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The Casebook, the Daybook, and the Diary as Sources in Medical Historiography

DAVID SHEPHARD

Abstract. Casebooks, daybooks and diaries were among a number of literary forms commonly used by physicians in the nineteenth century to record the details of their medical cases. Because they constitute primary sources on medical practice in that era they have value to the medical historian. To illustrate this, the writings of three Canadian physicians-John Mackieson, Jonathan Woolverton, and James Langstaff-are discussed, together with a consideration of some of the principles relating to the study of their manuscripts, particularly in relation to the study of the history of practice in rural areas. RdsumB. Les m&lecins du XIXe sikle compilaient couranunent les details de leurs cas medicaux dam des dossiers ou des journaux intirnes. Ces documents representent donc pour l'historien une source prkieuse de renseignementssur la pratique mkdicale de cette 6poque. Dans cet article, l'auteur analyse les ecrits de trois medicins canadiens- John Mackieson, Jonathan Woolverton, et James Langstaff ceci afin de mieux comprendre l'histoire de la practique medicale en milieu rural.

Diaries and journals have long been used in order to describe personal experiences, but doctors, to relate their medical experiences, also have made particular use of casebooks and daybooks. Together with "casebooks," "daybooks," "account books," and "clinicalnotes" they made up a common literary genre among physicians in the nineteenth century. They were used to report the details of interesting clinical cases, to provide records for future reference, to serve asaides-memoiresin the preparation o journal articles, books and lectures, and sometimes to fulfilrequiref

David Shephard, an anesthesiologist,is chair of the Archives Committee, Medical Society of Prince Edward Island. Address for correspandence:20 Katie Drive, Charlottetown,PE1 CIE 1x8

CBMH/BCHM / Volume 17: 2000 / p. 245-255

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ments in a student's training. But, as one nineteenth-century editorialist suggested, their historical value was evident:
Every medical practitioner may do something to advance the progress of medical science by carefully noting the cases which he has under his observation, and the remedies he has found most successful in treating them. It is to be lamented that so many lose the advantages given of their own experience by neglecting to record medical facts; and while they are unjust to themselves, they cannot possibly bequeath anything to posterity.'

This editorialist was thinking about the value for posterity of casebooks in the progress of medicine, but this literary form also has value for posterity in a different way. Roland and Rubashewsky, for example, ob. served that the historian "can take names and numbers from the pages o f . . . account books, order and link them with other primary sources, and construct a model of the medical practice in the community that can help us to understand who the patients were, how the physicians interacted with them, and for what r e ~ a r d . "Casebooks, diaries, and ~ similar writings thus are invaluable to anyone who is studying the life and work of an author of such writings, and, used in this way, are valuable sources in medical historiography. Sources such as these have particular use in studies of physicians who are not otherwise well-known, such as those who practised in rural areas. Ackeman pointed out that account books and daybooks are of value because "they furnish us with a detailed account of what actually went on between rural physicians and their patients," and other historians have made use of this genre in their various studies4In this paper, the writings of three nineteenth-century Canadian physicians are considered in order to illustrate the value of the casebook, the daybook, and the diary in this context, and some of the principles of using them as sources are discussed.
I

THE PHYSICIANS AND THEIR MANUSCRIPTS

The three physicians, chronologically presented, are the following: John Mackieson (1795-1885), Jonathan Woolverton (1811-1883), and James Langstaff (1825-1889). None of them was a major figure-certainly not an Osler nor a Banting nor a Penfield -and they are remembered only by what they wrote and for the historical value of their writing as sources of information about medical practice in nineteenth-century Canada. John Mackieson was born near Stirling, Scotland, trained in Glasgow and emigrated to Prince Edward Island in 1821.5A generalist in an era that predated specialists, he was particularly interested and proficient in surgery and obstetrics; as medical superintendent of the Charlotte-

