the name of science and medicine, but they've always been a tiny minority among scientists and for that matter, a very small subset of murderers. Shelton's wild allegation seems absurd unless you buy into some nasty stereotypes about doctors and scientists.

He makes no attempt to rule out less brutal schemes by which they might have improved their odds relative to common grave-robbers. Could they have performed unauthorized autopsies on pregnant patients who died of natural causes? Bribed the families of the deceased? Stolen the bodies of their own indigent patients? If a body was returned to the family with an incision in the abdomen, the obstetricians could always claim it was a cesarean section.

Were all their subjects even dead? Presumably they could have learned from examining and treating live women. It's a mundane possibility, but who's to say these guys didn't exaggerate the number of corpses they actually looked at? Academic dishonesty is more common than murder.

Obviously, I'm speculating here, but so is Shelton. He makes probabilistic arguments, so I'll make one too: If same end can be achieved through subterfuge or serial murder, most people will opt for subterfuge. Dead pregnant women are rare, but mass murderers are rarer still. Of course, tall tales of body snatchers, natural and supernatural, are as common as dirt.

Shelton is right to question how these doctors got their cadavers, but he simply does not have enough evidence to conclude that these pioneers of modern obstetrics killed more women than Jack the Ripper. This paper is just going to give the science bashers unearned ammunition.

Comments

"Birth outcomes at The Farm birth center are orders of magnitude better than those achieved by any doctor."

Actually, they're not. In the only published paper on The Farm (Durand, 1992) had an appallingly high mortality rate of 10/1000 almost 3 times higher than the death rate for low risk white women in the same time period. Durand tried to hide that fact by comparing homebirth at The Farm to high risk births.

Ginmar:

more people died of their treatment rather than their wounds

I don't think that's entirely accurate. Certainly, far more people died from infection than from immediate trauma, but that applied weather or not they were actually treated, or just left on their own.

If these guys wanted to study bodies, they should have snatched up corpses from battlefields.

This wouldn't have been particularly helpful for aspiring gynecologists.

I don't think that's entirely accurate. Certainly, far more people died from infection than from immediate trauma, but that applied weather or not they were actually treated, or just left on their own.

How did they get those infections? Notice I said 'treatment'. Events in hospital are documented; people left to---what, exactly? die out in the field somewhere?---do they even exist?----are, well, unknown. So I don't get what point you're trying to make.

This wouldn't have been particularly helpful for.....

I was speaking more generally. One doesn't, for example, tend to find a great many pregnant women on the battlefield, though there have always been women who have joined up and fought.

Lindsay,

It wasn't at all backhanded. Grave robbing had been a criminal act for mostly religious reasons but the Anatomy Act of 1832 demoted it to a misdemeanor.

That said there was in fact a far simpler explanation for at least some of the bodies they accessed. That same act created several entirely legitimate methods for doctors to get their hands on bodies to study. Unclaimed bodies (such as those from from either prisons or workhouses) could be claimed by a licensed autopsy practitioner and as mentioned before women facing capital charges would often try to get pregnant as a way to avoid hanging. Add in the general conditions in Victorian prisons and what it would do to the natural risks of pregnancy a small supply of pregnant corpses makes perfect sense.

Alternatively the act allowed poor families could allow dissection of a body in return for the recipient paying all funeral expenses.

Basically there were a number of ways to get their hands on the corpses they wanted for study all easier, cheaper, and far less risky then murder for science. This simply doesn't hold water.

And then I look again and realize I'm off by 100 years. Never mind and I'll be over here quietly sitting in a corner and rereading things before I shoot off my mouth

"The claim that doctors, ignoring the work of the Viennese physician Ignaz Semmelweis, continued to spread disease by failing to wash their hands even after learning the true cause of sepsis is a pretend "fact" made up by homebirth advocates."

Every layperson knows the importance of proper hygiene, yet according to the CDC, over 100,000 Americans die every year due to hospital-acquired infections, many of which are due to doctors and other health professionals failing to wash their hands.

Let's forget about ancient history, and focus on the unbelievably cavalier attitude the modern American medical industry takes towards patient safety, adverse reactions to drugs and procedures, and medical errors, all of which may be responsible for as many as 250,000 deaths a year or more--a bodycount of genocidal proportions.

Sean: the figure I've seen for nosocomial infections is 88,000. I haven't seen any higher figures. Have you?

The fact that doctors started washing their hands in the middle of the 19th century can hardly be counted as a comfort to 18th-century patients.

Your disdain for modern homebirth advocates does a disservice to history. While it is true that midwives did not practice better hygiene than doctors, it is also true that midwife-attended births in the 18th century had lower death rates than doctor-attended births of the same era, due in large part to doctors' willingness to use experimental interventions. For statistics and discussion of this phenomenon in an American context, see Laurel Thatcher Ulrich's Pulitzer-winning A Midwife's Tale: The Life of Martha Ballard, Based on Her Diary, 1785-1812.

I think Lindsay makes a good point — I don't think it would have been necessary to murder pregnant women in order to get 5-6 corpses per year. If you were on the lookout for a specific type of corpse and were willing to bribe families, doctors, vicars, gravediggers, etc., you wouldn't have to rely on grave robbers stumbling across a lucky find.

Sean: the figure I've seen for nosocomial infections is 88,000. I haven't seen any higher figures. Have you?

Barring the fact that these figure are likely an underestimation, as they are based on hospital self-reports, is 12,000 less deaths a year any less a disaster? I am getting the figure of 100,000 (actually 98,000) from the Consumer's Union report (click the link on "Consumers Union's report" (sic) to download the PDF and search for "CDC" to see where it cites the CDC figure.)

http://www.consumersunion.org/pub/core_health_care/011324.html

Sean, your link says "as many as 98,000" die each year from "preventable medical errors," a larger class of deaths than nosocomial infections. The CDC figure, cited in the most commonly cited article on American nosocomial infections, is a range from 44,000 to 98,000; said article then goes on and argues for 225,000 using a compilation of older studies, and is I believe where the 88,000 figure comes from. (In either case, this article is precious if only for demolishing the idea that American health outcomes are bad because of lifestyle issues.)

But now that I've looked I just saw the CDC give a figure of 99,000 as of 2002 (and I can't find any newer data).

Either way, few of those deaths come from doctors not washing their hands. For example, a CDC survey on nosocomial bloodstream infections says that washing hands properly with a high volume of antiseptic soap would save 500-2,000 lives a year in the US; it argues for increased hand washing as a low-cost method of reducing infection rates, but also says that almost all of the reduction in preventable deaths would have to come from technological improvements, such as antibiotic-bonded catheters.

How did they get those infections?

Usually, from getting stabbed by a dirty chunk of metal on an equally dirty battlefield. In those days, "treatment" usually consisted of chopping off limbs that were thought to be too badly mangled to save, stitching up other wounds, and bandaging them with cloth of questionable cleanliness. All of which is considerably worse that what we do now, and a source of infection in its own right, but _not_ as bad as not treating the wounds at all would be.

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