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town Lunatic Asylum, he was also interested in mental illness. He was a prolific writer, producing two casebooks, a synopsis of some medical conditions, a formulary, and a diary. These manuscripts6 constitute a primary source that is unique in Prince Edward Island. Jonathan Woolverton was a native of Grimsby, Ontario, studied at McGill University and the University of Pennsylvania, and then returned in 1834 to practise in Grimsby. He is remembered through his diary, which was described by Roland in 1971.' This diary, which Woolverton kept intermittently from 1832 to 1862, includes references to events in his own life and some accounts of illness and diseases. Jarnes Langstaff was born in Richmond Hill, Ontario and trained in Toronto under John Rolph and in London at Guy's Hospital. He practised in his native town from 1849 onwards. His daybooks have been analyzed by Duffin, who has given us a comprehensive portrait of Langstaff himself, of his practice; and the society in which he lived and worked. Except for a gap of a few years, his daybooks are chronologically complete and cover the period from 1849 to 1889, and give a unique picture of one medical practice in nineteenth-century Ontario.
CASEBOOKS, DAYBOOKS, AND DIARIES AS HISTORICALSOURCES

While Mackieson, Woolverton, and Langstaff had their own reasons for writing up their experiences, their writings have become sources that are part of the sparse literature on the history of medical practice in Canada, particularly in rural areas. Their interest for us lies in their being sources of both biographical and contextual value.

Life Writing in Historz Biography as a Prism of History Mackieson's casebooks and diary, Woolverton's diary, and Langstaff's daybooks tell us about these physicians' times and their communities but also about their lives. The study of material o a biographical nature f is one approach to historiography, and Barbara Tuchman, for example, regards biography as a prism of history? In this respect, these three physicians' manuscripts have a broader significance than as accounts of individuals' lives. Tuchman also suggested bhat "biography attracts and holds the reader's interest in the larger subject" of a certain period of history, thus to "encapsulate history."1 While the writings of these three physicianti focus our attention on them as individuals, they also serve as plrimary sources on rural medical practice in nineteenth-century Canada.

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The Universal in the Particular Biographical material is useful to the historian because it provides "a focus that allows the writer to narrow his field to manageable dimensions and the reader to more easily comprehend the subject."ll It provides a starting point for a discussion of more general points. For example, in her i study of Langstaff, Duffin examines h s practice in detail but also relates it to medicine in nineteenth-century Ontario and the wider world.12 Unpublished cases also have general relevance. In several of his case records, Mackieson generalized from the particular. The following paragraph, from a record of a three-year-old girl who died after being burned, and whom he saw after some delay in which she was treated by a surgeon, is an example:
Remarks-This is a case where death takes place from exhaustion or from the shock received by the Nervous System, without the intervention of any inflammatory reaction. The child should have been nourished & supported with cordials, Laudanum & liquids from the beginning, till reaction could be brought about-instead of being kept all the while with only a sheet for a covering--& getting only cold drinks-under the idea that some Phantom called Inflamrnation was about to intervene, or that the symptoms of exhaustion were those of determination to the Brain-4 that her dilated pupil anterior to dissolution was another proof of congestion there.13

Mackieson recognized the need for fluids and for sedation and the need to prevent heat loss from the girl's body. He appears to have had a clear understanding of the physiological disturbances and the treatment that was desirable. The Granite of Truth and the Rainbow of Personality One of the problems with biography is that, as Virginia Woolf pointed out, it is necessary to blend the "rock-solid" facts of what happened with the less concrete aspects of a personality.14If a physician's writings are to be useful as sources, any annotation or interpretation of them and of the physician's career must be both informed and well-written. A valuable aspect of Roland's account of Woolverton's diary, for example, is his use of footnotes, about both the physician and his times;15 and Langstaff 'S personality comes across in Duffin's observation that "on one point. ..the record is absolutely clear: Langstaff cared for all his patients, was sensitive to their pain, and tried always to help or at least to do no harm."16 Woolverton, Langstaff, and Mackieson are minor figures in nineteenth-century Canadian medicine, but this does not prevent their writings from being of historical value. Geoffrey Wolff has discussed this very topic of writing about individuals of minor import, and his observation on minor poets has some general relevance. Wolff wrote that "I

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knew when I began that I would not introduce to the world a great lost poet, or even a good one.. . I hoped, when I was done.. .to understand a man, not to have unriddled the secret of Man."17 So it is with these three physicians: their writings aid us in understanding them and their careers. The Figure Under the Carpet A fourth principle concerns what Edel has termed "the figure under the carpet."18 He pointed out that "a biographer fashions a man or a woman out of the seemingly intractable material of archives, diaries, documents, dreams, a glimpse, a series of memories."19 The biographer may describe what is familiar about a subject but also may make implications about what is less obvious. In a case report of Mackieson's, for example, one can find a key not only to the practice of one physician in the nineteenth century but also to the therapeutic environment of that period-and to the difference between "science" then and now-just in a single illuminating remark. Thus in a case record of a patient in whom "mania" had developed "from improper use of spirits," Mackieson reached the following conclusion:
Remarks-In this caw the vomiting was immediately relieved by the Laudanum & soda draughts, the tone of the Stomach was restored by the Sulphuric Acid & Bitters, but the Mental affection was not alleviated until1 [sic] after the bleeding & purging, when it vanished as by a charm.20

Mackieson's use of the word "charm" merits comment in the context of his use of bloodletting and cathartics, or depletive therapy. In fact, he used this term in a second case reportz1 and the term "magic" in a third.22Practising in an era that was uncharacterized by clinical trials (Louis's study on venesection in pneumonia being a notable exceptionZ3),Mackieson was not in a position to argue objectively for or against efficacy of a form of treatment, and an apparently remarkable, or "magical," effect of treatment therefore would rank high in any assessment of therapy. Mackieson was, perhaps, using these terms not in simply a "conversational" sense but to emphasize therapeutic value in an era in which controlled trials were unknown.z4

Some Principles ofHistory Writing The Genre as a Primary Source These three physicians' manuscripts are most valuable as primary sources of information on medical practice in nineteenth-century Canada. Their clinical accounts describe more personally and more directly what happened in a doctor's office or at a patient's bedside than do secondary sources such as contemporary textbooks or medical journals. This

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point is illustrated by comparing two accounts of acute hydrocephalus: rhe first is from a textbook, the second, from Woolverton's diary.
The symptoms generally begin to show themselves before the child is six months old in cases where they do not exist from birth. Although the child takes its food eagerly, it does not thrive; and consequently, after a time, the marasmus becomes extreme. The wasted appearance of the body makes the increased size of the head the more remarkable. . . .The intelligence may . . .be unaffected, but often it is much enfeebled; there is great irritability, and sometimes a liability to epilepsy; while the muscular weakness is occasionally very great. A peculiar rolling movement of the eyeball can often be noticed; and there may be strabismus, with occasionally amaurosis.. . . The head, often drooping helplessly on one side, is in the erect position.25 Samuel S. Moore.. . lost his younger child by hydrocephalus, it was ill for about ten days. It was always a weakly child. During its illness it was remarkably irritable, the bowels were obstinately costive, the secretion of the kidneys were [sic]almost wholly arrested, the pulse for about a week before it died was irregular and intermittent, the least motion of the head caused much distress, the light was very offensive.. . the stomach was very irritable rejecting for the most part both food and medicine and the child laid for the greater part of its time in a stupid or comatose state with occasional startlings; . .. the pupils became much dilated, the eyes put on a glassy appearance and rolled upwards. .. open and fixed, the hands clenched and in short every indication of agony was presenLZ6

Woolverton's is the more vivid and interesting of the two accounts, partly because it is based on a particular patient's illness. One gets the impression that he was actually at the bedside. Woolverton's account is just a single source, but add to it other sources, such as that of Burritt's obstetric casesz7 well as the Langstaff as and Mackieson material, and the corpus of source material then becomes large enough to be comprehensive in a way that a single source could not. In addition, as Stowe has suggested, they "form a rich body of relatively untapped source material on the experience of doctoring in that time.. .."28 This type of material is of value in another respect. Acquiring information about nineteenth-century medical practice is hampered partly because, as Coombs pointed out, in the absence of general hospitals in much of that era, there were no hospital records.29 Casebooks and daybooks thus become unique sources of information. One of Langstaff's case reports, for example, might have made a hospital record if it had occurred a few decades later. Duffin wrote as follows:
A boy whose rheumatic heart murmurs Langstaff had followed for four years died a "very easy" death; on taking him from the rocking chair to the bed, he just lay down and was gone. The 300-word descriptionof the cardiac abnormalities shows that, for this attending physician, the post-mortem inspection was the final interpretation of the strange heart sounds he had studied for months

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on end. It included mention of the "small bodies less than the size of a pin head . . . placed quite close to each other forming a fine crest. . .along the mitral and semi-lunar valves.30

Uniqueness and Variety of Accounts These three physicians' accounts have some features in common, but each is unique and thus has an individual historical value. Mackiesonls manuscripts provide an example. The clinical case records include 257 from his general practice, covering a spectrum of medical, surgical, obstetric and gynecological and psychiatric cases, as well as of 115mentalillness records from his tenure as medical superintendent of the Charlottetown Lunatic Asylum. Taken together, they provide information about many aspects of of the nature of medical practice, and certainlya graphic account of the shortcomings of health care in Prince Edward Island in the middle decades of the nineteenth century. In this respect they are a unique primary source, since no other sources tell us about Island medicine in that era. Pieces in a Jigsaw Puzzle Our knowledge of medical practice in the nineteenth century is something of a jigsaw puzzle: we have several pieces but we would like to have more, both to give us the whole picture and to define the picture more clearly. Completing the puzzle comprises two processes: fitting each with others that match and then seeing the larger picture. Each piece complements the others. So it is with casebooks, daybooks, and diaries; each adds one more piece. With respect to medical practice in Prince Edward Island in relation to practice elsewhere in Canada, a question that can be answered by using the present material is whether Mackieson practised according to the norm elsewhere in Canada. Was Mackieson seeing similar types of cases and was his treatment similar to the experiences of his colleagues in Ontario? A comparison of the frequency of treatments that Mackieson and Langstaff favored in the same decade of the 1850s (Table 1) suggests that there were no significant differences between the two practices in this respect, and, as far as therapy is concerned, it is reasonable to conclude that Mackieson practised in a similar manner to Langstaff. That Mackieson practised according to the general norm of nineteenthcentury physicians is likely, for his casebooks and other material show that he was familiar with the current medical literature. Corroboration of Different Elements in the Same Author's Corpus In addition, if the archive of a physician contains several different elements, they must all be studied to provide as complete a historical picture of that physician's practice as possible. In the Mackieson archive, two elements are his general medical casebook and his diary. The for-

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mer, which is wholly medical in content, covers the period from 1826 to 1858, while the latter, the content of which is only partly medical, runs from 1845 to 1885. We therefore have two separate sources about medical practice in Prince Edward Island, which can be used in different ways. For example, for the period that is common to the two sources, the diary can be used to confirm information in the casebook concerning his activities at certain times, while after 1858 the diary adds to our information about Mackieson and his times. Thus we know from his casebook that he operated for hernias in the early part of his career, but his diary entry for October 28,1870, in which he reported that he had to travel from Charlottetown to operate on a patient with a femoral hernia?* tells us that he continued to operate when he was in his 70s; it also reminds us that surgeons then commonly performed operations in patients' homes. Table 1 Ranking of the Ten Most Frequently Used Therapeutic Measures Used by Langstaff and Mackieson in the 1850s.
Langstaff Ranking
1 2 3 4 5 6 7 8 9

Mackieson Mercurials Opiate Quinine Jalap Venesectiona Water (Hot &/or cold) Black 13raughtb Blister Turpentine Castor Oil

Therapy Quinine Opiate Venesection Tartar Emetic Mercurial Blister/Plaster Ipecacuanha Cupping Iron Jalap

10

a Includes one arteriotomy.

Senna with rnagnesiwnsulfate. Sources: Duffin, Langstafl, p. 75, and J. Mackieson, Sketches, 1826-1858.

Mackieson's diary can be used in other ways to augment the information in his casebooks. In it Mackieson entered the names of fellow practitioners in Prince Edward ~ s l a n d ? ~ adding to a list of Island physithus cians that can be compiled from a study of other sources such as his casebooks. The diary, which covers a later period than does Mackieson's general medical casebook, also is valuable in contributing to the discussion on change of type with respect to diseases in the nineteenth century.33A comparison of the two elements in the Mackieson archive

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suggests-but perhaps only suggests-that diseases did not change significantly in the 60 years of Mackieson's career.
CONCLUSION

Casebooks, daybooks, diaries, and similar materials constitute a source of information that has considerable value in the writing of history, whether the emphasis be biographical or on the subject's socie times. The diaries and journals of physicians like William Halsted and Harvey Cushing35 in the United States, Richard Bright36 and John Snow3' in England, and Frederick Banting" and W d e r P e ~ ~ f i e in ~ ~ Id Canada have been of inestimable value in the historiography. Studies based on that material have, apart from being inherently interesting, introduced many readers to the "Iarger subject" of history. There is, however, a considerable difference in the lives and careers of such well-known medical heroes, on the one hand, and of less wellknown Canadian physicians like Mackieson, Woolvekton and Langstaff. Their writings focus our attention on a smaller historical arena that, through the appIication of sound principles of historical practice, permits us to appreciate the nature of medical practice in rural areas, rather than in cities, where the "great" figures in medicine practised. The nature of the practices of Mackieson, Woolverton and Langstaff was quite different from the consultant practice of their better known contemporaries, and their writings give them, to borrow a phrase of Shortt's, "an archetypal chara~ter."~ Although he was referring to the United States, Stowe has pointed out that "surprisingly little has been written about routine medical practice in any region. .. in the mid-nineteenth century,"41 and Berman, discussing rural obstetrics in New England in this period, observed that "traditional sources do not necessarily reflect In Canada the literature on actual rural practice at the ordinary medicaI practice in rural areas in the nineteenth century, too, is sparse, which is the chief reason why the writings of Mackieson, Woolverton and Langstaff are so valuable.
NOTES
1 Anonymous Review, "The Medical Practitioner's Private Register of Cases ProfessionallyAttended;' Medical Times, 18(1848):159. 2 Charles Roland and Bohodar Rubashewsky, "The Economic Status of the Practice of Dr. Harmaunus Smith in Wentworth County, Ontario;' Canadian Bulletin of Medical History, 5,1(1988): 8 4 . 2-9 3 Evelyn Bernette Ackerman, "The Activities of a Country Doctor in New York State: Dr. Elias Cornelius Somers of Somers, 17941803," Historical Reflections/Rejlexions Historiques, 9 (1982): 181-93. 4 See, for example, Paul Berman, "The Practice of Obstetria in Rural America, 1800-1869," Journal of the Hisfory of Medicine and Allied Sciences, 50 (1993): 175-93;

?Fd

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J. M. C n u ~ l e y"The Daybooks of Robert MacLellan: A ComparativeStudy of a Nova , Scotia Family Practice W i g World War I," Canadian Medical Association Journal, 120 (1979):492-97; and John Norris, "The Country Doctor in British Columbia: 1887-1975. An Historical Profile," BC Studies, 49 (Spring 1981):15-39; Samuel E. D. Shortt, " 'Before the Age of Wades': The Rise, Fall and Rebirth of General Practice in Canada, 1890-1940," in CharlesG. Roland, ed.,Health, Disesase and Medicine: Essays in Canadian History (Toronto: The Hannah Institute for the History of Medicine, 1984),p. 123-52; Seven M. Stowe, "Obstetrics and the Work of Doctoring in the Mid-Nineteenth Century American South," Bylletin of the Histoy of Medicine, 64 (1990): 540-66; and Melvine Watson, "An Account of an ObstetiiCal Practice in Upper Canada," Canadian Medical Association Journal, 40 (1939): 181-88. 1 Irene L. Rogers, "John Mackieson," Dictionay of Canadian Biography, Vol. 1 , 18~1-1890(Toronto: University of TorontoPress, l982), p. 5 6 - 6 6 David Shephard, "An Island Doctor: The Life and Times of Dr. John Mackieson (1795-1885)," The lsbnd Magazine, 3 (Fall/Wmter 1995): 32-38; and "A Light on Medical Practice in NineteenthCentury Canada," Canadian Medical Association Journal, 159 (1998):253-57. Charles Roland, "Diary of a Country Physician: Jonathan Woolverton (1811-1883); Medical History, 15(1971):168-80. Jacalyn Duffin, Langstaf: A Nineteexth-Century Medical Lifr? (Toronto: University of Taronto Pws, 1993). Barbara Tuchman, 'Biography as a Prism of History,'' in Marc Pachw, ed., Telling Liws: The Biographer's Art (Philadelphia:University of Pennsylvania Press, l98l), p. 132-47. Tuchman, "Biography as a Prismof History," p. 134. 'kchman, "Biography as a Prismof History," p. 134. Duffin,LangstH, especially chapter 2. J ~ hMaqkieson, Case Report, 9 December 1841, "Death (by Sinking)from a Burn," in n Sketches of Medical and Surgical Cases, unpublished manuscript, 1826 (Charlottetown: Medical Society of Prince Edward Island). Vfr@ Woolf, Granite and Rainbow: Essays by Virginia Woolf (London: Hogarth Press, 1958),p. 149-50. Roland, "Diary." Duffin,Langstaf, p. 255. Ceoffrey Wolff,"r 'o Lives," in Pachter, Tding Lives, p. 60. Lean Edel, "The Figure Under the Carpet," in Pachter, Telling Lives, p. 28. Edel, "The FigureUnder theCarpet," p. 20. Mackieson, Case Report, 29 July 1827, "Mania from Improper Use of Spirits," in Sketches. kckiison, case ~eport, Mdy 1855, "Quotidian Intermittent Fever," in Sketches. 19 Mcldeson, Ca& Report, 28 July 1834, "Delirium Tremens- SuccessfullyTreated by the Effusionof Cold Water," in Sketches. Pierre Charles-Alexandre Louis,Researches on the Eficts of Bloodletting in Some Inflammatory Diseases, and on the Influence of Tartarized Antimony and Vesication in Pneumonitis, translated by C. G. Putnam (Boston:HWrd Gray, 1836). J. W. Estes, "Drug Usage at the Infirmary:The Example of Dr. Andrew Duncan Sr.," in G. B. Risse, Hospital L# in EnlightCnment Scotland: Care and Teaching at the Royal InJrm a y of Edinburgh (Cambridge:CambridgeUniversity Press, 1986),p. 365. Thomas Tanner, A M a ~ w of the P+actice of Medicine (Philadelphia: Lindsay and Blakisl ton, l864), p. 223-24. Jonathan Wooherton, Diary, 21October 1834, cited by Roland, "Diary," p. 173. Watson, "An Account." Stowe, "Obstetrics and the Work," p. 541. Jan Coombs, "Rural Medical Practice in the 1880s: A View from Central Wisconsin," Bulletin of the Histo y of Medicine, 64 (1990):35-62. Duffin,Lanastaff, D. 69.

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31 Mackieson, Diary, 28 October 1870,Public Archives and Records Office, Prince Edward Island, Acc. No. 2353/359. 32 Mackieson, Diary, 2 October 1856,dated inside back cover. 1 33 John Harley Warner, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in Amerrca, 1820-1885 (Cambridge: Harvard University Press, 1 8 ) p. 166-68, 96, 213-19. 34 Edward Holman, "WilliamStewart Halsted as Revealed in HsLetters," Stanford Medi ical Bullettn, 10(1952):137-51. 35 JohnFulton, Harvey Cushing: A Biography (Springfield:CharlesThomas, 1 4 ) 96. 36 Pamela Bright, Dr. Rtchard Bright 1789-1858 (London:The Bodley Head, 1 8 ) 93. 37 Richard Ellis, ed., The Case Books o Dr. John Snow (London:Wellcome Institute for the f History of Medicine,MedicalHistory Suppl. No. 14,1994). 38 Michael Bliss, Banting: A Biography (Toronto:McClelland and Stewart, 1&. 9) 39 Jefferson Lewis, SomethingHidden: A Biography o Wilder Penfield (Toronto: Doubleday, f 1981). 40 Shortt, "Before the Age,"p. 123. 41 Stowe, "Obstetrics and the Work," p. 541. 42 Berman, "The Practice of Obstetrics," p. 192.